Paraphimosis Treatment & Management
- Author: Nathan A Brooks, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS more...
Medical therapy for paraphimosis involves reassuring the patient, reducing the preputial edema, and restoring the prepuce to its original position and condition. Several methods of reducing the penile swelling have been described. Ice packs, penile wraps, and manual compression mechanically disperse the penile and preputial edema, while osmotic agents, such as granulated sugar or mannitol have been reported as effective agents to reduce swelling. Hyaluronidase has been effectively used in the pediatric population as a method of increasing fluid diffusion, thus decreasing local edema. If a Foley catheter is present, remove it temporarily until the paraphimosis has resolved.
Prior to reduction, consider the use of local anesthesia
Dorsal penile block: Insert a short 25-gauge needle anterior to the pubic arch at the 10-o'clock position until the Buck fascia is encountered. Insert the needle through the Buck fascia, but remain outside of the corporal bodies. Aspirate to make sure the needle is not in a corporal body. Inject 10 mL of 1% lidocaine solution. Repeat the process at the 2-o'clock position.
Ring block: Insert a short 25-gauge needle at the base of the penis until the Buck fascia is encountered. Remain outside of the corporal bodies. Inject the anesthetic into the Buck fascia circumferentially around the base of the penis.
A combination of dorsal penile and ring blocks should provide adequate local anesthesia. If not, inject additional anesthetic directly into the incision line.
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 should 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 with the same principal of traction on the foreskin and counter traction on the glans. In addition, reduction can include the use of the forceps and clamps to pull the foreskin. Caution should be used as the use of an instrument which crushes the skin will result in necrosis of this tissue due to revascularization. The use of a 25 gauge needle to make several small stab incisions as an outlet for edema has also been described After two or three solid attempts, the authors resort to a dorsal slit procedure as described in Surgical therapy.
Several other methods to effectively reduce the glanular and prepucial edema prior to reduction of the foreskin have been described in the literature. Some of these methods are described are as follows:
Wrap the penis in plastic and apply ice packs.
Use compressive elastic dressings.
Apply direct circumferential manual compression. (Application of a topical anesthetic such as 2% lidocaine gel or eutectic mixture of local anesthetics cream [2.5% prilocaine, 2.5% lidocaine; see lidocaine/prilocaine] to the penile skin a few minutes to an hour before penile manipulation reduces pain and helps patients, particularly children, tolerate the procedure.)
Apply granulated sugar or mannitol-soaked gauze to the surface of the edematous prepuce and cover it with a condom or a finger of a rubber glove. The hypotonic fluid from the swollen foreskin moves down the osmotic gradient into the hypertonic agent, which results in a reduction of the preputial edema. This treatment is based on the principle that fluid transfer occurs via an osmotic gradient.
Using a tuberculin syringe, inject 1 mL of hyaluronidase (150 U/mL Wydase) directly into several sites of the edematous prepuce. Hyaluronidase breaks down hyaluronic acid in connective tissue and enhances fluid diffusion between tissue planes, decreasing preputial swelling and resulting in almost immediate resolution of the edema. (The use of hyaluronidase in the pediatric population has been well documented.)
Using ice and osmotic agents might take 1-2 hours to have an effect and should not be used when arterial compromise is suspected.
Regardless of the method chosen, when the preputial swelling and edema have subsided, correct the paraphimosis by gentle manual reduction (see image below).
To reposition the prepuce, place both thumbs on the glans penis and wrap the fingers behind the prepuce. Apply gentle steady pressure to the prepuce with counterpressure to the glans penis as the prepuce is pulled down.
When performed properly, the constricting band of tissue should come down to completely cover the glans with the prepuce. If the prepuce comes down but the constricting band remains behind, the paraphimosis has not been reduced properly or sufficiently.
For more information, see Paraphimosis Reduction Procedures.
In patients who are determined to retain the appearance of an uncircumcised phallus, the authors have the patient apply triamcinolone cream 0.1% to the affected area to possibly reduce the fibrosis of the ring. This has been described in the treatment of phimosis and has proven efficacious in temporarily preventing recurrent phimosis, decreasing the need for circumcision. After 6 weeks of triamcinolone application, if the prepuce can easily be retracted and reduced, the patient may proceed as such, but the risk for recurrent phimosis and paraphimosis remains. More often than not, the authors ultimately perform circumcision.
The puncture technique,[14, 15] a minimally invasive procedure, and blood aspiration are common therapies used to decompress the edematous prepuce.
To perform the puncture technique, commonly referred to as the Perth-Dundee method, an 18- or 21-gauge hypodermic needle is used to puncture the edematous prepuce at multiple sites and to release the trapped fluid (see image below). External drainage results in rapid resolution of edema, which is followed by manual reduction of the foreskin.
Alternatively, blood aspiration of the penis may be attempted after a tourniquet has been applied.
If a severely constricting band of tissue precludes all forms of conservative or minimally invasive therapy, an emergency bedside dorsal slit procedure may be performed, followed by a delayed circumcision.
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, a hemostat is then used 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 hemostasis for 30-60 seconds. The crushed area is then sharply incised with scissors. The edges are often over sewn with an interrupted or running 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 room setting and then following the acute interaction for consideration of circumcision are crucial.
Obtaining properly informed consent before performing circumcision is critical. Inform patients, parents, and/or caregivers of the potential risks of bleeding, infection, suture disruption, urethral injury, and too much or too little skin being removed. Also inform patients that circumcision does not affect the length or girth of the penis.
Instruct patients to abstain from genital stimulation for up to 6 weeks after surgery. Inadvertent erections can strain suture lines and cause incisions to break down.
Patients undergoing circumcision for recurrent balanitis should be free of infection before the procedure.
