eMedicine Specialties > Clinical Procedures > Genitourinary Procedures

Dorsal Slit of the Foreskin

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
Eric W Snyder, MD, Chief Resident, Department of Emergency Medicine, University of California at Los Angeles/Olive View-UCLA Medical Center

Updated: Nov 10, 2009

Introduction

Dorsal slit of the foreskin is performed to relieve strangulation of the glans by a paraphimosis or to visualize the urethral meatus in patients with phimosis.^{[1,2 ]}

Indications

Phimosis

Phimosis is the inability of the foreskin to retract and expose the glans.^{[3 ]}Dorsal slit of the foreskin should only be performed on patients who are experiencing urinary retention as a result of the phimosis and in whom a urethral catheter cannot be blindly inserted.^{[4 ]}See image below.

Phimotic foreskin. The distal foreskin is edematous, with cracked fissures. The patient was unable to retract the foreskin.

Paraphimosis

Paraphimosis is the inability to replace the retracted foreskin.^{[5,6 ]}Dorsal slit of the foreskin should only be performed on patients whose paraphimosis could not be reduced with manual techniques.^{[7 ]}See image below.

Paraphimosis.

Contraindications

No absolute contraindications exist to the performance of dorsal slit of the foreskin.
Dorsal slit of the foreskin should be performed only after failure of noninvasive techniques. For detailed descriptions of manual reduction techniques for paraphimosis, please see eMedicine article Paraphimosis Reduction.
Pediatric patients, patients who have bleeding disorders or are taking anticoagulants, and patients who are immunocompromised or have an infected foreskin are better treated by (or after consultation with) a urologist.^{[8,9 ]}

Anesthesia

Dorsal slit of the foreskin is a painful procedure. Consider the use of parenteral analgesia with or without procedural sedation to reduce the patient's discomfort.
Using a 5-mL syringe with a 27-gauge (ga) needle, raise a skin wheal of local anesthetic solution without epinephrine subcutaneously in the 12-o'clock position of the dorsal midline of the penis. Insert the needle through the skin wheal and advance it distally, injecting subcutaneously as the needle advances to the distal edge of the foreskin (see image below). This method does not provide analgesia to the ventral aspect of the penis and foreskin.
- Local anesthesia of the dorsal foreskin.
Alternatively, local anesthesia can be achieved by doing a dorsal nerve block with or without a ring block. For more information, see Nerve Block, Dorsal Penile.

Equipment

Povidone-iodine solution (eg, Betadine)
Lidocaine 1-2% without epinephrine
Sterile gloves
Sterile drapes
Syringe, 5 mL
Needles, 18 and 27 ga
Gauze squares, 4 x 4 inches
Straight hemostats or straight Kelly clamps
Iris scissors or No. 15 scalpel
Needle driver
Absorbable sutures, 3-0 or 4-0
Petroleum gauze
Topical antibacterial ointment

Positioning

The patient should lie supine with his genitalia exposed.

Technique

Obtain informed consent from the patient.
Administer parenteral analgesia with or without a sedative, followed by local anesthesia of the foreskin and penis.
Apply povidone-iodine solution to the penis in circular motions from the glans and proximally to include the scrotum and the surrounding skin. Repeat the iodine application at least 2 more times and apply sterile drapes to create a sterile field.

Dorsal slit of the paraphimotic foreskin

After verifying adequate anesthesia of the foreskin, apply 2 hemostats over the foreskin and phimotic ring at the 11-o'clock and 1-o'clock positions. Make sure that the inferior jaw of the clamp is below the phimotic ring and that the superior jaw is on top of it. Be sure not to clamp the skin of the penile shaft.
Pull the 2 hemostats away from each other and have an assistant hold them. Using Iris scissors or a No. 15 scalpel, incise the foreskin at the 12-o'clock position (in between the 2 clamps). Be sure not to incise the skin of the penile shaft. See image below.
- Incision of the foreskin at the 12-o'clock position.
An alternative method is to crush the foreskin at the 12-o'clock position with a straight hemostat for 2-3 minutes before incising the crushed foreskin.
Remove the hemostats, cover with a dry sterile gauze pad, and let the edges ooze for a few minutes. Then, reduce the paraphimotic foreskin using a manual technique.

Dorsal slit of the phimotic foreskin

After verifying adequate anesthesia of the foreskin, insert the bottom jaw of a straight hemostat between the foreskin and the glans penis at the 12-o'clock position. Advance the hemostat until its tip reaches the coronal sulcus.
Gently swipe the hemostat to break any adhesions between the glans and the foreskin.
The tip of the hemostat should be easily palpated and seen tenting the foreskin at the coronal sulcus. If the possibility exists that the jaw of the hemostat is inside the urethra, pull the hemostat out and reinsert it.
After confirming correct placement of the bottom jaw of the hemostat (at the 12-o'clock position between the glans and the foreskin), close the instrument and allow it to crush the foreskin for 2-3 minutes. See image below.
- The redundant foreskin is clamped at the 12-o'clock position for 2 minutes for hemostasis.
Remove the hemostat and use the straight scissors to carefully cut the crushed foreskin. Cover with a dry sterile gauze pad and let the edges ooze for a few minutes. Then, reduce the phimotic foreskin using a manual technique.

