- Author: Nathan A Brooks, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS more...
Paraphimosis is a urologic emergency in which the retracted foreskin of an uncircumcised male cannot be returned to its normal anatomic position. It is important for clinicians to recognize this condition promptly, as it can result in gangrene and amputation of the glans penis. Prompt urologic intervention is indicated.
Paraphimosis occurs when the foreskin of an uncircumcised or partially circumcised male is retracted for an extended period of time. This in turn causes venous occlusion, edema, and eventual arterial occlusion. The foreskin is unable to be reduced easily over the glans owing to this progressive edema. The condition represents a urologic emergency, as compromise of the arterial flow to the glans and constriction can cause gangrene and amputation of the glans penis.
Paraphimosis differs from phimosis, a nonemergent condition in which the foreskin cannot be retracted behind the glans penis. Paraphimosis occurs only in uncircumcised or partially circumcised males.
Paraphimosis may occur when the foreskin has been pulled back behind the head of the penis for an extended period and is often caused by well-meaning health professionals who have retracted the foreskin to perform penile examination or urethral instrumentation. Because paraphimosiis is almost always iatrogenically or inadvertently induced, simple education and clarification of proper prepuce care to parents, the individuals themselves, and health care professionals may be all that is required to prevent it.
When paraphimosis is suspected, immediately obtain a urology consult for proper evaluation and diagnosis. Prompt attention and treatment of this emergency should lead to a favorable outcome.
Paraphimosis is a relatively uncommon condition and is less common than phimosis.
Paraphimosis is almost always an iatrogenically or inadvertently induced condition; however, case reports have described coital paraphimosis leading to penile necrosis, as well as penile piercings leading to paraphimosis. Paraphimosis occurs more often in hospitals and nursing homes than in the private community, where the affected individual or a parent often retracts the prepuce and then inadvertently leaves it in its retracted position. In most cases, the foreskin reduces on its own and therefore precludes paraphimosis; however, if the slightest resistance to retraction of the prepuce is present, leaving it in this state predisposes it to paraphimosis. As edema accumulates, the condition worsens.
A large minority of males in the United States are uncircumcised, and thus are susceptible to paraphimosis. According to the National Hospital Discharge Survey (NHDS), circumcision rates in the US declined from an all-time high of 78-80% in the mid-to-late 1960s to 55%-60% in 2003.The NHDS found that in 1999-2010, 59% of newborn boys were circumcised. Actual rates were presumably somewhat higher, however, as this figure does not include circumcisions performed in the community.
Paraphimosis can occur after retraction of the foreskin during detailed penile examination, cleaning of the glans penis, urethral catheterization, or cystoscopy. For healthcare providers or patients retracting the patient’s foreskin for any intervention or examiniation it is of vital importance to replace the foreskin to the anatomic position covering the glans.
Development of paraphimosis after catheterization is not uncommon. Before the insertion of a urethral catheter, a health professional retracts the foreskin to sterilely prepare and drape the glans penis. The retracted foreskin may be left in that manner for several hours to days. The failure to restore the prepuce to its original position sometimes leads to the development of paraphimosis.
More unusual causes of paraphimosis include the following:
When the foreskin becomes trapped behind the corona for a prolonged period, a tight band of tissue forms around the penis. This constricting ring initially impairs venous blood and lymphatic flow from the glans penis and prepuce, in turn causing edema of the glans. As the edema worsens, arterial blood flow becomes compromised. The ensuing tissue ischemia and vascular engorgement cause painful swelling of the glans and prepuce and may eventually lead to gangrene or autoamputation of the distal penis.
Adult patients with symptomatic paraphimosis most often report penile pain. In the pediatric population, paraphimosis may manifest as acute urinary tract obstruction and may be reported as obstructive voiding symptoms.
On examination, the glans penis is enlarged and congested with a collar of edematous foreskin. A constricting band of tissue is noted directly behind the head of the penis. The remainder of the penile shaft is unremarkable. An indwelling urethral catheter is often present. Simply removing the catheter may help treat paraphimosis caused by an indwelling urethral catheter. The image below depicts mild-to-moderate paraphimosis.
