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Summary Table

Feature	Detail
Risk Factors	Male children (physiologic phimosis peaks in infancy and resolves by age 3 to 5); poor hygiene, recurrent balanoposthitis, lichen sclerosus (BXO), forceful retraction causing scarring (pathologic/secondary phimosis); iatrogenic injury post-circumcision attempt
Etiology	Physiologic (primary): normal developmental adhesion of the prepuce to the glans. Pathologic (secondary): scarring from infection, inflammation, or trauma producing a fibrotic, non-retractable preputial ring. Paraphimosis: the retracted foreskin becomes trapped proximal to the glans, causing venous congestion and edema
Patient Presentation	Phimosis: inability to retract the foreskin, ballooning during urination, recurrent balanitis. Paraphimosis: painful swollen glans with a tight constricting band of foreskin behind the corona, often after catheterization, examination, or hygiene attempt
Classic Physical Exam	Phimosis: a narrow preputial ring that prevents retraction; graded by the Kikiros classification (Grade 0 to 5). Paraphimosis: edematous, congested glans distal to a constricting ring of retracted prepuce at the coronal sulcus
Key Diagnostic Results	Clinical diagnosis based on history and physical exam; no labs or imaging are routinely required. Urinalysis if UTI is suspected
Management	Phimosis (primary): topical corticosteroid cream (betamethasone 0.05 to 0.1%) BID for 4 to 8 weeks. Phimosis (secondary or refractory): circumcision. Paraphimosis: manual reduction (compression then repositioning); if that fails, dorsal slit of the constricting band, followed by circumcision either immediately or electively
Keywords	"Unable to retract foreskin," "ballooning during urination," "tight phimotic ring," "paraphimotic ring at coronal sulcus," "swollen glans after retraction," "trapped foreskin"

1. Pathophysiology

Adhesion of the prepuce to the glans is a normal physiologic phenomenon in neonates and young boys. At birth, the inner preputial epithelium is fused to the glans by congenital adhesions. Over time, the accumulation of epithelial debris (smegma) and intermittent erections gradually separate the prepuce from the glans, allowing progressive retractability. By age 3, approximately 90% of boys will have at least partial retraction. This natural timeline is the reason that physiologic phimosis in young children should not be treated as pathology.

Pathologic (secondary) phimosis arises when the preputial orifice becomes scarred and fibrotic, typically from recurrent infections (balanoposthitis), forceful premature retraction attempts, or inflammatory dermatoses such as lichen sclerosus et atrophicus (balanitis xerotica obliterans). The scarring replaces the normally elastic preputial tissue with collagen-dense, non-compliant tissue, creating a fixed, non-retractable ring. This is an important distinction because pathologic phimosis will not resolve spontaneously and generally requires surgical intervention.

The pathophysiology of paraphimosis is a vascular emergency driven by mechanical obstruction. When the tight foreskin is retracted behind the glans and not promptly returned, the constricting band compresses the superficial venous and lymphatic drainage while arterial inflow continues. This imbalance produces progressive edema of the glans and inner prepuce, which in turn increases the circumferential pressure of the band, creating a vicious cycle. If left unreduced, the venous congestion can progress to arterial compromise, ischemia, and ultimately necrosis of the glans. This is why paraphimosis is always treated as an urgent condition.

As noted in Urologi Pediatrik IAUI 2022, excessive retraction of the prepuce must be avoided to prevent scar formation, and the diagnosis of paraphimosis is made clinically by identifying the preputial entrapment at the coronal sulcus with inability to reposition the foreskin.

2. Classification and Clinical Manifestation

Kikiros Classification of Phimosis

Grade	Clinical Finding
0	Full retraction, no constriction behind the glans, or easily retracted with limitation only by congenital adhesions to the glans
1	Full retraction of the prepuce, but tight behind the glans
2	Partial exposure of the glans with preputial limitation (not congenital adhesion)
3	Partial retraction with meatus visible
4	Slight retraction, but neither meatus nor glans can be visualized
5	No retraction at all

Clinical Manifestation by Type

Feature	Physiologic (Primary) Phimosis	Pathologic (Secondary) Phimosis	Paraphimosis
Age group	Neonates and young boys (< 3 to 5 years)	Any age; more common after recurrent infection	Any age; often after catheterization, cystoscopy, or hygiene
Appearance of prepuce	Soft, supple, non-scarred tip; may balloon during voiding	White, scarred, fibrotic ring (lichen sclerosus); rigid, non-pliable	Retracted foreskin trapped behind the corona; edematous glans
Retractability	Limited but improving over time	Fixed, non-retractable; Kikiros grade 4 to 5	Foreskin retracted but cannot be returned to original position
Symptoms	Usually asymptomatic; occasional ballooning	Dysuria, recurrent UTI, balanoposthitis, obstructive voiding	Acute pain, progressive swelling, potential ischemia
Natural history	Resolves spontaneously in most boys by age 3 to 5	Does not resolve; progressive scarring	Urologic emergency; will not self-resolve

Additionally, as described in Urologi Pediatrik IAUI 2022, when the prepuce cannot be retracted or forms a constriction ring behind the glans, the examiner should suspect a disproportion between the width of the preputial skin and the diameter of the glans. Frenulum breve may also be present, causing ventral deviation of the glans during retraction, and should be assessed during examination.

