Paraphimosis

Paraphimosis is the term used to describe the condition that occurs when a narrow foreskin is forcibly retracted and becomes trapped behind the head of the penis.

The retracted foreskin initially blocks lymphatic drainage from the distal penis, progressively causing further edema of the retracted foreskin. If the foreskin remains retracted and the edema continuous, venous obstruction followed by arterial flow are expected within hours to days.

 

Paraphimosis is most often iatrogenic, occurring when medical personnel forget to reduce the foreskin after instrumentation or catheterization of the urethra. The foreskin does not become fully mobile before the age of 3-4 years, predisposing children younger than 3-4 years to paraphimosis when their caregivers retract the foreskin for cleaning. Patients present with a red, painful, and swollen glans penis associated with an edematous, proximally retracted foreskin that forms a circumferential constricting band.

Pain and swelling make it difficult to return the foreskin to the non-retracted position.

 

Note!Forcible retraction of a narrow foreskin should be avoided. The foreskin should be returned to the forward position after cleaning or sexual intercourse.

 

If this condition persists for several hours or there is any sign of a lack of blood flow, paraphimosis should be treated as a medical emergency, as it can result in gangrene or other serious complications (a risk of consecutive necrosis).

The diagnosis of paraphimosis is made by physical examination (Image 8.7).

Image 8.7 The paraphimosis is characterized by retracted foreskin with the constrictive ring localized at the level of the sulcus, which prevents replacement of the foreskin over the glans.

 

Treatment of paraphimosis consists of manual compression (reduction) of the oedematous tissue with a subsequent attempt to retract the tightened foreskin over the glans penis (Image 8.8).

Note! Paraphimosis can usually be corrected without surgery.

 

This technique may be facilitated by the use of ice and/or hand compression on the foreskin, glans, and penis to minimize edema of the glans prior to manual reduction.

Soaking the penis in a glove full of ice for 5 minutes before attempting manual reduction has been reported to be effective 90% of the time.

Adequate analgesia or sedation should be given. Liberally covering the entire foreskin and glans in topical anaesthetic cream for 1 hour may be effective. Local infiltration of anaesthetic is best avoided as it increases the swelling.

Image 8.8 Manual reduction The swollen area is gently but firmly compressed within one hand, for a few minutes, to squeeze out the oedema fluid. Manual reduction is performed by placing both index fingers on the dorsal border of the penis behind the retracted prepuce and both thumbs on the end of the glans. The glans is pushed back through the prepuce with the help of constant thumb pressure while the index fingers pull the prepuce over the glans.

 

Hospital treatment with injection of hyaluronidase has been shown to be successful (level of evidence: 4, grade C recommendation). Hyaluronidase works by reducing the oedema, after which the foreskin may be returned to its normal position.

The puncture method can be enhanced by the injection of 1-mL aliquots of hyaluronidase (using a tuberculin syringe) into one or more sites of the edematous prepuce. It is thought that hyaluronidase disperses extracellular edema by modifying the permeability of intercellular substance in connective tissue.

!Drawbacks to this method include the risk of anaphylaxis and shock.

 

When the foreskin has been returned to its normal position, no further treatment is necessary.

 

If the conservative treatment (manual reduction) fails, a dorsal incision of the constrictive ring is required (Image 8.9).

Image 8.9 Dorsal incision (in local anesthesia) is the initial therapy of a paraphimosis, which cannot be reduced. The dorsal incision cuts the phimotic ring in longitudinal direction. After the incision, the prepuce should be retractable without resistance. Transverse suture of the dorsal incision closes the skin defect and helps in hemostasis. Circumcision should be postponed until the edema of the prepuce has resolved.

 

Depending on the local findings, a circumcision is carried out immediately or can be performed in a second session.

Although some doctors recommend circumcision there is no evidence in the medical literature to support this recommendation