eMedicine Specialties > Clinical Procedures > Genitourinary Procedures

Paraphimosis Reduction

Updated: May 22, 2008

Introduction

Paraphimosis is the inability to reduce a swollen and proximally positioned foreskin over the glans penis.^1,2,3 Paraphimosis is most often iatrogenic, occurring when medical personnel forget to reduce the foreskin after instrumentation or catheterization of the urethra.^1,4 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.

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.⁵

Paraphimosis.

Constricting (phimotic) ring.

For more information on paraphimosis and the related condition phimosis, see eMedicine article Phimosis and Paraphimosis.

Indications

All patients with paraphimosis require emergent reduction.

Contraindications

Nonsurgical techniques are contraindicated in patients who have the following conditions:
- Necrotic or ulcerated foreskin
- Necrotic or ulcerated penis
Surgical techniques should be performed by or after consultation with a urologist.⁶

Anesthesia

Reduction of paraphimosis is a painful procedure. The use of parenteral analgesic and sedative agents is recommended. Anesthesia with local infiltration may be used.
Various methods of penile anesthesia exist (see Technique section). For more information, see Nerve Block, Dorsal Penile.
Procedural sedation is recommended in the pediatric patient. For more information, see Procedural Sedation. Click here to complete a Medscape CME activity on pediatric procedural sedation.

Equipment

Topical anesthetic cream (eutectic mixture of local anesthetics [EMLA]; lidocaine, adrenaline, tetracaine [LAT]; tetracaine, adrenaline, cocaine [TAC]) (For more information, see Anesthesia, Topical.)
4 x 4 gauze
Povidone-iodine solution (eg, Betadine)
Sterile drapes
Sterile gloves
Local anesthetic solution without epinephrine (lidocaine 1%)
Syringe, 10 mL
Needles, 18- and 27-gauge (ga)
Crushed ice
Babcock clamps, 6-8

Positioning

Position the patient supine, with his legs separated.

Technique

Preparation and anesthesia

Obtain informed consent. Explain the procedure in detail to the parent/guardian of a pediatric patient.
Apply a liberal amount of the local anesthetic cream to the glans and foreskin.
Wait for the anesthesia to take effect.
Clean the penis of the local anesthetic cream.
Apply an antiseptic solution to the penis and foreskin.

Application of antiseptic solution and identification of the superficial dorsal penile vein.
Place sterile drapes to create a sterile field around the penis.
If adequate anesthesia has not been achieved, penile anesthesia should be performed. One of two techniques may be used for penile anesthesia. Both techniques are painful and require the administration of parenteral analgesics and/or procedural sedation and analgesia.
1. Inject 1-2 mL of lidocaine 1% near the right and left dorsal penile nerves (the 10- and 2-o’clock positions close to the base of the penis).
  
  Anesthetic injection sites in the 10- and 2-o'clock positions.
2. Circumferentially infiltrate lidocaine 1% around the base of the penis.
  
  Circumferential infiltration of local anesthetic.

Manual reduction

Apply slow and steady manual compression over the glans penis and edematous foreskin, squeezing distally to proximally in order to mobilize the edema proximally.

Manual compression of the glans and foreskin.
The pressure should be applied for 5-10 minutes and can be delegated to the patient or caregiver.
After manual compression, position the thumbs on both sides of the urethral meatus and the index and middle fingers proximal to the phimotic ring.

Manual reduction of paraphimosis.
Apply continuous force to move the phimotic ring distally over the glans.

Manual reduction of paraphimosis.

Manual reduction of paraphimosis.
Presentation available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79934-143885-143935.avi.

Iced glove technique⁷

Half fill a surgical glove with water and ice chips, express the remaining air, and tie a knot in the wrist of the glove.
Insert the penis into the invaginated thumb of the glove.
Apply circumferential pressure for 5-10 minutes.
Attempt to manually reduce the foreskin again.

Babcock clamp technique

This technique requires administration of local anesthetic.
The Babcock clamp is a noncrushing tissue clamp.
- It can be safely used to reduce the paraphimotic foreskin.
- All other clamps will crush the foreskin tissue.
Apply 6-8 Babcock clamps evenly spaced around the foreskin by placing one edge just proximal to the phimotic ring with the other edge just distal to the phimotic ring.

The Babcock clamps should be placed along the phimotic ring.
Grasp all clamps in one hand, and simultaneously apply distal traction to pull the phimotic ring over the glans.
After reduction, remove the clamps and inspect the foreskin for injuries.

Needle decompression technique

This technique requires administration of local anesthetic.
Clean the penis, apply antiseptic solution, and place drapes to create a sterile field.
Use an 18-gauge needle to create 8-12 circumferential holes, 3-5 mm deep, in the foreskin.

