II. Definitions
- Paraphimosis
- Foreskin stuck in retracted position
- Emergency condition due to Compartment Syndrome and risk of vascular compromise
- Contrast with the benign Phimosis in which the foreskin cannot be retracted
III. Pathophysiology
- Foreskin forms tight circumferential band around base of glans penis
- Strangulates glans penis and obstructs arterial Blood Flow
- Necrosis of glans penis results if Paraphimosis not treated emergently
IV. Causes
- Forceful retraction of foreskin in infants
- Chronic Balanitis
- Indwelling catheter
V. Signs
- Glans penis and distal penile shaft swollen, red and tender to palpation
- Foreskin is retracted proximally in fixed position behind head of penis (glans)
VI. Management
- Emergent Urology Consultation for immediate reduction
- Adequate Anesthesia
- Preparation: Decrease glans penis edema prior to reduction
- Method 1
- Be patient, while applying steady, circumferential pressure for 10 minutes until foreskin floppy
- Method 2
- Wrap glans penis in 2x2 gauze soaked in cold water for 10 minutes prior to reduction
- May be held in place with IV start kit rubber Tourniquet
- Method 3
- Place granulated sugar or dextrose water in a Condom (or Ultrasound probe cover)
- Apply the Condom to the penis and paraphymosis
- Wrap Condom and glans penis with ace wrap for 10 minutes prior to manual reduction
- Method 1
- Manual Reduction
- Perform one of the methods above to reduce glans edema
- Hold foreskin with both hands, applying distal tension
- Thumbs used to push glans penis through paraphymosis
- Consider lubrication (e.g. Lidocaine Jelly) of glans prior to attempted reduction
- Refractory paraphymosis measures
- Anesthesia
- Needle decompress foreskin
- Insert 21 gauge needle in several locations through foreskin to try to reduce edema
- Hyaluronidase injection
- Inject hyaluronidase into foreskin
- Dorsal slit
- Indicated if refractory to all other reduction methods above
- Cut a dorsal slit of foreskin to allow foreskin reduction
- Commits patient to Circumcision
- Disposition
- If able to urinate after Paraphimosis reduction, may discharge home with urology follow-up
VII. Prevention
VIII. Complications
- Urinary Obstruction
- Necrosis of glans penis if not reduced
IX. References
- Claudius, Behar and Lockhart in Herbert (2017) EM:Rap 17(10): 3
- Herman and Arhancet (2020) Crit Dec Emerg Med 34(10): 17-21
- Majoewsky (2012) EM:Rap-C3 2(9): 2
- Walsh (1998) Campbell's Urology, Saunders, p. 3330-1
- Lundquist (2001) Emerg Med Clin North Am 19(3):529-46 [PubMed]