Basics
Description
- The entrapment of the retracted foreskin proximal to the glans of the penis
- Leads to lymphatic congestion and venous obstruction, which may result in arterial compromise to the glans
- Paraphimosis is a urologic emergency.
Etiology
- A number of conditions of the foreskin may predispose to paraphimosis, including:
- Phimosis
- Inflammation
- Trauma
- Sexually naive may be unaware of the need to reduce foreskin after intercourse
- Commonly iatrogenic, from failure to replace the foreskin after exam, catheterization, or cleaning
Diagnosis
Signs and Symptoms
- Retracted prepuce (foreskin)
- Pain
- Swollen, edematous glans
- Local cellulitis
- Necrosis of glans in untreated cases
Physical Exam
Exam of the genitalia should include a search for constricting foreign bodies or constricting bands.
Essential Workup
- Paraphimosis is a clinical diagnosis with the clinical findings described earlier.
- Treatment must not be delayed pending diagnostic lab or radiographic studies.
Diagnosis Tests & Interpretation
Imaging
If history suggests penile foreign body, radiographs may be obtained once the vascular compromise has been relieved.
Differential Diagnosis
- Foreign bodies constricting the penile shaft may mimic paraphimosis; these include:
- Hair tourniquets
- Wire, string, or other materials used for sexual enhancement or punishment
- Balanoposthitis
- Trauma (zipper injuries)
- Acute idiopathic penile edema
Treatment
Pre-Hospital
- Patients should be transported promptly; do not attempt reduction in the field.
- Pre-hospital personnel can be advised to apply an ice pack to the glans with adequate protection of the skin.
- Pain control
Initial Stabilization/Therapy
- Ice can be applied to the glans while preparing to reduce the prepuce:
- Use the thumb of a glove as an ice-filled condom to aid in direct application.
- The incarcerated foreskin must be released as soon as possible to prevent ischemia and necrosis of the glans.
- The pain associated with reduction techniques must be managed with some combination of conscious sedation, adequate analgesia, and local anesthesia.
Ed Treatment/Procedures
- Medical therapy for paraphimosis involves reassuring the patient, reducing the preputial edema, and restoring the prepuce to its original position and condition.
- The following sequence of procedures should be followed:
- Paraphimosis can most frequently be reduced using a penile block and compressing the glans manually while applying traction on the foreskin.
- Penile block is performed by infiltrating 5 mL of 1% lidocaine without epinephrine in the angle between the inferior rami of the symphysis pubis:
- Then use another 5 mL to infiltrate a wheel along the sides of the penis.
- This produces a block after 5 min.
- Successful reduction requires steady circumferential pressure on the distal edema with simultaneous manual reduction of the foreskin.
- In children, conscious sedation is usually required.
- If manual reduction is unsuccessful, then the technique of multiple punctures may facilitate reduction:
- Make ¢ ¼20 holes in the swollen foreskin with a small sterile needle (26G), allowing expression of edema fluid, then resume manual reduction.
- If this fails to return the foreskin to its original position, it will be necessary to incise the constricting ring of tissue with a dorsal longitudinal slit in the foreskin after sterile preparation:
- If the incision made is too long, after reduction it may be necessary to suture the incision transversely with 3.0 absorbable sutures.
- If a delay is likely before the paraphimosis can be treated (e.g., NPO status), then applying a gauze swab soaked in 50% dextrose will reduce edema by osmosis and facilitate reduction.
- For patients who want to retain uncircumcised phallus steroid therapy can be attempted to reduce fibrose ring. Consult urology for close follow-up:
- Triamcinolone cream 0.1% to affected area 6 wk
- If unsuccessful, circumcision may still be required.
Medication
- Appropriate analgesics or anesthetics as required
- Antibiotics generally not required unless treating associated cellulitis or balanoposthitis.
Follow-Up
Disposition
Admission Criteria
Necrosis or cellulitis of the penis
Discharge Criteria
- Successful reduction with relief of symptoms
- Close urologic follow-up
Issues for Referral
- Urologic consultation is required.
- Subsequent circumcision to prevent recurrence is an area of clinical debate; historically, it has been common practice.
Follow-Up Recommendations
- Education regarding importance of replacement of the foreskin after retraction for instrumentation or cleaning
- Emphasis on prepuce hygiene
Pearls and Pitfalls
- Goal is to reduce penile edema enough to allow the foreskin to return to original position over the glans.
- Generally, noninvasive reduction methods (at least 2 or 3 attempts) are successful and dorsal slit incision is mostly required only in severe cases.
Additional Reading
- Donohoe JM, Burnette JO, Brown JA. Paraphimosis treatment. eMedicine. Available at http://www.emedicine.medscape.com/article/442883. Updated October 7, 2009.
- Ghory HZ, Sharma R. Phimosis and paraphimosis. eMedicine. Available at http://www.emedicine.medscape.com/article/777539. Updated April 28, 2010.
- Huang CJ. Problems of the foreskin and glans penis. Clin Pediatr Emerg Med. 2009;10:56 " 59.
- Marx JA, Hockberger RS, Walls RM. Rosens Emergency Medicine: Concepts and Clinical Practice, 7th ed. St. Louis, MO: Mosby; 2009:2201 " 2202.
- Ramos-Fernandez MR, Medero-Colon R, Mendez-Carreno L. Critical urologic skills and procedures in the emergency department. Emerg Med Clin North Am. 2013;31(1):237 " 260.
See Also (Topic, Algorithm, Electronic Media Element)
Codes
ICD9
605 Redundant prepuce and phimosis
ICD10
N47.2 Paraphimosis
SNOMED
- 13758004 paraphimosis (disorder)