eMedicine Specialties > Emergency Medicine > Genitourinary

Phimosis and Paraphimosis: Treatment & Medication

Author: Hina Z Ghory, MD, Chief Resident Physician, Department of Emergency Medicine, New York Presbyterian Hospital
Coauthor(s): Rahul Sharma, MD, MBA, Instructor in Medicine, Weill Medical College of Cornell University; Consulting Staff, Department of Emergency Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center
Contributor Information and Disclosures

Updated: Apr 29, 2009

Treatment

Emergency Department Care

Patients with phimosis rarely require any emergency intervention and should be referred to a urologist as on an outpatient basis prior to development of irreversible penile damage.

A paraphimosis is a urologic emergency and needs to be attended to immediately. Many techniques of paraphimosis reduction have been described. The main goal of each method is to reduce the foreskin to its naturally occurring position over the glans penis by manipulating the edematous glans and/or the distal prepuce. When necessary, all of the following procedures can be facilitated by the use of local anesthesia, a penile block using lidocaine hydrochloride without epinephrine or, especially in children, conscious sedation. Sterile technique should be used for all invasive procedures.

The authors recommend attempting to reduce the paraphimosis in the following sequence, from least to most invasive. The urologist should be involved early on in all cases of paraphimosis that require more than minimally invasive methods of reduction.

  • Manual reduction
    • 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.
    • 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.
    • An elastic bandage can also be wrapped from the glans to the base of the penis for 5-7 minutes to minimize edema.4
    • Noncrushing clamps can be placed on the constricting portion of the foreskin at the 3- and 9-o'clock positions to apply gentle continuous symmetrical traction.5 Also see, Paraphimosis Reduction.
  • Osmotic method: Substances with a high solute concentration can be used to osmotically draw out fluid from the edematous glans and foreskin prior to manual reduction. Granulated sugar spread over the glans and foreskin for 2 hours has been shown to facilitate manual reduction.5 Alternatively, a swab soaked in 50 mL of 50% dextrose (more readily available in the ED) can be wrapped around the glans and foreskin for an hour prior to attempting reduction.5 A major drawback of these methods is that they are time consuming.
  • Puncture method: This method requires the use of a 21- to 26-gauge needle to puncture openings into the foreskin to allow edematous fluid to escape from the puncture sites during manual compression. Successful reductions have been reported with single and up to 20 punctures.5
  • Hyaluronidase method: 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. The use of this method is contraindicated in those with the presence of infection or cancer, since the technique may result in the spread of bacteria or malignant cells. Drawbacks to this method include the risk of anaphylaxis and shock and the lack of availability of hyaluronidase in many EDs.
  • Aspiration: A tourniquet is applied to the shaft of the penis. A 20-guage needle is then used to aspirate 3-12 mL of blood from the glans, parallel to the urethra. This reduces the volume of the glans sufficiently to facilitate manual reduction.
  • Vertical incision: If none of the above methods are successful, the constricting band of the foreskin should be incised using a 1-2 cm longitudinal incision between two straight hemostats placed in the 12-o'clock position for hemostasis.4 This frees the constricting ring and allows for easy reduction of the paraphimosis. The incised margins can then be reapproximated using 4/0 nylon sutures. Also see, Dorsal Slit of the Foreskin and Nerve Block, Dorsal Penile. (See Media file 4.)
Dorsal slit procedure.

Dorsal slit procedure.

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Dorsal slit procedure.

Dorsal slit procedure.

  • Emergent circumcision: This is a last resort, to be performed by a urologist, to achieve the necessary reduction of a paraphimosis.

Consultations

A paraphimosis is a urologic emergency and prompt efforts to reduce the paraphimosis must be made by the emergency physician. If minimally invasive measures fail to reduce the paraphimosis, a urologic consultation is required.

Medication

Up to 85% of cases of mild-to-moderate phimosis have been shown to respond to application of topical steroids to the preputial orifice, although some studies have suggested that this response rate may decline several months after the regimen is completed.6

The ED physician may choose to recommend 0.05-0.1% betamethasone dipropionate applied to the preputial orifice twice a day for 4-6 weeks.6

More on Phimosis and Paraphimosis

Overview: Phimosis and Paraphimosis
Differential Diagnoses & Workup: Phimosis and Paraphimosis
Treatment & Medication: Phimosis and Paraphimosis
Follow-up: Phimosis and Paraphimosis
Multimedia: Phimosis and Paraphimosis
References
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References

  1. McGregor TB, Pike JG, Leonard MP. Pathologic and physiologic phimosis: approach to the phimotic foreskin. Can Fam Physician. Mar 2007;53(3):445-8. [Medline].

