Highlights & Basics
- Congenital and acquired conditions that affect the male genitalia; some may require emergency evaluation and treatment.
- Diagnosis based on clinical findings identified in a wide variety of age groups from newborn to adult.
- Localized occurrences of inflammation and infection are amenable to medical treatment; surgery with varying degrees of reconstruction may be required.
- Inadequate, untimely, and failed treatment may have long-term consequences of sexual dysfunction or cosmetic deformity of the penis.
Quick Reference
History & Exam
Key Factors
newborn and toddler age
abnormal location of urethra
incomplete prepuce
penile curvature and/or torsion
recent genital exam or procedure
history of short or small penis
penile pain and swelling
foreskin adherent to glans
penile adhesions and smegma
penile cicatrix
penile glans edema
prominent prepubic fat pad
presence of hernia or hydrocele
Other Factors
forced retraction of foreskin
dyspareunia
recent penile trauma
history of balanitis or balanoposthitis
urinary obstruction or retention
necrosis of penile skin
discoloration of glans
penile length discrepancy
history of UTI
history of pelvic or genitourinary surgery
erectile dysfunction
Diagnostics Tests
1st Tests to Order
clinical diagnosis
Treatment Options
acute
phimosis <12 years old, congenital or physiologic
phimosis <12 years old, congenital or physiologic
with cicatrix or balanitis xerotica obliterans (BXO)
phimosis ≥12 years old
topical corticosteroid
preputial surgery
Definition
Vignette
Common Vignette 1
Common Vignette 2
Other Presentations
Epidemiology
Etiology
Pathophysiology
Images
Paraphimosis
Pathologic phimosis with cicatrix
Infant with distal hypospadias. The urethral meatus is located in the glans or distal shaft and prepuce is typically incomplete
Infant with proximal hypospadias. The urethral meatus is located from the perineum to the proximal shaft
Congenital penile curvature (congenital chordee)
Congenital buried penis
Congenital buried penis: abundant inner preputial skin with paucity of shaft skin
Congenital buried penis
Congenital buried penis
Physiologic phimosis
Balanitis xerotica obliterans (lichen sclerosis)
Repaired congenital buried penis (with bilateral hernia repair and scrotoplasty)
Repaired congenital buried penis
Early paraphimosis
Pathologic phimosis in a patient with balanitis xerotic obliterans
Small keratin pearls
Large keratin pearl
Diagnostic Approach
History
Physical exam
Laboratory and tests
Risk Factors
History & Exam
Tests
Differential Diagnosis
Balanoposthitis
Differentiating Signs/Symptoms
- Inflammation of the glans penis without constrictive foreskin.
Differentiating Tests
- Clinical diagnosis.
Differentiating Signs/Symptoms
- A foreign body wrapped around the penis (such as a hair or thread) can lead to distal swelling and edema similar to paraphimosis.
Differentiating Tests
- Clinical diagnosis.
Differentiating Signs/Symptoms
- A trapped penis is a buried penis due to scar tissue, typically from previous circumcision. This scar is usually palpable around the penis, rather than a smooth transition from prepubic to penile skin.
Differentiating Tests
- Clinical diagnosis.
Differentiating Signs/Symptoms
- A diminutive penis is a penis that seems small due to abnormality such as epispadias or hypospadias. Evident by an abnormally positioned urethral meatus.
Differentiating Tests
- Clinical diagnosis.
Differentiating Signs/Symptoms
- A webbed penis is a buried penis due to skin webbing at the penoscrotal junction. A small bridge of tissue connecting the ventral proximal penis to the scrotum is palpable.
Differentiating Tests
- Clinical diagnosis.
Intersex disorder
Differentiating Signs/Symptoms
- Boys with hypospadias and unilateral or bilateral nonpalpable testes (cryptorchidism) may have an intersex condition.
Differentiating Tests
- Endocrine evaluation is abnormal.
Treatment Approach
Phimosis
Paraphimosis
Hypospadias
Congenital penile curvature and/or torsion
Concealed penis
Micropenis
Treatment Options
phimosis <12 years old, congenital or physiologic
reassurance and hygiene
Comments
- In patients with congenital or physiologic phimosis, the best treatment is simply observation over time.
