Paraphimosis Treatment & Management

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,^[5] 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.^[6] If a Foley catheter is present, remove it temporarily until the paraphimosis has resolved.

The authors have never used any management options other than gentle reassurance, local anesthesia (1% lidocaine without epinephrine), intravenous sedation with morphine or midazolam (Versed) (in select cases), and then manual compression with simultaneous manual reduction, which is the standard method of reduction.^[7] The authors identify the location of the cicatricial ring, reduce the edema distally, and, as quickly and efficiently as possible, reduce the cicatricial ring with one hand while the second hand has been compressing the glans and forcing out the edema. After 2 or 3 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] 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 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 sugar, 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.)

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.

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,^{[8, 9]} 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.

To perform a dorsal slit procedure, initially, the penis is prepared and draped in the typical sterile fashion. Then, the cicatricial ring is identified. Of note, an assistant may be needed to retract the edematous glans away from the incision site. Next, the ring is crushed with a hemostat at the 12-o'clock position and then cut with scissors, ensuring that the entire ring is incised. The entire ring is usually no more than 5-10 mm thick. Once this is completed, the prepuce can easily be reduced. Sutures, if necessary, are placed to control bleeding from the cut edges of the ring. Long-term management is discussed with the patient. Options include surgical treatment via circumcision or conservative therapy via application of triamcinolone cream for 6 weeks and watchful waiting.

Circumcision is the definitive therapy for paraphimosis.

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.

Place the patient in a supine position. Preparation includes a thorough surgical scrub of the genital area with povidone-iodine solution. Shaving or clipping pubic hair is unnecessary.

Either general or local anesthetics may be used. General anesthesia is recommended for children, while local anesthesia is recommended for adults.

Local anesthesia can be accomplished by a dorsal penile nerve block with a ring block. Equal volumes of 0.5% bupivacaine (Marcaine) and 1-2% lidocaine (Xylocaine) without epinephrine are commonly used. The maximum recommended dose of lidocaine without epinephrine is 4.5 mg/kg, or 315 mg in a 70-kg male.

• 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.

To perform a dorsal slit procedure for emergent reduction of paraphimosis, use the following technique:

• Identify the constricting band of prepuce.
• Place 2 straight hemostats at the 12-o'clock position to crush the constricting foreskin. See image below.The dorsal slit technique to treat paraphimosis is begun by crushing the foreskin at the 12-o'clock position with 2 straight hemostats. A sharp incision is made between the hemostats.
• After 1 full minute, sharply incise the crushed tissues between 2 hemostats. See image below.In this case, a dorsal slit procedure to treat paraphimosis has been performed halfway. Note that the edges of the incision have been oversewn with absorbable sutures.
• In running fashion, close each edge of the incision with 4.0-5.0 absorbable sutures (children) or 3.0-4.0 absorbable sutures (adults). See image below. A finished product of the dorsal slit procedure to treat paraphimosis. Note that the cosmetic appearance of the completed dorsal slit is similar to that of a finished circumcision.

When performing a circumcision, either the dorsal slit or sleeve techniques are commonly used. The dorsal slit technique is preferred for patients with severe phimosis and those with paraphimosis in whom intraoperative manipulation of the foreskin is difficult.

To perform the dorsal slit, use the following technique:

• Sharply incise the foreskin at the 12-o'clock position, perpendicular to the corona.
• With scissors, excise the foreskin at its base.
• Ligate superficial veins.
• Use electrocautery to obtain hemostasis.
• Circumferentially approximate the proximal and distal edges of the foreskin with 4.0-5.0 absorbable sutures in an interrupted fashion. See image below. To remove the foreskin completely after a dorsal slit procedure to treat paraphimosis, a circumcision is performed. The circumcision is begun, circumscribing proximal and distal skin incisions to create a sleeve of excess foreskin that is removed. This sleeve of excess foreskin is crushed at the 12-o'clock position for hemostasis.

The sleeve technique is an alternative method for circumcision and may be used as a primary surgical procedure or as a secondary definitive operation after an emergency dorsal slit has been made at bedside.

• After administering anesthesia, outline the redundant foreskin using a surgical marker.
• Incise the proximal and distal skirts of the foreskin so that a sleeve of foreskin is present between the incisions. See image below. During circumcision, the foreskin is sharply incised between 2 hemostats.
• Remove the sleeve using electrocautery. See image below.Excess foreskin is removed during a circumcision. The shaft of the penis is displaced downward with a sponge while the foreskin is peeled off using electrocautery.
• Use electrocautery and ligatures to achieve adequate hemostasis before circumferentially approximating the edges of the foreskin with 3.0-5.0 absorbable sutures in an interrupted fashion. See image below. After the excess foreskin has been removed by circumcision, the preputial skin edges are reapproximated with absorbable sutures. The operation is completed.

After the circumcision, 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.

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.

One ampule of amyl nitrate may be used in instances of postoperative erections.

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.

For excellent patient education resources, visit eMedicine's Men's Health Center. Also, see eMedicine's patient education articles Foreskin Problems and Circumcision.

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 circumcision 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.

Infection after circumcision is uncommon. If acquired, it may be treated with oral antibiotics.

Urethral injury is extremely rare.

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.