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Foreskin Problems Care Pathway Overview

This document is designed to clarify the management of foreskin problems in adults and children in Gloucestershire.

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Red Flags

Acute Paraphimosis:

This happens when the narrow tip of the foreskin is retracted behind the glans at the coronal sulcus causing oedema of the glans and foreskin and inability to manipulate the foreskin back over the glans.

Early Reduction is essential. Initial attempts to reduce should be made in primary care. Compression should be applied to the glans penis for at least 10 mins prior to attempting reduction. If reduction is not possible then early referral to A & E is indicated. This does not require direct admission. It is rare for these cases to require an operation.

 

Penile Cancer

This is a rare condition. It usually presents over the age of 50 as a fungating lesion on the penis which increases in size and may bleed or itch. It may involve the foreskin and/or glans. There may be associated inguinal lymphadenopathy. The risk factors are smoking, age and HPV infection.  Refer via the 2ww Cancer Pathway

Presentation

Common foreskin conditions

Balanoposthitis: inflammation of the glans and foreskin.

Balanitis: inflammation of the glans that often spreads along the shaft and may occur in the circumcised population.

Posthitis: inflammation restricted to the foreskin itself.

Symptoms may include:

  • Local rash ­may be scaly or ulcerated
  • Dyspareunia and soreness
  • Itch
  • Odour
  • Inability to retract the foreskin
  • Discharge from the glans / behind the foreskin

Physiological phimosis (non-retractile healthy foreskin)

  • 50% of boys will have a non-retractile foreskin at 1 year
  • 8% of 6-7year olds will have a non-retractile foreskin.
  • 6% of 10-11 year olds will have a non-retractile foreskin
  • 1%of 16-17 year olds will have a non-retractile foreskin

Practice point:

Ballooning of the foreskin when voiding in children is physiological and not an indication for a circumcision.

Symptoms include:

  • Difficulty with urination
  • Pain upon urination
  • Blood in the urine
  • Pain in the penis

Pathological phimosis – Lichen Sclerosis (previously known as balanitis xerotica obliterans) is a lesion which causes true scarring of the foreskin -.

  • It is rare before the age of 5 years and presents with discomfort on voiding and white firm scarring of the foreskin tip.
  • Peak age 9-11 years.

Appearance: thickened/scarred/fissured/pale white patches/ no pouting of prepuce.

The aetiology is unknown but may be of viral origin. This condition may also affect the glans and urethra.

Practice Point

This is an absolute indication for circumcision.

Tight frenulum - the frenulum of the penis, which is an elastic band of tissue under the glans penis that connects to the foreskin and helps contract it over the glans, is too short and thus restricts the movement of the foreskin. It can be treated by a frenuloplasty

Hypospadias – The urethral meatus is sited on the ventral aspect of the penis between the glans and the perineum. Classically this is associated with a hooded foreskin and ventral chordee, causing curvature of the penis.

Practice Point

There is an association with undescended testis.

Congenital Megaprepuce

Capacious preputial sac, which engulfs the whole penile shaft and upper scrotum. Urine collects in foreskin and has to be milked out.

Differential Diagnosis
  • A constricting foreign body (usually a piece of hair wrapped around the penis, seen most often in infants); in adults it can occur with certain sexual practices.
  • Insect bites
  • Contact dermatitis
  • Infection
Initial Primary Care Assessment
  • Full history, including previous occurrences
  • Sexual history

Examination:

  • A full genital examination
  • Urinalysis to look for evidence of infection (if indicated) and to exclude glycosuria
Initial Primary Care Management

(balanitis, balanoposthitis, posthitis)

Treatment:

  • Simple bathing
  • Topical steroids and/or antibiotics.

  • Children <2 years of age: no treatment is needed, as most will spontaneously resolve
  • First-line treatment: a trial of a strong topical corticosteroid ointment or cream e.g.such as betamethasone 0.05% applied twice daily for a month
When to refer

Referral to Urology should be considered for circumcision for:

a. Children:

  • Phimosis secondary to lichen sclerosis (balanitis xerotica obliterans)
  • Recurrent balanoposthitis

b. Adults:

  • Lichen Sclerosis (Balanitis xerotica obliterans)
  • Scarred foreskin

Please see the GCCG Criteria Based Access policy for further information on referral criteria.

 

Referral to Urology for:

  • Hypospadias – many need urethroplasty with reconstruction.
  • Short penile frenulum – many need frenuloplasty.
Secondary Care Management

The vast majority of circumcisions are performed as day case procedures. A local anaesthetic, spinal anaesthetic or full general anaesthetic may be required. The entire foreskin is removed using an incision made behind the head of the penis and the skin of the shaft of the penis is stitched to the skin of the head of the penis using dissolvable stitches.

Routine follow up is not usually necessary.

The frenulum is divided to allow the foreskin to retract fully with diathermy and sutures used to control the bleeding from the frenular artery.
Ongoing Care

Advice to parents/carers of children:

  • In phimosis, do not forcibly retract the foreskin.
  • Penis hygiene:
    • gently wash the penis daily while bathing or showering using warm water
    • Regularly wash beneath the foreskin after gentle retraction
    • If soaps are used, use mild or non-perfumed products to reduce the risk of skin irritation
    • Avoid using talcs and deodorants on the penis because they may cause irritation
    • Circumcised men should also regularly clean their penis with warm water with or without a mild soap.
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