- Expectant management for congenital (physiologic) phimosis is preferred up to the time of puberty (12 years of age). Reassurance to parents and child about normal penile anatomy and proper hygiene (without the need to forcibly retract the foreskin) will generally suffice. Routine cleaning of the external skin is desirable, but it is not necessary to retract the phimotic foreskin for cleaning until natural separation of the foreskin occurs.
with cicatrix or balanitis xerotica obliterans (BXO)
topical corticosteroids
Primary Options
- betamethasone dipropionate topical
(0.05%) apply sparingly to the preputial outlet twice daily
- betamethasone dipropionate topical
- triamcinolone topical
(0.1%) apply sparingly to the preputial outlet twice daily
- triamcinolone topical
Comments
- Success rates of 83% have been reported at a median follow-up of 22 months, including 67% of patients with BXO.[25]
- Treatment course: 4 to 6 weeks. Course may be repeated once.
preputial surgery
Primary Options
circumcision
preputioplasty
Comments
- Those patients with phimosis who do not respond to a topical corticosteroid are best managed with circumcision.[18] If the patient or caregiver wishes to avoid the cosmetic effect of circumcision but needs surgical intervention, they may be offered a preputioplasty. A preputioplasty consists of limited dorsal slit(s) with transverse closure made along the constricting band of skin. Preputioplasty can be an effective alternative to full circumcision in most children; however, patients with BXO should undergo circumcision.[28]
phimosis ≥12 years old
topical corticosteroid
Primary Options
- betamethasone dipropionate topical
(0.05%) apply sparingly to the preputial outlet twice daily
- betamethasone dipropionate topical
- triamcinolone topical
(0.1%) apply sparingly to the preputial outlet twice daily
- triamcinolone topical
Comments
- Phimosis persisting past 12 years of age and into adulthood is generally treated with topical corticosteroid.[23] [24] [25] The phimotic ring may respond to a 6-week trial of a topical corticosteroid and allow for retraction of the foreskin. Acquired or pathologic phimosis (e.g., cicatrix or balanitis xerotica obliterans [BXO] / lichen sclerosis) requires treatment regardless of age. One study has shown a success rate of 83% at a median follow-up of 22 months, including a success rate of 67% in boys with BXO.[25] A randomized study in Brazil demonstrated topical corticosteroid treatment of phimosis to be more cost-effective than circumcision.[26] A systematic review concluded that topical corticosteroids are the recommended first-line therapy for the management of phimosis.[27]
- Therapeutic trial of corticosteroid cream application may be repeated.
- Treatment course: 4 to 6 weeks. Course may be repeated once.
preputial surgery
Primary Options
circumcision
preputioplasty
Comments
- Those patients with phimosis who do not respond to a topical corticosteroid are best managed with circumcision.[18] If the patient or caregiver wishes to avoid the cosmetic effect of circumcision but needs surgical intervention, they may be offered a preputioplasty. A preputioplasty consists of limited dorsal slit(s) with transverse closure made along the constricting band of skin. Preputioplasty can be an effective alternative to full circumcision in most children; however, patients with BXO should undergo circumcision.[28]
paraphimosis
manual reduction
Comments
- Paraphimosis should be managed conservatively with manual reduction. Image The goal of treatment is prompt reduction of the foreskin to its normal anatomic position distal to the glans penis. If there is difficulty with manual reduction, several therapeutic measures can be attempted, including pressure, sugar, hyaluronidase injection, and puncture technique.
- To perform manual reduction, adequate anesthesia is administered in the form of dorsal penile nerve block or ring block with local anesthetic (lidocaine or bupivacaine, without epinephrine). Children may require conscious sedation and/or general anesthesia. Circumferential pressure around the edematous ring of foreskin for several minutes may help reduce the edema.
- Both thumbs are placed on the glans with the fingers wrapped around the shaft of the penis proximal to the foreskin. Gentle pressure is applied to pull the foreskin with the fingers and push the glans with the thumbs until the foreskin is reduced to its anatomic position.[29] The penis is wrapped gently in a gauze soaked with 50% dextrose in water for 10 to 20 minutes.