If paraphimosis is left untreated for too long, necrosis of the glans penis can occur. Partial amputation of the distal penis has been reported. The image below depicts severe paraphimosis.
The penis is divided into the following three parts:
The root of the penis lies under the pubic bone and provides stability when the penis is erect.
The body of the penis constitutes the major portion of the penis and is composed of 2 cavernosal bodies (ie, corpora cavernosa) and a corpus spongiosum (ie, head of the penis). The male urethra traverses through the corpus spongiosum and exits from the meatus. The cavernosal bodies produce an erection when filled with blood.
The glans is the distal expansion of the corpus spongiosum usually covered by the loose skin of the prepuce in uncircumcised individuals. A collar of tissue immediately behind the glans penis is known as the coronal sulcus.
The penis is innervated by the left and right dorsal nerves (main sensory nerve supply), which are branches of the pudendal nerve.
The penis is a highly vascular organ supplied by the internal pudendal artery, which arises from the internal iliac artery and then branches into the deep penile artery, the bulbar artery, and the urethral artery.
The deep penile artery becomes the cavernosal arteries, which supply the entire corpus cavernosum. The urethral artery supplies the glans penis and the corpus spongiosum. The bulbar artery nourishes the bulbar urethra and the bulbospongiosus muscle.
When diagnosed early, paraphimosis can be remedied easily with simple manual reduction in combination with other conservative measures. Patients with severe paraphimosis that proves refractory to conservative therapy will require a bedside emergency dorsal slit procedure to save the penis. Formal circumcision can be performed in the operating room at a later date.
Paraphimosis is a a painful condition and care should be taken to ensure patient comfort by providing adequate analgesia and local anesthesia using a dorsal penile nerve block and circumferential penile ring block with lidocaine, bupivicaine, or a combination of the two. Epinephrine should never be injected. In additional, topical application of lidocaine or prilocaine creams and direct injection of anesthetic into the foreskin can be used.
Once pain control is adequate, manual reduction by attempting to circumferentially compress the foreskin and holding for 2-10 minutes to “squeeze” the edematous fluid along the penile shaft may be attempted. After this fluid has passed proximally, the foreskin is reduced by placing both thumbs on the glans and using the remaining fingers to pull the foreskin back over the glans into the anatomic location. There are many variations of this technique, all using the same principle of traction on the foreskin and countertraction on the glans.
In addition, reduction can include the use of forceps and clamps to pull the foreskin. Those instruments must be used cautiously, however, as they can crush the skin and cause necrosis of this tissue due to devascularization. The use of a 25-gauge needle to make several small stab incisions as an outlet for edema fluid has also been described .
Adjuncts to reduction
Ice, osmotic agents such as sugar, and compression wrapping with Coban® have been used as adjuncts to manual reduction and can be considered. Ice and osmotic agents may require 1-2 hours to take effect, however, so they should not be used when arterial compromise is suspected.
After adequate local anesthesia (with or without sedation) or general anesthesia, the plane between the dorsal foreskin and the corona is identified. Normally, when performing a dorsal slit, the operator then uses a hemostat to crush the foreskin at the 12 o’clock position, which is also the midline of the dorsal foreskin. This is left in place for 30-60 seconds, to provide hemostasis. The crushed area is then sharply incised with scissors. The edges are often oversewn with an interrupted or running stitch, using a dissolvable suture such as chromic.
However, when performing a dorsal slit for paraphimosis, one should identify the dorsal midline of the rolled preputial skin. Make a vertical incision at the junction of the rolled foreskin (identified as the point between the mucosal, smooth skin and the preputial thicker, dull skin). This should release the contricting tissue. Mobilize the foreskin so that it can slide over the glans and back and then oversew the cut edges.
Regardless of the method used, urologic evaluation acutely in the emergency department and then following the acute interaction for consideration of circumcision are crucial.
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