3. Diagnostic Workup

Test	Role	Expected Finding
Physical examination	Best initial and confirmatory test for both phimosis and paraphimosis	Phimosis: non-retractable prepuce graded by Kikiros classification. Paraphimosis: edematous glans with constricting preputial band at the coronal sulcus
Urinalysis / Urine culture	Indicated only if UTI is suspected	Pyuria, bacteriuria
Imaging	Not routinely indicated	Renal ultrasound only if recurrent UTI raises concern for urinary tract anomalies

The diagnosis of phimosis is entirely clinical. No laboratory or imaging study is needed to confirm it. The examiner gently attempts to retract the foreskin and grades the degree of retractability using the Kikiros scale. The critical clinical judgment is to distinguish physiologic from pathologic phimosis, because this determines whether the patient can be observed or needs intervention.

Key features favoring pathologic phimosis include: visible scarring or whitish discoloration of the preputial ring (suggesting lichen sclerosus), a history of recurrent balanoposthitis, or a previously retractable foreskin that has become fixed.

The diagnosis of paraphimosis is also clinical and should be recognized on sight. The hallmark is the triad of a retracted foreskin, a constricting band at the coronal sulcus, and a swollen, congested glans. As stated in Urologi Pediatrik IAUI 2022, this diagnosis is established by anamnesis and physical examination alone.

There is no role for a "confirmatory test" beyond the physical exam. The clinical question on an exam will test whether the student recognizes the presentation and acts on it immediately rather than ordering unnecessary workup.

4. Management and Treatment

Condition	First-Line Treatment	Second-Line / Refractory	Evidence Level
Primary (physiologic) phimosis	Topical corticosteroid cream (0.05 to 0.1%) BID for 4 to 8 weeks	Circumcision if medical therapy fails	LoE 1b (per Urologi Pediatrik IAUI 2022)
Secondary (pathologic) phimosis	Circumcision	N/A	LoE 2b
Phimosis with complications (recurrent UTI, balanoposthitis, balloning with obstruction)	Urgent circumcision regardless of age	N/A	LoE 2b
Paraphimosis	Manual reduction (compression + repositioning)	Dorsal slit incision of the constricting ring, then circumcision (immediate or delayed)	LoE 3

Conservative Therapy for Primary Phimosis

The first-line treatment for symptomatic primary phimosis is topical corticosteroid cream or ointment at a concentration of 0.05 to 0.1% (e.g., betamethasone valerate), applied to the phimotic ring twice daily for 4 to 8 weeks. The steroid thins the preputial skin, reduces inflammation, and facilitates gradual retraction. Per Urologi Pediatrik IAUI 2022, this approach carries a success rate exceeding 80% (Level of Evidence 1b), making it the recommended first step before any surgical consideration.

However, the recurrence rate is up to 17%, meaning a proportion of patients will relapse after completing the course. Parents should be counseled that gentle retraction exercises during and after treatment help maintain gains. Importantly, congenital adhesions between the prepuce and the glans do not respond to steroid therapy (Level of Evidence 2), so the examiner must distinguish between true phimosis (preputial ring narrowing) and simple adhesions.

The hypothalamic-pituitary-adrenal axis is not significantly affected by topical corticosteroid application in this setting, which is a testable pearl regarding the safety of this treatment in children.

Surgical Therapy for Phimosis

The absolute indication for circumcision is secondary (pathologic) phimosis, including cases caused by lichen sclerosus. In primary phimosis that has failed conservative management, or in the presence of complications such as recurrent UTIs, recurrent balanoposthitis, or balloning of the prepuce during micturition, circumcision should be performed without delay, regardless of patient age.

Preputioplasty (plastic circumcision) is an alternative procedure that widens the preputial ring while preserving the foreskin for cosmetic purposes. As described in Urologi Pediatrik IAUI 2022, at the same time the surgeon releases adhesions and performs a frenulotomy with ligation of the frenular artery if frenulum breve is present.

Contraindications to circumcision include: acute local infection, and congenital penile anomalies, particularly hypospadias or buried penis, because the preputial tissue is needed as graft material for future reconstructive surgery. This is a high-yield contraindication that is commonly tested.

Treatment for phimosis is generally initiated after age 2 years, or earlier based on caregiver preference (Level of Evidence 3 per Urologi Pediatrik IAUI 2022).

Management of Paraphimosis

Paraphimosis requires urgent reduction. The first step is manual compression of the edematous glans and distal prepuce for several minutes to reduce the swelling, followed by gentle repositioning of the foreskin over the glans. Applying ice or granulated sugar to the glans has been described as osmotic techniques to reduce edema before the manual attempt.