- If there is difficulty with manual reduction, an osmotic agent (e.g., fine granulated sugar) is applied in liberal amounts, on the principle that fluid flows down a concentration gradient; in this case the hypotonic fluid in the penis flows to the hypertonic agent on the outside of the skin.
sugar
Comments
- Where manual reduction is difficult, applying granulated sugar to the area of edema, or wrapping a glucose-soaked gauze around the penis for 10 to 20 minutes before attempted manual reduction, may help extract some of the edema by osmosis.[30]
needle puncture
Comments
- If paraphimosis cannot be treated with more conservative measures, a more invasive technique using needle puncture may be employed. Pressure is then applied as the needle-puncture holes facilitate reduction of edema before manual reduction is attempted.[31]
- The penis is sterilely prepped and a 26-gauge needle is used to make multiple (about 20) punctures in the edematous ring of foreskin.
hyaluronidase
Primary Options
- hyaluronidase
consult specialist for guidance on dose
- hyaluronidase
Comments
- Injection of hyaluronidase into the edematous tissue may break down hyaluronic acid and its subsequent osmotic gradient.[32] Hyaluronidase may be used to augment the puncture technique.
- Induces osmotic diuresis with movement of hyaluronic acid from edematous tissue.
preputial surgery
Primary Options
dorsal slit
circumcision
Comments
- If conservative measures fail, definitive management in terms of either dorsal slit or circumcision may be performed.[15]
hypospadias
specialist referral and possible surgery
Comments
- Although some minor forms of hypospadias are observed without surgical intervention, infants with hypospadias should be referred to a specialist for further evaluation to determine the extent of urethral involvement.
- Surgery can be performed in most patients on an outpatient basis after the age of 3 months.[33]
- Patient may need a postoperative urethral stent for up to 2 weeks after surgery depending upon the severity.
- Boys with an incomplete prepuce should not undergo circumcision in the neonatal period and should instead be referred to a specialist. The foreskin can be reconstructed or a circumcision can be performed at the time of urethroplasty with similar outcomes in distal hypospadias.[34]
- If megameatus with intact prepuce (a mild variant of distal hypospadias) is discovered during routine neonatal circumcision, the circumcision should be completed and the patient referred electively for urologic evaluation thereafter.[35]
congenital penile curvature and/or torsion
surgery
Comments
- Surgery to straighten the penis is the treatment of choice for congenital penile curvature >30 degrees or torsion >90 degrees. This can be done in conjunction with a circumcision or with foreskin preservation.
concealed penis <3 years old
observation
Comments
- Management of concealed penis is controversial. Although some advocate early intervention, most pediatric urologists feel that observation may be warranted up until the age of toilet training (2 to 3 years of age).[1] [38] In this age group, redistribution of fat often leads to spontaneous resolution.
with foreskin disproportion, disfiguring trauma, or scarring
phalloplasty
Comments
- Urologic surgical options are available where weight loss fails to improve concealed penis. In cases of congenital concealed penis (congenital megaprepuce) that are associated with an excess of inner preputial skin with a relative paucity of shaft skin, surgical intervention is warranted at an earlier date. Images In cases of concealed penis related to trauma or postoperative scarring, surgery is also indicated.
concealed penis ≥3 years old
without foreskin disproportion, disfiguring trauma, or scarring
weight loss
Comments
- Boys will have difficulty with a concealed penis as toilet training begins. Weight loss is the primary treatment for concealed penis.
- Older boys and adults with concealed penis are unlikely to have spontaneous resolution. Weight loss is recommended primarily, with urologic surgical options also available. Although weight loss may help in adolescents and adults, the psychological impact of the condition and the low rate of improvement may warrant surgical referral.
phalloplasty
Comments
- Urologic surgical options are available where weight loss fails to improve concealed penis.
- Although weight loss may help in adolescents and adults, the psychological impact of the condition and the low rate of improvement may warrant surgical referral. Several operative techniques have been described, although treatment preferences vary among patient populations and surgeons.[1] [2] [11] [12] [14] [15] [21] [32]
with foreskin disproportion, disfiguring trauma, or scarring
phalloplasty
Comments
- Surgical techniques vary widely among different patient populations and surgeons.[32] In patients who have undergone prior circumcision and have a paucity of penile shaft skin, skin grafting may be necessary for complete penile coverage.
micropenis
endocrine evaluation
Comments
- In true cases of micropenis (penile length of 2 or more standard deviations less than normal), endocrine evaluation by a specialist is recommended.