Approximation of the incised foreskin and aftercare

Note that the foreskin opens up in a rectangular fashion. See image below.
- The incised foreskin opens up in a rectangular fashion.
Using an absorbable 3-0 or 4-0 suture, approximate the edges of the foreskin to the opposite edge on the same side. A gap remains in the 12-o'clock position. See image below.
- Approximation of the incised foreskin.
An alternative is to use a simple running absorbable suture to ensure hemostasis of the incised edges. See image below.
- Approximation of the incised foreskin with a running absorbable suture.
Make sure that the foreskin is reduced to a natural position covering the glans to avoid iatrogenic paraphimosis.
Generously apply a topical antibacterial ointment over the suture line and loosely cover with petroleum gauze and sterile gauze.
Use paper tape to secure the dressing to the penile skin. Avoid circumferential dressing or taping around the penis, as this can cause ischemia and necrosis.
Some authors recommend the routine administration of prophylactic antibiotics, though this practice is not evidence-based.
The patient should be observed in the emergency department for at least 30 minutes to ensure adequate hemostasis. An urgent (1-2 d) follow-up with a urologist should be arranged for aftercare and consideration of elective circumcision.^{[10,11 ]}

Pearls

Dorsal slit of the foreskin should be performed only after failure of noninvasive techniques.
In the setting of phimosis, ensure that the tip of the hemostat is easily palpated after insertion below the foreskin and that tenting at the coronal sulcus is observed. If the possibility exists that the jaw of the hemostat is inside the urethra, pull the hemostat out and reinsert it.

Complications

Injury to the urethra or glans: Use of proper technique should prevent inadvertent injury.
Skin laceration: Inadvertent lacerations to the penile shaft skin should be sutured with an absorbable suture.
Bleeding: Crushing of the foreskin with a clamp before incising it and placing stitches appropriately after the foreskin incision should decrease bleeding.
Wound infection: Daily inspection and local wound care by the patient or his caregiver should minimize rates of infection. Some authors recommend the prophylactic use of antibiotics.

Multimedia

Media file 1: Paraphimosis.

Media file 2: Local anesthesia of the dorsal foreskin.

Media file 3: Incision of the foreskin at the 12-o'clock position.

Media file 4: The incised foreskin opens up in a rectangular fashion.

Media file 5: Approximation of the incised foreskin.

Media file 6: Approximation of the incised foreskin with a running absorbable suture.

Media file 7: Phimotic foreskin. The distal foreskin is edematous, with cracked fissures. The patient was unable to retract the foreskin.

Media file 8: The redundant foreskin is clamped at the 12-o'clock position for 2 minutes for hemostasis.

References

Stine RJ, Avila JA, Lemons MF, Sickorez GJ. Diagnostic and therapeutic urologic procedures. Emerg Med Clin North Am. Aug 1988;6(3):547-78. [Medline].
Lawless MR. The foreskin. Pediatr Rev. Dec 2006;27(12):477-8. [Medline].
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].
Thiruchelvam N, Nayak P, Mostafid H. Emergency dorsal slit for balanitis with retention. J R Soc Med. Apr 2004;97(4):205-6. [Medline].
Choe JM. Paraphimosis: current treatment options. Am Fam Physician. Dec 15 2000;62(12):2623-6, 2628. [Medline].
Rangarajan M, Jayakar SM. Paraphimosis revisited: is chronic paraphimosis a predominantly third world condition?. Trop Doct. Jan 2008;38(1):40-2. [Medline].
Williams JC, Morrison PM, Richardson JR. Paraphimosis in elderly men. Am J Emerg Med. May 1995;13(3):351-3. [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].
Chu CC, Chen YH, Diau GY, Loh IW, Chen KC. Preputial flaps to correct buried penis. Pediatr Surg Int. Nov 2007;23(11):1119-21. [Medline].
Holman JR, Stuessi KA. Adult Circumcision. American Family Physician [serial online]. March 15, 1999;59(6):1514-8. Available from: http://www.aafp.org. [Medline]. Available at http://www.aafp.org/afp/990315ap/1514.html.
Williams JC, Morrison PM, Richardson JR. Paraphimosis in elderly men. Am J Emerg Med. May 1995;13(3):351-3. [Medline].
Reichman E, Simon R. Dorsal slit of the foreskin. In: Emergency Medicine Procedures. New York, NY: McGraw-Hill; 2004.
Roberts JR, Hedges JR. Urologic procedures. In: Chanmugam AS, Chudnofsky CR, Custalow CB, Dronen SC, eds. Roberts: Clinical Procedures in Emergency Medicine. 4^th ed. Philadelphia, Pa: WB Saunders; 2004:1075-6.

Keywords

dorsal slit, dorsal slit of foreskin, phimosis, paraphimosis, circumcision, adult circumcision, foreskin, foreskin reduction, phimosis reduction, paraphimosis reduction, glans, anesthesia of foreskin, anesthesia of penis, foreskin anesthesia, penis anesthesia, phimotic, paraphimotic, foreskin incision, dorsal incision

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.

Coauthor(s)

Eric W Snyder, MD, Chief Resident, Department of Emergency Medicine, University of California at Los Angeles/Olive View-UCLA Medical Center
Eric W Snyder, MD is a member of the following medical societies: Alpha Omega Alpha
Disclosure: Nothing to disclose.

Medical Editor

Luis M Lovato, MD, Associate 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: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

Acknowledgments

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

For more information

Web Links

American Family Physician: Adult Circumcision

Further Reading