Pediatric emergency medicine trisk 3860 3860

Clinical Recognition. A tight phimosis can result in ballooning of the foreskin
during voiding, which in turn traps urine and can lead to inflammation. In a child
over 2 years old, the foreskin should be able to be retracted to the point where the
urethral meatus can be visualized.
Paraphimosis is evident as a broad, edematous band of skin proximal to the
glans. This skin is often erythematous and very tender to touch.
Management. Phimosis does not have to be treated emergently. Betamethasone
cream, 0.05%, applied twice daily for 6 weeks, is the first-line treatment.
Hydrocortisone cream is an alternative. The patient/family must be instructed to
pull the foreskin back as far as it will go, then to apply a small amount directly to
the tightened area.
The goal in paraphimosis is to bring the foreskin back into normal location.
This requires reduction of the edema in the skin. The application of ice and steady
manual compression on the inflamed ring of foreskin usually reduces the edema
and permits manual reduction of the paraphimosis. Topical anesthetic cream or a
dorsal penile nerve block will reduce the discomfort experienced by the child
during compression of the edematous foreskin. Once a portion of the edema has
been reduced, pressure on the glans (like turning a sock inside out) usually
permits reduction of the foreskin back to its normal position. If manual reduction
fails, a surgical division of the foreskin to permit reduction is indicated; however
it is uncommon to need to perform this. The family should be counseled not to
pull the foreskin back over the glans for at least a week. Vaseline can be applied
to the raw edges of the foreskin, especially in the setting of small abrasions, to
prevent infection. The family can be counseled about circumcision, although this
is not required.