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Paraphimosis, Emergency Medicine

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Paraphimosis, Emergency Medicine

Basics

Description

Exam of the genitalia should include a search for constricting foreign bodies or constricting bands.

If history suggests penile foreign body, radiographs may be obtained once the vascular compromise has been relieved.

605 Redundant prepuce and phimosis

  • 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:PhimosisInflammationTraumaSexually 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
  • Phimosis
  • Inflammation
  • Trauma
  • Sexually naive may be unaware of the need to reduce foreskin after intercourse

Diagnosis

Signs and Symptoms

  • Retracted prepuce (foreskin)
  • Pain
  • Swollen, edematous glans
  • Local cellulitis
  • Necrosis of glans in untreated cases

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

Differential Diagnosis

  • Foreign bodies constricting the penile shaft may mimic paraphimosis; these include:Hair tourniquetsWire, string, or other materials used for sexual enhancement or punishment
  • Balanoposthitis
  • Trauma (zipper injuries)
  • Acute idiopathic penile edema
  • Hair tourniquets
  • Wire, string, or other materials used for sexual enhancement or punishment

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.
  • Use the thumb of a glove as an ice-filled condom to aid in direct application.

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 ¢ ˆ 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 ƒ — 6 wkIf unsuccessful, circumcision may still be required.
  • 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 ¢ ˆ 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.
  • Then use another 5 mL to infiltrate a wheel along the sides of the penis.
  • This produces a block after 5 min.
  • Make ¢ ˆ ¼20 holes in the swollen foreskin with a small sterile needle (26G), allowing expression of edema fluid, then resume manual reduction.
  • If the incision made is too long, after reduction it may be necessary to suture the incision transversely with 3.0 absorbable sutures.
  • Triamcinolone cream 0.1% to affected area ƒ — 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

  • Successful reduction with relief of symptoms
  • Close urologic follow-up
  • 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)

  • Phimosis
  • Priapism

Codes

ICD9

ICD10

SNOMED

  • 13758004 paraphimosis (disorder)