Phimosis in Children

Phimosis in children is inability to retract the foreskin over the glans, which is physiological in young boys and pathological when due to scarring.

• Physiological phimosis is present in nearly all newborn boys. The foreskin separates from the glans progressively. About 50 percent retract by age 1 year, 90 percent by age 3 years and 99 percent by age 16 years.
• Pathological phimosis results from balanitis xerotica obliterans (lichen sclerosus), recurrent balanoposthitis, or forceful retraction with scarring. It presents with a white, fibrotic ring.
• Paraphimosis occurs when a retracted foreskin cannot be returned and constricts behind the glans.
• Ballooning of the foreskin during voiding is common and benign.

Findings depend on the cause.

• Physiological: non-retractile foreskin with pink, supple tip, ballooning when voiding, painless.
• Pathological: a white, fibrotic, stenotic ring (lichen sclerosus), thickened meatal area, dysuria, poor stream, recurrent balanitis, haematuria.
• Balanoposthitis: red, swollen, painful foreskin with discharge.
• Paraphimosis: painful swollen glans with retracted foreskin forming a tight constricting band.
• Differential diagnosis: balanitis, lichen sclerosus, congenital meatal stenosis, hypospadias, penile adhesions, buried penis and trauma.
• Complications: recurrent balanoposthitis, urinary tract infection, urinary retention, paraphimosis, scarring, and penile carcinoma in adults with lichen sclerosus.

Diagnosis is clinical.

• Inspect the foreskin tip and glans without forceful retraction. Look for scarring ring, meatal stenosis and balanitis.
• Urinalysis for infection.
• Biopsy (circumcision specimen) if lichen sclerosus is suspected.

Physiological phimosis needs no treatment.

• Supportive: reassure parents. Do not forcibly retract the foreskin. Clean externally with water; do not use soap on the glans. Allow spontaneous separation.
• Pharmacological, for persistent phimosis beyond age 3 to 4 years (if symptomatic or by parental choice): topical betamethasone 0.05 or 0.1 percent cream twice daily for 4 to 8 weeks, with gentle retraction exercises, achieving success in about 80 to 90 percent. Topical clobetasol 0.05 percent is used for lichen sclerosus.
• Balanoposthitis: warm saline soaks and topical antifungal (clotrimazole 1 percent twice daily) or antibiotic (fusidic acid 2 percent three times daily) for 7 days; oral amoxicillin-clavulanate for severe infection.
• Procedures: paraphimosis: reduction with analgesia, local anaesthetic and manual compression (or hyaluronidase injection or the puncture technique), with dorsal slit or circumcision if reduction fails. Circumcision or preputioplasty for scarring (lichen sclerosus), recurrent balanoposthitis or urinary infection, or failure of steroid cream. Circumcision may also be done for cultural, religious or preventive reasons by trained operators.
• Special groups: boys with urinary tract anomalies or recurrent infection may benefit from circumcision. Bleeding disorders need correction before surgery. Hypospadias is a contraindication to circumcision.
• Red flags: paraphimosis, urinary retention, white scarred ring, haematuria, recurrent infection, and poor stream.
• Follow-up: review at 4 to 8 weeks of steroid treatment. Refer to paediatric surgery or urology if there is no response.