Paraphimosis

Updated: Nov 30, 2020
  • Author: Nathan A Brooks, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Overview

Practice Essentials

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. [1, 2]

Illustration of paraphimosis. The foreskin is swol Illustration of paraphimosis. The foreskin is swollen and edematous. A constricting collar or band is present behind the glans penis.

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.

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Relevant Anatomy

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.

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Pathophysiology

When the foreskin becomes trapped behind the corona for a prolonged period, it forms a tight band of tissue 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.

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Etiology

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:

  • Self-infliction, such as piercing with a penile ring into the glans [3, 4]
  • Placement of a preputial bead
  • Erotic dancing [5]
  • P lasmodium falciparum infection [6]
  • Contact dermatitis (eg, from the application of celandine juice to the foreskin [7] )
  • Haemophilus ducreyi infection (chancroid) [8]
  • Lichens Sclerosus (LS) [9]
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Epidemiology

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, [10] as well as penile piercings leading to paraphimosis. [11] 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 2010, 58.3% of newborn boys were circumcised. Actual rates were presumably somewhat higher, however, as this figure does not include circumcisions performed in the community. [12]

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Prognosis

Complications of paraphimosis include pain, infection, and swelling of the glans penis. The distal portion of the penis can become ischemic and even necrotic. [13]

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.

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