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SU30.1 | Phimosis, Paraphimosis and Carcinoma Penis — SDL Guide (Part 2)

Surgical and Emergency Management

Management follows directly from the diagnosis and its urgency. Physiological phimosis in a young boy needs only reassurance and hygiene advice — most resolve spontaneously and forcible retraction is harmful; a short course of topical steroid can soften a mildly tight ring in selected children, with circumcision reserved for true pathological or symptomatic cases. Pathological phimosis (a scarred ring, recurrent balanitis, BXO, or obstructive symptoms) is treated by circumcision, the definitive removal of the prepuce, which is also therapeutic for recurrent infection. Paraphimosis is the emergency: attempt prompt manual reduction — squeeze the oedematous glans steadily for several minutes to reduce its bulk (a compressive technique, with adequate analgesia or a penile block), then push the glans back through the constricting ring while drawing the foreskin forward. If manual reduction fails, a dorsal slit of the constricting band relieves it urgently; once the acute episode settles, an elective circumcision prevents recurrence. Carcinoma penis is managed by stage- and grade-directed surgery plus management of the inguinal nodes. Small, superficial, low-grade lesions may be treated with organ-sparing options (wide local excision, glansectomy, laser or topical therapy for premalignant disease) to preserve length and function; larger or invasive tumours need partial or total penectomy with an adequate margin. The inguinal nodes are addressed according to risk: dynamic sentinel node biopsy or inguinal lymphadenectomy for node-positive or high-risk disease, with chemotherapy/radiotherapy in advanced cases. Throughout, the message is that prevention — hygiene and, where culturally appropriate, circumcision — and early biopsy of any suspicious lesion are what change outcomes.

Provided image

Condition	Definition	Urgency	Key feature	Principal management
Phimosis	Non-retractile prepuce	Elective	Tight/scarred preputial ring (BXO in adults)	Reassurance/topical steroid (physiological); circumcision (pathological)
Paraphimosis	Retracted foreskin trapped behind glans	Emergency	Painful swollen dusky glans, constricting band	Immediate manual reduction; dorsal slit if it fails; later circumcision
Carcinoma penis	Squamous cell carcinoma of glans/prepuce	Urgent (cancer pathway)	Non-healing ulcer/fungating lesion ± inguinal nodes	Biopsy; organ-sparing or partial/total penectomy + inguinal node management

Check Your Understanding

Bring the three patients from the hook back to mind and test whether the foreskin thread now ties them together. The four-year-old has physiological phimosis: a naturally non-retractile prepuce with a normal stream needs only reassurance and hygiene, and forcible retraction would do harm — so you can reason your way from 'non-retractile foreskin' to 'reassure and wait'. The 24-year-old has paraphimosis: a retracted foreskin trapped behind the glans, a constricting ring, and progressive painful oedema that you have learned can threaten the glans with ischaemia — so you can reason from 'trapped retracted foreskin' to 'reduce it now, dorsal slit if that fails, circumcise later'. The 62-year-old with a non-healing, bleeding, malodorous lesion who was never circumcised has carcinoma penis until biopsy says otherwise — so you can reason from 'non-healing penile ulcer in an uncircumcised man with chronic phimosis' to 'biopsy the lesion, examine both groins, and stage'. Use these threads to self-test the competency: can you define each of the three precisely; separate physiological from pathological phimosis; list the risk factors for penile carcinoma and explain why neonatal circumcision is protective; and state the immediate management of paraphimosis and the principles (biopsy, organ-sparing vs penectomy, inguinal node management) for carcinoma? The questions that follow check exactly these links.