In sub-Saharan Africa, symptoms of phimosis can include difficulty retracting the foreskin, pain during urination or sexual activity, and recurrent infections such as balanitis. Swelling, redness, and discharge from the foreskin may also occur. Severe cases can lead to urinary retention or obstructed urine flow. In young children, physiological phimosis is usually asymptomatic, whereas pathological phimosis in adults often results from underlying infections or poor hygiene. Limited access to healthcare may exacerbate these symptoms and delay appropriate treatment.

Clinical findings of phimosis include:

1. Inability to Retract Foreskin: The primary finding is the inability to retract the foreskin over the glans penis, which may be partial or complete.
2. Ballooning of the Foreskin: During urination, the foreskin may balloon due to trapped urine.
3. Scarring and Tightness: Visible fibrosis or scarring of the foreskin, often with a whitish ring at the tip, indicating pathological phimosis.
4. Signs of Infection: Redness, swelling, discharge, and tenderness of the foreskin and glans, indicative of balanitis or balanoposthitis.
5. Pain and Discomfort: Pain during urination, erections, or sexual activity due to the tight foreskin.

The differential diagnoses of phimosis in sub-Saharan Africa include:

1. Balanitis: Inflammation of the glans penis, often accompanied by redness, swelling, and discharge, which can also cause difficulty retracting the foreskin.
2. Balanitis Xerotica Obliterans (BXO): A chronic inflammatory condition causing scarring and fibrosis of the foreskin and glans, leading to a tight, non-retractable foreskin.
3. Paraphimosis: A condition where the retracted foreskin cannot be returned to its normal position, causing swelling and pain.
4. Penile Cancer: Rare but serious, presenting as a mass or ulceration on the penis, which can cause phimosis due to tissue changes.
5. Sexually Transmitted Infections (STIs): Infections like herpes or syphilis causing lesions, swelling, and discomfort, which may mimic or lead to secondary phimosis.

The most important investigations for phimosis in sub-Saharan Africa include:

1. Clinical Examination: Thorough physical examination of the foreskin and glans to assess the severity, presence of scarring, and any signs of infection or underlying conditions.
2. Urinalysis: To detect urinary tract infections or other abnormalities in the urine that might contribute to symptoms.
3. Swab and Culture: If there is discharge, swabs can be taken for microbiological culture to identify bacterial or fungal infections, guiding appropriate antimicrobial treatment.
4. Blood Tests: Screening for sexually transmitted 8infections (STIs), including HIV, which can influence the management and prognosis of phimosis.
5. Biopsy: In cases where there is suspicion of balanitis xerotica obliterans (BXO) or penile cancer, a biopsy may be necessary to confirm the diagnosis and guide further treatment.

The physiologic form of phimosis is often seen in children (of course, the uncircumcised) between 2 and 4 years of age. It requires no treatment and is self-limiting.

Though conservative treatment is an option in pathological phimosis, the surgical procedure of circumcision is the gold standard treatment of the condition. Circumcision is only absolutely indicated for pathological phimosis in children.

Treatment of phimosis includes non-surgical and surgical options. 

Non-surgical treatments involve topical corticosteroids and gentle stretching exercises to increase foreskin elasticity, along with improved hygiene practices. 

Surgical treatments include circumcision, the complete removal of the foreskin, and preputioplasty, a less invasive procedure to widen the foreskin while preserving it. 

In sub-Saharan Africa, limited healthcare access and cultural factors influence treatment availability and acceptance. Public health initiatives and education can help improve management and outcomes.

Follow-up for phimosis in sub-Saharan Africa involves regular monitoring to assess treatment effectiveness, hygiene education to prevent recurrence, and management of underlying conditions like infections. Community health programs and mobile clinics can improve access to follow-up care, especially in rural areas. Culturally sensitive engagement with community leaders enhances patient compliance and outcomes. Comprehensive follow-up combines medical care, education, and community support to ensure effective management and prevention of phimosis.

Preventing phimosis involves maintaining good hygiene, avoiding forceful retraction of the foreskin, addressing infections early, and educating caregivers on proper care. In some cases, circumcision may be considered as a preventive measure.