PassFinals
Sexual Health

Phimosis and Paraphimosis

Phimosis is a foreskin that cannot be retracted over the glans; paraphimosis is a retracted foreskin trapped behind the glans and is a urological emergency because its constricting ring can cause progressive oedema and ischaemia.

In a nutshell

Phimosis is inability to retract the foreskin; paraphimosis is a retracted foreskin trapped behind the glans. Normal childhood non-retractility needs reassurance and no forced retraction. Symptomatic or scarred phimosis needs clinician-directed topical treatment and possible urology referral. Paraphimosis is an emergency: provide analgesia and urgent manual reduction by a trained clinician, escalating immediately to surgery if reduction fails or perfusion is threatened.

Classic presentation

A person with a penis develops a painful swollen or dusky glans with a tight ring of retracted foreskin behind it after examination or catheterisation. This is paraphimosis and needs urgent reduction.

Key points

  • A non-retractile foreskin in a young boy can be normal; do not force retraction.
  • Acquired scarring, a white ring, recurrent inflammation, pain or urinary difficulty suggests pathological phimosis.
  • Paraphimosis is an emergency because the trapped foreskin can compromise glans blood flow.
  • Manual reduction requires analgesia, oedema reduction and a trained clinician; failed reduction needs urgent urology.
  • Always replace the foreskin after examination or catheterisation.
  • Persistent atypical lesions, especially with lichen sclerosus, need assessment for PeIN or penile cancer.

First-line investigation

Clinical examination of the foreskin and glans with assessment of perfusion, urinary function and cause; use targeted infection tests, glucose assessment or biopsy only when indicated.

Management

Reduce paraphimosis now

  • Treat paraphimosis as a urological emergency, provide analgesia or local anaesthesia and obtain urgent senior help for manual reduction; failed reduction or threatened perfusion needs immediate surgical escalation.1,4,3

Separate normal childhood development from disease

  • Reassure about asymptomatic childhood non-retractility and never force the foreskin back; symptoms, scarring, recurrent inflammation or urinary difficulty require assessment.1,3

Treat symptomatic or scarred phimosis

  • Use clinician-directed topical corticosteroid treatment for symptomatic disease; established lichen-sclerosus scarring, refractory symptoms or recurrent disease may require urology and circumcision.3,5,8,2

Escalate obstruction and suspicious lesions

  • Urinary retention is an acute urological problem, and persistent ulceration, mass, bleeding or induration needs senior urology or penile-cancer assessment rather than repeated empirical treatment.4,6

Prevent recurrence and review the cause

  • Replace the foreskin after every procedure, review recurrent balanitis or diabetes risk, and arrange follow-up for lichen sclerosus, meatal symptoms, recurrent paraphimosis or functional concerns.1,5,8

Exam traps

  • Do not forcibly retract a child's foreskin; this can cause injury and scarring.
  • Paraphimosis is not ordinary phimosis: the foreskin is retracted and trapped behind the glans.
  • Do not delay reduction for tests when the glans is swollen or dusky.
  • A normal childhood foreskin does not need circumcision; BXO, refractory symptomatic disease and selected urinary-risk situations are different.
  • Do not forcefully stretch a scarred foreskin.
  • A persistent ulcer, mass or indurated lesion needs cancer assessment even if balanitis or lichen sclerosus is present.

Illustrations

Paraphimosis with an oedematous glansA clinical photograph showing retracted foreskin trapped behind a swollen congested glans by a tight constricting preputial band, the characteristic appearance of paraphimosis.Drvgaikwad, Wikimedia Commons · CC-BY-3.0
Lichen sclerosus of the foreskinA clinical photograph of a white, fibrotic, scarred preputial ring due to lichen sclerosus causing pathological phimosis.Schakal1, Wikimedia Commons · CC-BY-4.0

Key sources

  1. NHS, Tight foreskin (phimosis) (Current NHS information on physiological childhood non-retractility, symptoms, treatment and paraphimosis emergency advice; last reviewed 6 March 2026)Published 6 Mar 2026
  2. BAUS, Tight foreskin (phimosis) (BAUS patient information on adult scarring, conservative measures, steroid treatment and surgical options; page dated March 2024 and due for review August 2026)Published 1 Mar 2024
  3. EAU Paediatric Urology Guideline, 2026 (Current specialist guideline used for symptomatic childhood phimosis, BXO, paediatric contraindications and paraphimosis reduction; international source used where no equally complete UK paediatric guideline was identified)
  4. BAUS, Balanitis and foreskin conditions (Current clinician-facing BAUS guidance on emergency paraphimosis reduction, phimosis assessment and escalation; accessed 4 August 2026)
  5. BASHH, National guideline on the management of balanoposthitis and related penile skin conditions, 2026 (Current UK sexual-health guideline covering structured assessment, targeted tests, lichen sclerosus recognition, topical steroid advice, biopsy and specialist referral; published 2026)
  6. NICE NG12, Suspected cancer: recognition and referral (Current NICE penile-cancer referral recommendations used for persistent or suspicious lesions under the foreskin)Published 23 Jun 2015
  7. NHS, Balanitis (Current NHS information on balanitis, infection assessment and when recurrent or treatment-resistant disease needs further review; next review due 30 May 2026)
  8. British Association of Dermatologists, Guidelines for the management of lichen sclerosus (UK dermatology guideline covering male genital lichen sclerosus, ultrapotent topical steroid treatment and urology referral for steroid-resistant phimosis; published 2018)Published 1 Apr 2018
  9. BNF, topical corticosteroids (Current UK prescribing cross-check for topical corticosteroid potency, application, cautions and monitoring; access to detailed BNF content is restricted in this environment)
  10. BNF, current antimicrobial prescribing information (Current UK prescribing cross-check for treatment of confirmed infective balanoposthitis; no unsupported regimen is reproduced here)
  11. NHS, Circumcision (Current NHS information on medical indications, recovery and complications of circumcision)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.