After the dorsal slit, petroleum jelly and sterile gauze or petrolatum gauze dressings may be applied over the sutures, followed by a sterile white gauze dressing. Prescribe oral narcotics and discharge the patient. Some surgeons also prescribe oral antibiotics. the patient should apply bacitracin or vasoline to the suture 2-3 times daily for the next 1-2 weeks or per the preference of the performing physician
Remove the dressing 24-48 hours after surgery. Advise patients to wear loose-fitting clothes, to gently wash the wound daily for the next 5-7 days, and to refrain from any sexual activity for the next 6 weeks to prevent breakdown of the sutures and incision line. Some surgeons additionally recommend keeping the wound completely dry to avoid inadvertent infection of the suture line.
Patients generally undergo follow-up examination in 2-3 weeks to check the wound. Assess the wound for signs of infection and inspect the suture line.
Complications of paraphimosis include pain, infection, and swelling of the glans penis. The distal portion of the penis can become ischemic and even necrotic.
Potential complications involved with any dorsal slit include bleeding, infection, shortening of penile skin, and urethral injury.
Postoperative bleeding is the most common complication. Meticulous hemostasis during the initial surgery is the rule. Bleeding may occur if a scab is pulled off during removal of the dressing. This bleeding can often be controlled with direct pressure. In rare cases, electrocautery or ligature is required.
Urethral injury is extremely rare.
Outcome and Prognosis
Paraphimosis does not recur after a proper circumcision.
Outcome after a dorsal slit procedure or a circumcision is excellent. Sometimes, patients with a favorable outcome from dorsal slit procedures decline circumcision.
Dubin J, Davis JE. Penile emergencies. Emerg Med Clin North Am. 2011 Aug. 29(3):485-99. [Medline].
Raman SR, Kate V, Ananthakrishnan N. Coital paraphimosis causing penile necrosis. Emerg Med J. 2008 Jul. 25(7):454. [Medline].
Koenig LM, Carnes M. Body piercing medical concerns with cutting-edge fashion. J Gen Intern Med. 1999 Jun. 14(6):379-85. [Medline].
Centers for Disease Control and Prevention (CDC). Trends in in-hospital newborn male circumcision--United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2011 Sep 2. 60 (34):1167-8. [Medline]. [Full Text].
Jones SA, Flynn RJ. An unusual (and somewhat piercing) cause of paraphimosis. British Journal of Urology. Nov 1996. 78:80-804. [Medline].
Farina LA, Alonso MV, Horjales M, Zungri ER. Contact-derived allergic balanoposthitis and paraphimosis through topical application of celandine juice. Actas Urologicas Españolas. June 1999. 23:554-555. [Medline].
Harvey K, Bishop L, Silver D, Jones T. A case of chancroid. The Medical Journal of Australia. 1977. 26:956-957. [Medline].
Pohlman GD, Phillips JM, Wilcox DT. Simple method of paraphimosis reduction revisited: Point of technique and review of the literature. Journal of Pediatric Urology. Feb 2013. 9:104-107. [Medline]. [Full Text].
Julian Wan. Dorsal Slit. Joseph Smith Jr, Stuart Howards, Glenn Preminger. Hinman's Atlas of Urologic Surgery. Third Edition. Philadephia, PA: Elsevier-Saunders; 2012. 145-146.
Anand A, Kapoor S. Mannitol for paraphimosis reduction. Urol Int. 2013. 90(1):106-8. [Medline].
Litzky GM. Reduction of paraphimosis with hyaluronidase. Urology. 1997 Jul. 50(1):160. [Medline].
Finkelstein JA. "Puncture" technique for treating paraphimosis. Pediatr Emerg Care. 1994 Apr. 10(2):127. [Medline].
Hamdy FC, Hastie KJ. Treatment for paraphimosis: the 'puncture' technique. Br J Surg. 1990 Oct. 77(10):1186. [Medline].
Hayashi Y, Kojima Y, Mizuno K, Kohri K. Prepuce: phimosis, paraphimosis, and circumcision. ScientificWorldJournal. 2011 Feb 3. 11:289-301. [Medline].
Little B, White M. Treatment options for paraphimosis. Int J Clin Pract. 2005 May. 59(5):591-3. [Medline].
Baigrie RJ. Treatment for paraphimosis. Br J Surg. 1991 Mar. 78(3):378. [Medline].
Fuenfer MM, Najmaldin A. Emergency reduction of paraphimosis. Eur J Pediatr Surg. 1994 Dec. 4(6):370-1. [Medline].
Gausche M. Genitourinary surgical emergencies. Pediatr Ann. 1996 Aug. 25(8):458-64; quiz 465-7. [Medline].
Hansen RB, Olsen LH, Langkilde NC. Piercing of the glans penis. Scand J Urol Nephrol. 1998 May. 32(3):219-20. [Medline].
Higgins SP. Painful swelling of the prepuce occurring during penile erection. Genitourin Med. 1996 Dec. 72(6):426. [Medline].
Hollowood AD, Sibley GN. Non-painful paraphimosis causing partial amputation. Br J Urol. 1997 Dec. 80(6):958. [Medline].
Jones SA, Flynn RJ. An unusual (and somewhat piercing) cause of paraphimosis. Br J Urol. 1996 Nov. 78(5):803-4. [Medline].
Olson C. Emergency treatment of paraphimosis. Can Fam Physician. 1998 Jun. 44:1253-4, 1257. [Medline].
Raveenthiran V. Reduction of paraphimosis: a technique based on pathophysiology. Br J Surg. 1996 Sep. 83(9):1247. [Medline].
Samm BJ, Dmochowski RR. Urologic emergencies. Trauma injuries and conditions affecting the penis, scrotum, and testicles. Postgrad Med. 1996 Oct. 100(4):187-90, 193-4, 199-200. [Medline].