If manual reduction fails, the next step is a dorsal slit (dorsumsisi) of the constricting preputial ring under local anesthesia. This releases the band and decompresses the glans. Per Urologi Pediatrik IAUI 2022, after the dorsal slit, circumcision can be performed immediately or deferred to a later date depending on local clinical findings.

The recommendation in Urologi Pediatrik IAUI 2022 is graded as: treat paraphimosis with manual repositioning first, and proceed to surgery if it fails (Level of Evidence 3, Strength Rating: Strong).

All surgical procedures on the prepuce require follow-up at 4 to 6 weeks post-operatively, per Urologi Pediatrik IAUI 2022.

Complications of Circumcision

Post-circumcision complication rates range from 0% to 30% in the literature. A study by Hung et al. over a 5-year follow-up found a 2.9% complication rate in nonneonatal circumcision, with 2.2% occurring within the first 30 days. Complications include bleeding, wound infection, meatal stenosis, excessive skin removal, poor cosmetic outcome, scar formation, and trapped penis. A case series by Satyagraha et al. (2020) reported 3 cases of iatrogenic penile amputation from circumcision at a single teaching hospital between 2013 and 2018, underscoring the importance of proper surgical technique and training.

Notably, routine neonatal circumcision for the prevention of penile carcinoma is not indicated. Meta-analyses have found no increased risk in uncircumcised men without a history of phimosis.

5. Differential Diagnosis and Distractors

Differential	Why It Is Similar	Key Discriminator
Balanitis / Balanoposthitis	Also presents with preputial swelling and inability to retract; may coexist with phimosis	Balanitis features erythema, discharge, and tenderness of the glans/prepuce; the primary problem is infection, not a structural narrowing of the preputial ring
Paraphimosis vs. penile tourniquet syndrome (hair thread tourniquet)	Both present with a swollen, congested glans in a young child	In hair tourniquet, a circumferential hair or thread is visible at the coronal sulcus; there is no retracted foreskin band. The child may be circumcised
Buried (concealed) penis	The penis appears short with the shaft hidden beneath suprapubic fat; the foreskin may appear tight	The prepuce is normal in a buried penis; the issue is inadequate penile fixation to the pubic bone and excess suprapubic adipose tissue. Circumcision is contraindicated
Hypospadias with hooded foreskin	The foreskin may appear abnormal and non-retractable	In hypospadias, the foreskin has a dorsal hood with a ventral deficit, and the urethral meatus is ventrally displaced. Circumcision is contraindicated because the prepuce is needed for reconstruction
Lichen sclerosus (BXO)	Presents with phimosis and is actually a cause of secondary phimosis	The key discriminator is the whitish, sclerotic appearance of the preputial tissue. This is pathologic phimosis and will not respond to conservative management alone; circumcision with histologic confirmation is indicated
Penile edema from insect bite or angioedema	Diffuse penile swelling may mimic paraphimosis	No constricting preputial ring at the coronal sulcus; the swelling is diffuse and symmetric, not localized distal to a band. History of allergen exposure or insect bite is usually present

6. Traps and High-Yield Pearls

The most common way students lose points on phimosis questions is by recommending circumcision for physiologic phimosis in a young child. A 2-year-old with a non-retractable foreskin, no scarring, no recurrent infections, and no voiding difficulty has a normal finding, not a surgical indication. The correct answer in this scenario is reassurance and observation, or topical corticosteroid if symptoms warrant treatment. Jumping to circumcision is the classic trap answer.

The second frequent error is confusing phimosis with paraphimosis. Both involve the foreskin, but the clinical urgency is entirely different. In phimosis, the foreskin cannot be pulled back. In paraphimosis, the foreskin has been pulled back and cannot be returned. The vignette for paraphimosis will typically describe a child or adult who had a catheter placed, an examination, or a hygiene attempt, followed by progressive painful swelling of the glans. Recognizing this as paraphimosis and choosing manual reduction as the first step (not immediate circumcision, not observation) is what the question tests.

A third trap involves contraindications to circumcision. If the vignette describes a boy with a non-retractable foreskin and a ventrally displaced urethral meatus (hypospadias) or a concealed penile shaft (buried penis), the student must recognize that circumcision is contraindicated because the preputial tissue is essential for future reconstructive surgery.

Finally, students should remember that asymptomatic preputial adhesions should not be forcibly retracted (Level of Evidence 2b, Strength Rating: Weak, per Urologi Pediatrik IAUI 2022). Forced retraction causes tearing, bleeding, and subsequent scarring, which paradoxically creates the pathologic phimosis the examiner was trying to prevent.

The core competency being tested across all phimosis/paraphimosis questions is the ability to differentiate physiologic from pathologic presentations, choose the correct stepwise management (conservative before surgical for primary phimosis, urgent reduction for paraphimosis), and recognize contraindications to surgical intervention.

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