Paraphimosis


Article Author:
Bradley Bragg


Article Editor:
Stephen Leslie


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
5/5/2019 11:39:35 PM

Introduction

Paraphimosis is a true urologic emergency which occurs in uncircumcised males when the foreskin becomes trapped behind the corona of the glans penis which can lead to strangulation of the glans as well as painful vascular compromise, distal venous engorgement, edema, and even necrosis. Phimosis, by comparison, is the condition when the foreskin is unable to be retracted behind the glans of the penis.[1]

Etiology

Paraphimosis commonly occurs iatrogenically, when the foreskin is retracted for cleaning, placement of a urinary catheter, a procedure such as a cystoscopy, or for penile examination.[1] Failure to return the retracted foreskin over the glans promptly after the initial retraction can lead to paraphimosis. Other, less common causes include penile coital trauma and self-inflicted injuries.

Epidemiology

In uncircumcised children, four months to 12 years old, with foreskin problems, paraphimosis (0.2%) is less common than other penile disorders such as balanitis (5.9%), irritation (3.6%), penile adhesions (1.5%), or phimosis (2.6%).[2]

In adults, paraphimosis most commonly is found in adolescents. It will occur in about 1% of all adult males over 16 years of age.

Pathophysiology

If a constricting band of the foreskin is allowed to remain retracted behind the glans penis for a prolonged period, this can lead to impairment of distal venous and lymphatic drainage as well as decreased arterial blood flow to the glans. Arterial blood flow can become affected over the course of hours to days. This change can ultimately lead to marked ischemia and potential necrosis of the glans.[3]

Histopathology

At birth, there is normal physiologic phimosis due to natural adhesions between the glans and the foreskin. During the first 3 to 4 years of life, debris, such as shed skin cells, accumulates under the foreskin, gradually separating it from the glans. Intermittent penile erectile activity, such as nocturnal erections, also contribute to the increased mobility of the foreskin, ultimately allowing it to become completely retractible.

History and Physical

When evaluating a patient with paraphimosis, a pertinent history is important. This history should include any recent penile catheterizations, instrumentation, cleaning or other procedures. [1]  The patient should be asked about his routine cleaning of the penis and if he or a caregiver routinely retract the foreskin for any reason. It is also important to ask if the patient is circumcised or uncircumcised. It is still possible to develop paraphimosis in a patient who has previously been circumcised. This can be due to the patient believing he was circumcised when he was not or excessive remaining foreskin despite the circumcision.

Typical paraphimosis symptoms include erythema, pain, and swelling of foreskin and glans due to the constricting ring of the phimotic foreskin.

The history usually makes the diagnosis, but if not, it will be obvious on direct physical examination. The physical exam should focus on the penis, foreskin, and urethral catheter (if present). A pink color to the glans is indicative of reasonably good blood supply; whereas a dark, dusky or black color implies possible ischemia or necrosis.

If a urinary catheter is in place, removing the catheter may aid in the reduction of the paraphimosis. After reduction, the indication for the catheter should be reviewed, and the catheter should be replaced if necessary.[1]

Evaluation

The patient typically presents with acute, distal, penile pain and swelling, but the pain is not always present. The glans and foreskin typically are markedly enlarged and congested, but the proximal penile shaft is flaccid and unremarkable. A tight band of constrictive tissue is present, often preventing easy manual reduction of the foreskin over the glans. Diagnosis is made clinically by direct visualization as well as the inability to easily reduce the retracted foreskin manually.

Treatment / Management

Mild, uncomplicated paraphimosis may be reduced manually, usually without the need for sedation or analgesia. More difficult or complicated cases may require local anesthesia with a dorsal penile block, systemic analgesia, or procedural sedation.

Several methods of reduction are available and can be classified into manual reduction or surgical repair. 

Manual, non-surgical, reduction of the paraphimosis can be done with or without compression methods, by osmotic agents, and using puncture-aspiration techniques.