Prevention
Primary Prevention
Secondary Prevention
Follow-Up Overview
Prognosis
Congenital phimosis and paraphimosis
Hypospadias
Concealed or buried penis
Monitoring
Complications
Citations
Øster J. Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child. 1968 Apr;43(228):200-3.[Abstract][Full Text]
Kiss A, Kiraly L, Kutasy B, et al. High incidence of balanitis xerotica obliterans in boys with phimosis: prospective 10-year study. Pediatr Dermatol. 2005 Jul-Aug;22(4):305-8.[Abstract]
Vorilhon P, Martin C, Pereira B, et al. Assessment of topical steroid treatment for childhood phimosis: review of the literature [in French]. Arch Pediatr. 2011 Apr;18(4):426-31.[Abstract]
1. Radhakrishnan J, Razzaq A, Manickam K, et al. Concealed penis. Pediatr Surg Int. 2002 Dec;18(8):668-72.[Abstract]
2. Tang SH, Kamat D, Santucci RA. Modern management of adult-acquired buried penis. Urology. 2008 Jul;72(1):124-7.[Abstract]
3. Gairdner D. The fate of the foreskin. A study of circumcision. Br Med J. 1949 Dec 24;2(4642):1433-7.[Abstract][Full Text]
4. Øster J. Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child. 1968 Apr;43(228):200-3.[Abstract][Full Text]
5. Imamura E. Phimosis of infants and young children in Japan. Acta Paediatr Jpn. 1997 Aug;39(4):403-5.[Abstract]
6. Spilsbury K, Semmens JB, Wisniewski ZS, et al. Circumcision for phimosis and other medical indications in Western Australian boys. Med J Aust. 2003 Feb 17;178(4):155-8.[Abstract]
7. Shankar KR, Rickwood AM. The incidence of phimosis in boys. BJU Int. 1999 Jul;84(1):101-2.[Abstract]
8. Snodgrass WT, Bush NC. Hypospadias. In: Snodgrass WT, ed. Pediatric urology: evidence for optimal patient management. New York, NY: Springer; 2013:117-52.
9. European Association of Urology, European Society for Paediatric Urology. Guidelines on paediatric urology. 2019 [internet publication].[Full Text]
10. Cold CJ, Taylor JR. The prepuce. BJU Int. 1999 Jan;83(Suppl 1):34-44.[Abstract]
11. Jones SA, Flynn RJ. An unusual (and somewhat piercing) cause of paraphimosis. Br J Urol. 1996 Nov;78(5):803-4.[Abstract]
12. Higgins SP. Painful swelling of the prepuce occurring during penile erection. Genitourin Med. 1996 Dec;72(6):426.[Abstract][Full Text]
13. Redman JF. Buried penis: a congenital syndrome of a short penile shaft and a paucity of penile skin. J. Urol. 2005 May;173(5):1714-7.[Abstract]
14. Kiss A, Kiraly L, Kutasy B, et al. High incidence of balanitis xerotica obliterans in boys with phimosis: prospective 10-year study. Pediatr Dermatol. 2005 Jul-Aug;22(4):305-8.[Abstract]
15. Choe JM. Paraphimosis: current treatment options. Am Fam Physician. 2000 Dec 15;62(12):2623-6, 2628.[Abstract][Full Text]
16. Eroglu E, Gundogdu G. Isolated penile torsion in newborns. Can Urol Assoc J. 2015 Nov 4;9(11-12):E805-7.[Abstract][Full Text]
17. Metcalfe PD, Rink RC. The concealed penis: management and outcomes. Curr Opin Urol. 2005 Jul;15(4):268-72.[Abstract]
18. McGregor TB, Pike JG, Leonard MP. Pathologic and physiologic phimosis: approach to the phimotic foreskin. Can Fam Physician. 2007 Mar;53(3):445-8.[Abstract][Full Text]
19. Donatucci C, Ritter E. Management of buried penis in adults. J Urol. 1998 Feb;159(2):420-4.[Abstract]
20. Snodgrass WT. Hypospadias. In: McDougal WS, Wein AJ, Kavoussi LR, et al, eds. Campbell-Walsh urology. 10th ed. Philadelphia, PA: Elsevier; 2009:634-8.
