Levels of evidence (1a-4) and grades of recommendation (A-C) are defined at the end of the "Major Recommendations" field.
Diagnosis
The diagnosis of phimosis and paraphimosis is made by physical examination.
If the prepuce is not retractable or only partly retractable and shows a constrictive ring on drawing back over the glans penis, a disproportion between the width of the foreskin and the diameter of the glans penis has to be assumed. In addition to the constricted foreskin, there may be adhesions between the inner surface of the prepuce and the glanular epithelium and/or a fraenulum breve. A fraenulum breve leads to a ventral deviation of the glans once the foreskin is retracted. If the tip remains narrow and glanular adhesions were separated, than the space is filled with urine during voiding causing the foreskin to balloon outward.
The paraphimosis is characterized by retracted foreskin with the constrictive ring localized at the level of the sulcus, which prevents replacement of the foreskin over the glans.
Treatment
Treatment of phimosis in children is dependent on the parents' preferences and can be plastic or radical circumcision after completion of the second year of life. Plastic circumcision has the objective of achieving a wide foreskin circumference with full retractability, while the foreskin is preserved (dorsal incision, partial circumcision). However, this procedure carries the potential for recurrence of the phimosis. In the same session, adhesions are released and an associated fraenulum breve is corrected by fraenulotomy. Meatoplasty is added if necessary.
An absolute indication for circumcision is secondary phimosis. The indications in primary phimosis are recurrent balanoposthitis and recurrent urinary tract infections in patients with urinary tract abnormalities (Level of evidence: 2, Grade B recommendation). Simple ballooning of the foreskin during micturition is not a strict indication for circumcision.
Routine neonatal circumcision to prevent penile carcinoma is not indicated. Contraindications for circumcision are coagulopathy, an acute local infection and congenital anomalies of the penis, particularly hypospadias or buried penis, because the foreskin may be required for a reconstructive procedure. Childhood circumcision has an appreciable morbidity and should not be recommended without a medical reason (Level of evidence: 2, Grade B recommendation). As a conservative treatment option of the primary phimosis, a corticoid ointment or cream (0.05-0.1%) can be administered twice a day over a period of 20 to 30 days (Level of evidence: 1, Grade A recommendation). This treatment has no side effects and the mean bloodspot cortisol levels are not significantly different from an untreated group of patients (Level of evidence: 1). Agglutination of the foreskin does not respond to steroid treatment (Level of evidence: 2).
Treatment of paraphimosis consists of manual compression of the oedematous tissue with a subsequent attempt to retract the tightened foreskin over the glans penis. Injection of hyaluronidase beneath the narrow band may be helpful to release it (Level of evidence: 4, Grade C recommendation). If this manoeuvre fails, a dorsal incision of the constrictive ring is required. Depending on the local findings, a circumcision is carried out immediately or can be performed in a second session.
Definitions:
Levels of Evidence
1a Evidence obtained from meta-analysis of randomized trials
1b Evidence obtained from at least one randomized trial
2a Evidence obtained from at least one well-designed controlled study without randomization
2b Evidence obtained from at least one other type of well-designed quasi-experimental study
3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports
4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities
Grades of Recommendation
- Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
- Based on well-conducted clinical studies, but without randomized clinical studies
- Made despite the absence of directly applicable clinical studies of good quality