  2. Tews M, Singer JI. Paraphimosis: Definition, pathophysiology, and clinical features. www.utdol.com [database online]. UpToDate Online; 9/20/2008. Updated 6/11/2008.

  3. Lundquist ST, Stack LB. Diseases of the foreskin, penis, and urethra. Emerg Med Clin North Am. Aug 2001;19(3):529-46. [Medline].

  4. Choe JM. Paraphimosis: current treatment options. Am Fam Physician. Dec 15 2000;62(12):2623-6, 2628. [Medline].

  5. Little B, White M. Treatment options for paraphimosis. Int J Clin Pract. May 2005;59(5):591-3. [Medline].

  6. Palmer LS, Palmer JS. The efficacy of topical betamethasone for treating phimosis: a comparison of two treatment regimens. Urology. Jul 2008;72(1):68-71. [Medline].

  7. Atilla MK, Dundaroz R, Odabas O. A nonsurgical approach to the treatment of phimosis: local nonsteroidal anti-inflammatory ointment application. J Urol. Jul 1997;158(1):196-7. [Medline].

  8. Brendler, CB. Evaluation of the urologic patient. In: Walsh PC, et al, eds. Campbell's Urology. 7th ed. Philadelphia, Pa: WB Saunders Co; 1997:1-142.

  9. DeVries CR, Miller AK, Packer MG. Reduction of paraphimosis with hyaluronidase. Urology. Sep 1996;48(3):464-5. [Medline].

  10. Elder JS. Congenital anomalies of the genitalia. In: Walsh PC, et al, eds. Campbell's Urology. 7th ed. Philadelphia, Pa: WB Saunders Co; 1997.

  11. Gairdner D. The fate of the foreskin, a study of circumcision. Br Med J. Dec 24 1949;2(4642):1433-7, illust. [Medline].

  12. Green M, Stange GR. Paraphimosis reduction. In: Henretig FM, King C, eds. Textbook of Pediatric Emergency Procedures. Baltimore, Md: 1997:1007-10.

  13. Hamdy FC, Hastie KJ. Treatment for paraphimosis: the 'puncture' technique. Br J Surg. Oct 1990;77(10):1186. [Medline].

  14. Imamura E, ALIA. Phimosis of infants and young children in Japan. Acta Paediatr Jpn. Aug 1997;39(4):403-5. [Medline].

  15. Jones SA, Flynn RJ. An unusual (and somewhat piercing) cause of paraphimosis. Br J Urol. Nov 1996;78(5):803-4. [Medline].

  16. Kerwat R, Shandall A, Stephenson B. Reduction of paraphimosis with granulated sugar. Br J Urol. Nov 1998;82(5):755. [Medline].

  17. Litzky GM. Reduction of paraphimosis with hyaluronidase. Urology. Jul 1997;50(1):160. [Medline].

  18. Monsour MA, Rabinovitch HH, Dean GE. Medical management of phimosis in children: our experience with topical steroids. J Urol. Sep 1999;162(3 Pt 2):1162-4. [Medline].

  19. O'Donnell, JA II. Phimosis and paraphimosis. In: Barkin RM, et al, eds. Pediatric Emergency Medicine. 2nd ed. St Louis, Mo: Mosby; 1997:1152-3.

  20. Oster J. Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child. Apr 1968;43(228):200-3. [Medline].

  21. Treatment of Paraphimosis. Available at http://forum.doctissimo.fr/doctissimo/Prepuce-et-phimosis/cicatrice-operation-sujet_301_1.htm. Accessed October 21, 2008.

  22. Waseem M, Devas G. Photo Quiz. Resident and Staff Physician [serial online]. June 2007;53(6):Accessed October 21, 2008. Available at http://www.residentandstaff.com/issues/articles/2007-06_09.asp.

  23. Williams JC, Morrison PM, Richardson JR. Paraphimosis in elderly men. Am J Emerg Med. May 1995;13(3):351-3. [Medline].

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Further Reading

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Keywords

phimosis, paraphimosis, congenital phimosis, acquired phimosis, physiologic phimosis, pathologic phimosis, entrapment of a retracted foreskin, uncircumcised penis, incorrectly circumcised penis, foreskin, glans penis, balanitis, balanoposthitis, dorsal slit of foreskin

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Contributor Information and Disclosures

Author

Hina Z Ghory, MD, Chief Resident Physician, Department of Emergency Medicine, New York Presbyterian Hospital
Hina Z Ghory, MD is a member of the following medical societies: American Medical Women's Association and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

Rahul Sharma, MD, MBA, Instructor in Medicine, Weill Medical College of Cornell University; Consulting Staff, Department of Emergency Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center
Rahul Sharma, MD, MBA is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St. Barnabas Hospital
Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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