II. Definitions

  1. Paraphimosis
    1. Foreskin stuck in retracted position
    2. Emergency condition due to Compartment Syndrome and risk of vascular compromise
    3. Contrast with the benign Phimosis in which the foreskin cannot be retracted

III. Pathophysiology

  1. Foreskin forms tight circumferential band around base of glans penis
  2. Strangulates glans penis and obstructs arterial Blood Flow
  3. Necrosis of glans penis results if Paraphimosis not treated emergently

IV. Causes

  1. Forceful retraction of foreskin in infants
  2. Chronic Balanitis
  3. Indwelling catheter

V. Signs

  1. Glans penis and distal penile shaft swollen, red and tender to palpation
  2. Foreskin is retracted proximally in fixed position behind head of penis (glans)

VI. Management

  1. Emergent Urology Consultation for immediate reduction
  2. Adequate Anesthesia
    1. Dorsal Penile Nerve Block
    2. Conscious Sedation
  3. Preparation: Decrease glans penis edema prior to reduction
    1. Method 1
      1. Be patient, while applying steady, circumferential pressure for 10 minutes until foreskin floppy
    2. Method 2
      1. Wrap glans penis in 2x2 gauze soaked in cold water for 10 minutes prior to reduction
      2. May be held in place with IV start kit rubber Tourniquet
    3. Method 3
      1. Place granulated sugar or dextrose water in a Condom (or Ultrasound probe cover)
      2. Apply the Condom to the penis and paraphymosis
      3. Wrap Condom and glans penis with ace wrap for 10 minutes prior to manual reduction
  4. Manual Reduction
    1. Perform one of the methods above to reduce glans edema
    2. Hold foreskin with both hands, applying distal tension
    3. Thumbs used to push glans penis through paraphymosis
    4. Consider lubrication (e.g. Lidocaine Jelly) of glans prior to attempted reduction
  5. Refractory paraphymosis measures
    1. Anesthesia
      1. Dorsal Penile Nerve Block or
      2. Conscious Sedation
    2. Needle decompress foreskin
      1. Insert 21 gauge needle in several locations through foreskin to try to reduce edema
    3. Hyaluronidase injection
      1. Inject hyaluronidase into foreskin
    4. Dorsal slit
      1. Indicated if refractory to all other reduction methods above
      2. Cut a dorsal slit of foreskin to allow foreskin reduction
      3. Commits patient to Circumcision
  6. Disposition
    1. If able to urinate after Paraphimosis reduction, may discharge home with urology follow-up

VII. Prevention

VIII. Complications

  1. Urinary Obstruction
  2. Necrosis of glans penis if not reduced

IX. References

  1. Claudius, Behar and Lockhart in Herbert (2017) EM:Rap 17(10): 3
  2. Herman and Arhancet (2020) Crit Dec Emerg Med 34(10): 17-21
  3. Majoewsky (2012) EM:Rap-C3 2(9): 2
  4. Walsh (1998) Campbell's Urology, Saunders, p. 3330-1
  5. Lundquist (2001) Emerg Med Clin North Am 19(3):529-46 [PubMed]

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