An 18-gauge needle is used to circumferentially puncture the edematous foreskin.
Wrap a piece of 4 x 4 gauze around the glans and foreskin, and apply manual compression for 5-10 minutes, allowing the foreskin to decompress by draining edematous fluid and blood.
Attempt to manually reduce the foreskin again.

Aftercare

The successfully reduced foreskin should look like a normal uncircumcised penis.

The successfully reduced paraphimosis should have the appearance of a normal uncircumcised penis.
The patient should feel relief of pressure and pain.
Residual swelling is expected to resolve in a few days.
Observe the patient to ensure the following:
- Recovery from anesthesia
- Adequate hemostasis
- Ability to urinate
All patients should be referred to a urologist in 1-2 days.

Pearls

Apply slow and steady manual compression over the glans penis and edematous foreskin, squeezing distally to proximally in order to mobilize the edema proximally. This pressure should be applied for 5-10 minutes and can be delegated to the patient or caregiver.
Circumcision is the recommended definitive therapy for all patients who experience paraphimosis.^8,9 For more information on circumcision in children and adults, see eMedicine Pediatrics article Circumcision and eMedicine Urology article Phimosis, Adult Circumcision, and Buried Penis.

Complications

A significant degree of pain after the procedure is uncommon. If it occurs, it can be treated with a topical anesthetic.
Swelling usually takes a few days to resolve.
A dorsal slit of the foreskin is indicated if less invasive techniques fail to achieve reduction.^2,10
Penile or foreskin lacerations or tears that result from the manual reduction should be sutured with an absorbable material.
Some bleeding is common following needle decompression and dorsal slit techniques. A compressive dressing may aid with hemostasis.
Prescribing antibiotics to patients with evidence of skin infection or ulcers or after any invasive procedure that involves the foreskin is recommended.

Multimedia

Media file 1: Paraphimosis.

Media file 2: Application of antiseptic solution and identification of the superficial dorsal penile vein.

Media file 3: Anesthetic injection sites in the 10- and 2-o'clock positions.

Media file 4: Circumferential infiltration of local anesthetic.

Media file 5: Manual compression of the glans and foreskin.

Media file 6: Manual reduction of paraphimosis.

Media file 7: Manual reduction of paraphimosis.

Media file 8: Constricting (phimotic) ring.

Media file 9: The successfully reduced paraphimosis should have the appearance of a normal uncircumcised penis.

Media file 10: The Babcock clamps should be placed along the phimotic ring.

Media file 11: An 18-gauge needle is used to circumferentially puncture the edematous foreskin.

Media file 12: Manual reduction of paraphimosis.

Presentation available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79934-143885-143935.avi.

References

Choe JM. Paraphimosis: current treatment options. Am Fam Physician. Dec 15 2000;62(12):2623-6, 2628. [Medline].
Williams JC, Morrison PM, Richardson JR. Paraphimosis in elderly men. Am J Emerg Med. May 1995;13(3):351-3. [Medline].
Rangarajan M, Jayakar SM. Paraphimosis revisited: is chronic paraphimosis a predominantly third world condition?. Trop Doct. Jan 2008;38(1):40-2. [Medline].
Paynter M. Paraphimosis. Emerg Nurse. Jul 2006;14(4):18-9. [Medline].
Lawless MR. The foreskin. Pediatr Rev. Dec 2006;27(12):477-8. [Medline].
Borsellino A, Spagnoli A, Vallasciani S, Martini L, Ferro F. Surgical approach to concealed penis: technical refinements and outcome. Urology. Jun 2007;69(6):1195-8. [Medline].
Mackway-Jones K, Teece S. Best evidence topic reports. Ice, pins, or sugar to reduce paraphimosis. Emerg Med J. Jan 2004;21(1):77-8. [Medline].
Dawson C, Whitfield H. ABC of Urology. Urological emergencies in general practice. BMJ. Mar 30 1996;312(7034):838-40. [Medline].
Cathcart P, Nuttall M, van der Meulen J, Emberton M, Kenny SE. Trends in paediatric circumcision and its complications in England between 1997 and 2003. Br J Surg. Jul 2006;93(7):885-90. [Medline].
Little B, White M. Treatment options for paraphimosis. Int J Clin Pract. May 2005;59(5):591-3. [Medline].
Reichman EF, Simon RR. Emergency Medicine Procedures. Columbus, Ohio: McGraw Hill Medical Publishing; 2004.

Keywords

paraphimosis, paraphimosis reduction, uncircumcised, uncircumcized, penile anesthesia, penile block, phimotic ring, Babcock clamp technique, needle decompression technique, manual reduction of paraphimosis, swollen foreskin, iced glove technique, reduced foreskin, retracted foreskin, reduction of foreskin

Contributor Information and Disclosures

Author

Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT
Gil Z Shlamovitz, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Luis M Lovato, MD, Assistant Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center
Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.

Further Reading