Phimosis

Template

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DiagnosisChoose oneTitle

ReviewedChoose any

ExamChoose any

AssessmentChoose one

Associated findings presentChoose any

Associated findings absentChoose any

BallooningChoose any

Treatment decisionChoose one

CareChoose any

ReferralChoose one

Follow-upChoose one

Counseling paragraphChoose oneParagraph

Note when inserted as is

Physiologic phimosis
• Foreskin retractability, ballooning, pain, infections, voiding, scarring, and prior forced retraction reviewed
• Meatus visible through the foreskin opening with a normal stream
• Nonretractable foreskin without scarring, consistent with physiologic phimosis
• No urinary infections, trouble voiding, or prior paraphimosis
• No treatment needed; the foreskin separates on its own over years
• Discussed gentle hygiene and avoiding forced retraction
• Follow up as needed

The foreskin normally stays attached to the head of the penis in young children and separates gradually, often not until school age or puberty, and ballooning while urinating is normal. Recommended supportive care with an emphasis on rinsing with warm water and never forcing the foreskin back, which can cause tearing and scarring. Return precautions given including a foreskin stuck behind the head of the penis, trouble urinating, red or swollen foreskin, pain, fever, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

What the sources cover

Title physiologic vs pathologic
Physiologic; scarring (lichen sclerosus); symptomatic
Ballooning is normal
No treatment; Triamcinolone or Betamethasone with stretching
Gentle hygiene, no forced retraction
Urology referral with reasons

Return precautions in the template

a foreskin stuck behind the head of the penistrouble urinatingred or swollen foreskinpainfever

Sources

Few formal guidelines cover this topic, so the template also leans on expert opinion.