Manual reduction of paraphimosis can often be facilitated by simple compression of the glans and the swollen, edematous foreskin for several minutes before attempting the reduction. This allows the edematous swelling of the retracted foreskin to diminish before attempting repositioning of the foreskin to its usual position. One simple method involves manually compressing the edematous foreskin while pulling slowly upward on the phallus.

Manual reduction can also be attempted by placing both thumbs over the glans with both index and long fingers surrounding the trapped foreskin. Then slow, steady pressure is applied to advance the phimotic portion of the foreskin outwards slowly, back over the glans. This can be facilitated with a little lubricant. Excessive lubricant should be avoided as it may make the skin too slippery for reliable grasping.[4]

Another compression technique involves tightly wrapping the swollen portion of the penis from the glans towards the base with a 1-inch or 2-inch elastic bandage. A gauze pad should be applied first around the edematous foreskin. The compression bandage can remain for 10 to 20 minutes to minimize the edema. Then apply one of the manual reduction methods described above. This is often a preferred technique as the elastic wrap can be placed by nursing staff while you are traveling to the patient's location.[5]

Ice packs or surgical gloves filled with ice and applied to edematous areas have been described as possibly being useful in conjunction with other methods to aid in the reduction of the paraphimotic swelling.  However, since the main issue in paraphimosis is distal penile vascular compromise from a constricting fibrous band of the phimotic foreskin, many experts recommend against using ice in these situations as it may further compromise arterial inflow to the possibly ischemic portion of the penis.

Another possible compressive treatment method involves cutting the thumb from a surgical glove to make a "sleeve" and emptying a tube of EMLA cream (2.5% lidocaine and 2.5% prilocaine; AstraZeneca, London, UK) or similar into the sleeve. This is then placed over the penis and left for approximately 30 minutes. This allows for local anesthesia and softening of affected skin to aid in foreskin reduction.  However, while it does provide some analgesic relief, it may make the skin a little more slippery and harder to manipulate.[6]

Reducing the penile edema from paraphimosis can also be achieved by the injection of hyaluronidase directly into the edematous foreskin.  This has been effective, particularly in children and infants, in resolving the edema which then allows for easier manual reduction of the paraphimosis. The hyaluronidase increases the diffusion of trapped fluid within the tissue planes of the malpositioned foreskin which reduces the swelling and edema.[7]

Osmotic methods involve the application of substances with a high solute concentration on the external skin surfaces of the edematous tissue. This would tend to draw water along an osmotic gradient and thereby reduce the edema. For example, a generous topical application of granulated sugar to the affected glans and foreskin has been shown to be effective in aiding in the reduction of the edema from paraphimosis.[8]

Gauze soaked in 20% mannitol solution has also been used as an osmotic agent to reduce the edema from paraphimosis. The gauze is left in place for 30 to 45 minutes and has been reported to completely eradicate the troublesome edema allowing for easy resolution of the paraphimosis with manual techniques as described above. This technique is relatively painless and is well suited for children.[9]

In many cases, no additional local anesthetic or analgesia is needed, but if the paraphimosis is long-standing, extremely painful, or severe, then a formal penile anesthetic block can be used. A dorsal penile block is performed by using a 25-gauge or 27-gauge needle, infiltrating approximately 2.5 mL of 1% lidocaine without epinephrine into the base of the penis at the junction of the penis and suprapubic skin at the 10 o'clock position, off the midline to avoid the superficial dorsal vein. Another 2.5 mL is injected at the 2 o'clock position. Inject the lidocaine just deep to Buck's fascia, approximately 3 mm to 5 mm beneath the skin, ensuring negative aspiration of blood before injecting. Ultrasound guidance has been shown to be effective in helping to identify landmarks for this procedure.[10]

Puncture and aspiration methods are more invasive and should be reserved for cases refractory to other less-invasive techniques. The puncture technique involves puncturing the edematous foreskin several times with a hypodermic needle followed by manual expression of edematous fluid through the puncture holes. Experienced emergency practitioners can consider penile corporal aspiration of blood.