21. Maizels M, Zaontz M, Donovan J, et al. Surgical correction of the buried penis: description of a classification system and a technique to correct the disorder. J Urol. 1986 Jul;136(1 Pt 2):268-71.[Abstract]
22. Dave S, Afshar K, Braga LH, et al. Canadian Urological Association guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants (full version). Can Urol Assoc J. 2018 Feb; 12(2):E76-E99.[Abstract][Full Text]
23. Webster TM, Leonard MP. Topical steroid therapy for phimosis. Can J Urol. 2002 Apr;9(2):1492-5.[Abstract]
24. Monsour MA, Rabinovitch HH, Dean GE. Medical management of phimosis in children: our experience with topical steroids. J Urol. 1999 Sep;162(3 Pt 2):1162-4.[Abstract]
25. Ghysel C, Vander Eeckt K, Bogaert GA. Long-term efficiency of skin stretching and a topical corticoid cream application for unretractable foreskin and phimosis in prepubertal boys. Urol Int. 2009;82(1):81-8.[Abstract]
26. Nobre YD, Freitas RG, Felizardo MJ, et al. To circ or not to circ: clinical and pharmacoeconomic outcomes of a prospective trial of topical steroid versus primary circumcision. Int Braz J Urol. 2010 Jan-Feb;36(1):75-85.[Abstract][Full Text]
27. Vorilhon P, Martin C, Pereira B, et al. Assessment of topical steroid treatment for childhood phimosis: review of the literature [in French]. Arch Pediatr. 2011 Apr;18(4):426-31.[Abstract]
28. Cuckow PM, Rix G, Mouriquand PD. Preputial plasty: a good alternative to circumcision. J Pediatr. Surg. 1994 Apr;29(4):561-3.[Abstract]
29. Little B, White M. Treatment options for paraphimosis. Int J Clin Pract. 2005 May;59(5):591-3.[Abstract]
30. Cahill D, Rane A. Reduction of paraphimosis with granulated sugar. BJU Int. 1999 Feb;83(3):362.[Abstract]
31. Reynard JM, Barua JM. Reduction of paraphimosis the simple way - the Dundee technique. BJU Int. 1999 May;83(7):859-60.[Abstract]
32. Litzky GM. Reduction of paraphimosis with hyaluronidase. Urology. 1997 Feb;50(3):160.[Abstract]
33. Bush NC, Holzer M, Zhang S, et al. Age does not impact risk for urethroplasty complications after tubularized incised plate repair of hypospadias in prepubertal boys. J Pediatr Urol. 2013 Jun;9(3):252-6.[Abstract]
34. Snodgrass W, Dajusta D, Villanueva C, et al. Foreskin reconstruction does not increase urethroplasty or skin complications after distal TIP hypospadias repair. J Pediatr Urol. 2013 Aug;9(4):401-6.[Abstract]
35. Snodgrass WT, Khavari R. Prior circumcision does not complicate repair of hypospadias with an intact prepuce. J Urol. 2006 Jul;176(1):296-8.[Abstract]
36. Wright I, Cole E, Farrokhyar F, et al. Effect of preoperative hormonal stimulation on postoperative complication rates after proximal hypospadias repair: a systematic review. J Urol. 2013 Aug;190(2):652-9.[Abstract]
37. Netto JM, Ferrarez CE, Schindler Leal AA, et al. Hormone therapy in hypospadias surgery: a systematic review. J Pediatr Urol. 2013 Dec;9(6 Pt B):971-9.[Abstract]
38. Borsellino A, Spagnoli A, Vallasciani S, et al. Surgical approach to concealed penis: technical refinements and outcome. Urology. 2007 Jun;69(6):1195-8.[Abstract]
39. Madsen BS, van den Brule AJ, Jensen HL, et al. Risk factors for squamous cell carcinoma of the penis - population-based case-control study in Denmark. Cancer Epidemiol Biomarkers Prev. 2008 Oct;17(10):2683-91.[Abstract]
40. Kaplan GW. Complications of circumcision. Urol Clin North Am. 1983 Aug;10(3):543-9.[Abstract]
Key Articles
Referenced Articles
Guidelines
Diagnostic
Summary
Guidelines on the diagnosis of pediatric urological conditions; include information on new technological advances and non-invasive diagnostic screening modalities.Published by
European Association of Urology (EAU), European Society for Paediatric Urology (ESPU)
Published
2019
Treatment
Summary
Guidelines on the treatment of pediatric urological conditions.Published by
European Association of Urology (EAU), European Society for Paediatric Urology (ESPU)
Published
2019
Summary
Evidence-based guideline on the benefits and possible complications associated with male circumcision. Provides information on normal foreskin development and management of phimosis.Published by
Canadian Urological Association
Published
2017