Approach

Management of congenital (physiological) phimosis is expectant until the age of puberty (typically around 12 years of age). Parents and patients should be counselled on good hygiene practices and avoidance of forcible preputial retraction.[42]​ After puberty, definitive treatment (e.g., topical corticosteroid cream or circumcision) may be recommended.[11]​

Paraphimosis is a urological emergency. If the foreskin is not immediately reducible by manual technique (or other conservative therapeutic measure), paraphimosis requires surgical intervention to release the constricting foreskin.

Surgery should be discussed as an option for patients with hypospadias and congenital penile curvature >30 degrees.

Concealed penis usually resolves over time as children age and pre-pubertal fat recedes. If concealed penis persists into puberty or adulthood, treatment may include weight loss or phalloplasty. In severe cases, earlier surgical intervention may be appropriate.

Phimosis

Expectant management for congenital (physiological) phimosis is preferred up to the time of puberty (typically around 12 years of age).[11][46]​​​

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.[42]

Persistent phimosis

Phimosis persisting after puberty and into adulthood is generally treated with topical corticosteroid.[11][47][48][49]​​​​ Results from one systematic review (that included adolescents up to age 17 years) indicate that topical corticosteroid may resolve phimosis (low-quality evidence).[50]​

Acquired or pathological phimosis (e.g., cicatrix or balanitis xerotica obliterans [BXO] / lichen sclerosis) requires treatment regardless of age.

Phimosis: indications for surgery

Patients with phimosis who do not respond to or cannot tolerate a course of properly applied topical corticosteroid are managed with circumcision.[11][35]​​​ If the patient or carer wishes to avoid the cosmetic effect of circumcision but needs surgical intervention, they may be offered a preputioplasty.[11]​

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 standard circumcision.[51][52]

Paraphimosis

Paraphimosis should be managed with immediate manual reduction. The goal of treatment is prompt reduction of the foreskin to its normal anatomical position (distal to the glans penis).

To perform manual reduction, adequate anaesthesia is administered in the form of dorsal penile nerve block or ring block with local anaesthetic. Children may require conscious sedation and/or general anaesthesia. Circumferential pressure around the oedematous ring of foreskin for several minutes may help to reduce the oedema. 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 anatomical position.[53] Water-based lubrication may facilitate preputial reduction.[54]​

Paraphimosis: difficulty with manual reduction

Several therapeutic measures can be considered if manual reduction is difficult. Compression wrap, application of granulated sugar, hyaluronidase injection, and puncture technique are options.[55]​ However, reduction of the paraphimotic prepuce is a surgical emergency, and additional therapeutic measures may require time to be effective.

Applying granulated sugar to the area of oedema, or wrapping a glucose-soaked gauze around the penis for 10 to 20 minutes before attempted manual reduction, may help to extract some of the oedema by osmosis.[56] Note that in some cases topical administration of granulated sugar may take 1 to 2 hours to be effective.[53][57]​​​​​​

Needle puncture may be employed if paraphimosis cannot be treated with more conservative measures.[52]​ Pressure is applied following needle puncture to facilitate reduction of oedema before manual reduction is attempted.[58] Injection of hyaluronidase into the oedematous tissue may break down hyaluronic acid and its subsequent osmotic gradient.[52][59]​​

Wrapping the phallus with a tight bandage may help to reduce oedema.[60]​ Autoreduction of the foreskin has been reported, but manual reduction may be required when the compression wrap is removed.

If conservative measures fail, definitive management in terms of either dorsal slit or circumcision may be performed.[33][Figure caption and citation for the preceding image starts]: ParaphimosisFrom the collection of Nicol Corbin Bush, MD [Citation ends].com.bmj.content.model.Caption@4d768b9c

Hypospadias

Although some minor forms of hypospadias do not require surgical intervention, infants with hypospadias should be referred to a specialist for further evaluation to determine the severity of the condition. The goals of treatment are to restore normal urinary function, sexual function, and cosmesis.

Surgical intervention can be performed in most patients on an outpatient basis as early as 3 months of age.[61] The patient may need a postoperative urethral stent for up to 2 weeks after surgery depending upon the complexity of the repair.

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.[62]

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 urological evaluation thereafter.[63]

Not all patients with hypospadias will benefit from preoperative administration of topical oestrogen or testosterone, and use of topical corticosteroids should be considered for each individual patient.[64][65][66][67]

Congenital penile curvature and/or torsion

Surgery to straighten the penis should be offered for congenital penile curvature >30 degrees or torsion >90 degrees. This can be done in conjunction with a circumcision or with foreskin preservation.

Surgery for curvature can be deferred until after puberty.[68]

Concealed penis

Need for, and timing of, management for concealed penis remains controversial. Although some advocate early intervention, most paediatric urologists feel that observation may be warranted up until the age of toilet training (2-3 years of age).[1][69]​ In this age group, re-distribution of body fat often leads to spontaneous resolution of the buried penis.

If resolution has not occurred by 3 years of age, improvement without surgical intervention is unlikely. 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. In cases of concealed penis related to trauma or postoperative scarring, surgery is also indicated.

Older boys and adults with concealed penis are unlikely to have spontaneous resolution. Weight loss is recommended primarily, with urological 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. Several operative techniques have been described, although treatment preferences vary among patient populations and surgeons.[1][4][25][26][32][33][41][59][Figure caption and citation for the preceding image starts]: Congenital buried penisFrom the collection of Nicol Corbin Bush, MD [Citation ends].com.bmj.content.model.Caption@6d805104[Figure caption and citation for the preceding image starts]: Congenital buried penis: abundant inner preputial skin with paucity of shaft skinFrom the collection of Nicol Corbin Bush, MD [Citation ends].com.bmj.content.model.Caption@2223ff79[Figure caption and citation for the preceding image starts]: Congenital buried penisFrom the collection of Warren T. Snodgrass, MD [Citation ends].com.bmj.content.model.Caption@4636b7c4[Figure caption and citation for the preceding image starts]: Repaired congenital buried penis (with bilateral hernia repair and scrotoplasty)From the collection of Warren T. Snodgrass, MD [Citation ends].com.bmj.content.model.Caption@6e17c0f4

Micropenis

In true cases of micropenis (stretched penile length that is 2.5 or more standard deviations less than the mean for age), endocrine evaluation by a specialist is recommended.[45]

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