Surgical treatment of the paraphimosis will be required if the previously described manual reduction methods are unsuccessful. Prepare the penis and prepuce with a povidone-iodine or similar antiseptic solution. This can be achieved after the previously-described penile block. One method involves applying two straight hemostats to grab the dorsum of the constricting foreskin at the 12 o'clock position. This is followed by making a 1 cm to 2 cm longitudinal incision of the constricting band of edematous foreskin between the hemostats, which allows for passage over the glans. After reduction, the incised foreskin is not reapproximated, but the edges are oversown with a 3-0 or 4-0 absorbable suture. This will leave the phimotic portion of the foreskin widely separate and open to prevent recurrences.

Pearls and Other Issues

After successful manual reduction, the foreskin should carefully be cleaned. Any superficial abrasions or tears to the foreskin should be treated with a topical antibiotic ointment such as bacitracin. Patients should be instructed to avoid retracting the foreskin for one week and avoid any offending activities that contributed to the paraphimosis.

Reducing the paraphimosis successfully is insufficient long-term therapy. All such patients should be evaluated for further treatment involving a dorsal slit or circumcision procedure to definitively deal with the tightened foreskin and permanently prevent any recurrences of the paraphimosis.

Enhancing Healthcare Team Outcomes

Paraphimosis is a urological emergency that is best managed by a multidisciplinary team that includes a pediatrician, emergency department physician, urologist, nurse specialist, and a surgeon. Mild cases may be reduced manually but more complex cases usually require some type of anesthesia.

After a successful manual reduction, the foreskin should carefully be cleaned. Any superficial abrasions or tears to the foreskin should be treated with a topical antibiotic ointment such as bacitracin. Patients should be instructed to avoid retracting the foreskin for one week and avoid any offending activities that contributed to the paraphimosis.

Reducing the paraphimosis successfully is insufficient long-term therapy. All such patients should be evaluated for further treatment involving a dorsal slit or circumcision procedure to definitively deal with the tightened foreskin and permanently prevent any recurrences of the paraphimosis.


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Paraphimosis - Questions

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Which of the following is a urological emergency?



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A 17 year old male presents to the emergency room with penile pain. The foreskin is retracted but cannot be reduced. What is the diagnosis?



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Which of the following is considered a urological emergency?



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Which of the following is an emergency, requiring immediate treatment?



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A 3-year-old boy is brought in with penile pain. On exam, he has a tight, swollen foreskin retracted behind the glans penis and the mother has been unable to place the foreskin back over the head of the penis in a normal position. What condition does this describe?



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Paraphimosis - References

References

Prepuce: phimosis, paraphimosis, and circumcision., Hayashi Y,Kojima Y,Mizuno K,Kohri K,, TheScientificWorldJournal, 2011 Feb 3     [PubMed]
Reduction of paraphimosis in children: the EMLA® glove technique., Khan A,Riaz A,Rogawski KM,, Annals of the Royal College of Surgeons of England, 2014 Mar     [PubMed]
Paraphimosis: current treatment options., Choe JM,, American family physician, 2000 Dec 15     [PubMed]
Ultrasound-guided dorsal penile nerve block for ED paraphimosis reduction., Flores S,Herring AA,, The American journal of emergency medicine, 2015 Jun     [PubMed]
The frequency of foreskin problems in uncircumcised children., Herzog LW,Alvarez SR,, American journal of diseases of children (1960), 1986 Mar     [PubMed]
Mannitol for paraphimosis reduction., Anand A,Kapoor S,, Urologia internationalis, 2013     [PubMed]
Glans penis necrosis following paraphimosis: A rare case with brief literature review., Palmisano F,Gadda F,Spinelli MG,Montanari E,, Urology case reports, 2018 Jan     [PubMed]
Pohlman GD,Phillips JM,Wilcox DT, Simple method of paraphimosis reduction revisited: point of technique and review of the literature. Journal of pediatric urology. 2013 Feb     [PubMed]
Cahill D,Rane A, Reduction of paraphimosis with granulated sugar. BJU international. 1999 Feb     [PubMed]
Manjunath AS,Hofer MD, Urologic Emergencies. The Medical clinics of North America. 2018 Mar     [PubMed]

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