Paraphimosis
Background
- Retracted foreskin becomes trapped behind glans
- Acts as constricting band[1]
- May result in glans necrosis as venous engorgement leads to arterial compromise
- Urologic emergency
Clinical Features
- Penile pain
- Enlarged and erythematous glans[2]
- Constricting band immediately behind glans[3]
- Penile shaft flaccid[4]
- Pediatric patients may present with obstructive urinary symptoms[5]
Differential Diagnosis
Non-Traumatic penile diagnoses
Penile trauma types
Evaluation
- Typically a clinical diagnosis
Management
- Reduction
- Perform as soon as possible
- Consider penile block, local anesthetic cream (EMLA) or procedural sedation
Manual Reduction
- Wearing gloves, encircle the distal penis and apply circumferential pressure to reduce edema
- Maintain pressure for several minutes
- Release pressure and advance foreskin over glans
- Use thumbs to push glans toward foreskin while using fingers to pull foreskin over glans
Compressive Bandage Reduction
- Wearing gloves, wrap the distal penis in the distal to proximal direction with compressive bandage
- Leave bandage for several minutes to allow edema to disperse
- Remove bandage and advance foreskin over glans
- Use thumbs to push glans toward foreskin while using fingers to pull foreskin over glans
Adjunctive Therapies
- Apply ice packs in 3 minute intervals to reduce edema (monitor carefully for frostbite)
- Apply granulated sugar to distal penis as an osmotic agent
- Inject hyaluronidase into the swollen foreskin to decrease edema
- Apply several evenly-spaced, Babcock (non-crushing) clamps around foreskin
- Apply gentle traction on clamps to pull foreskin over glans
Reduction Failure
- If above techniques fail:
- Obtain emergent urology consult
- Proceed to Dundee aspiration or dorsal slit procedure if urology is not immediately available
Dundee Technique[6]
- Apply local anesthetic, perform a penile ring block, or sedate patient
- Prep the foreskin using antiseptic
- Use a 26 gauge needle to make approximately 20 puncture holes in the foreskin
- Use gentle manual pressure to express edema fluid from foreskin
- Advance the foreskin over the glans
- Use thumbs to push glans toward foreskin while using fingers to pull foreskin over glans
Dorsal Slit Procedure
- Dorsal Slit indicated if evidence of impaired perfusion and urologist unavailable
Disposition
- Refer all cases to urology to determine need for circumcision
See Also
References
- ↑ https://www.aafp.org/afp/2000/1215/p2623.html
- ↑ Choe, J. (2000). Paraphimosis: Current treatment options. American Family Physician, 62(12):2623-2626.
- ↑ Choe, J. (2000). Paraphimosis: Current treatment options. American Family Physician, 62(12):2623-2626.
- ↑ Choe, J. (2000). Paraphimosis: Current treatment options. American Family Physician, 62(12):2623-2626.
- ↑ Choe, J. (2000). Paraphimosis: Current treatment options. American Family Physician, 62(12):2623-2626.
- ↑ Reynard, J., and Barua, J. (1999). Reduction of paraphimosis the simple way - The Dundee technique. British Journal of Urology, 83(7):859-860.