Paraphimosis 

Updated: Dec 30, 2017
Author: Nathan A Brooks, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS 

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.

Background

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.

Epidemiology

Frequency

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,[3] as well as penile piercings leading to paraphimosis.[4] 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.[5]

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 [6]
  • Placement of a preputial bead
  • Erotic dancing [7]
  • P lasmodium falciparum infection [8]
  • Contact dermatitis (eg, from the application of celandine juice to the foreskin [9] )
  • Haemophilus ducreyi infection (chancroid) [10]

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.

Presentation

Adult patients with symptomatic paraphimosis most often report penile pain. In the pediatric population, paraphimosis may manifest as acute urinary tract obstruction and may be reported as obstructive voiding symptoms.

On examination, the glans penis is enlarged and congested with a collar of edematous foreskin. A constricting band of tissue is noted directly behind the head of the penis. The remainder of the penile shaft is unremarkable. An indwelling urethral catheter is often present. Simply removing the catheter may help treat paraphimosis caused by an indwelling urethral catheter. The image below depicts mild-to-moderate paraphimosis.

Mild-to-moderate form of paraphimosis. The treatme Mild-to-moderate form of paraphimosis. The treatment involves manual reduction, puncture technique, or medical therapy.

If paraphimosis is left untreated for too long, necrosis of the glans penis can occur. Partial amputation of the distal penis has been reported. The image below depicts severe paraphimosis.

Severe form of paraphimosis. The distal penis has Severe form of paraphimosis. The distal penis has begun the process of autoamputation.

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.

Management

When diagnosed early, paraphimosis can be remedied easily with simple manual reduction in combination with other conservative measures. Patients with severe paraphimosis that proves refractory to conservative therapy will require a bedside emergency dorsal slit procedure to save the penis. Formal circumcision can be performed in the operating room at a later date.

Pain control

Paraphimosis is a a painful condition and care should be taken to ensure patient comfort by providing adequate analgesia and local anesthesia using a dorsal penile nerve block and circumferential penile ring block with lidocaine, bupivicaine, or a combination of the two. Epinephrine should never be injected. In additional, topical application of lidocaine or prilocaine creams and direct injection of anesthetic into the foreskin can be used.

Reduction

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 may 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, all using the same principle of traction on the foreskin and countertraction on the glans.

In addition, reduction can include the use of forceps and clamps to pull the foreskin. Those instruments must be used cautiously, however, as they can crush the skin and cause necrosis of this tissue due to devascularization. The use of a 25-gauge needle to make several small stab incisions as an outlet for edema fluid has also been described[11] .

Adjuncts to reduction

Ice, osmotic agents such as sugar, and compression wrapping with Coban® have been used as adjuncts to manual reduction and can be considered. Ice and osmotic agents may require 1-2 hours to take effect, however, so they should not be used when arterial compromise is suspected.

Dorsal slit

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, the operator then uses a hemostat 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 30-60 seconds, to provide hemostasis. The crushed area is then sharply incised with scissors. The edges are often oversewn with an interrupted or running stitch, using a 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.[12]

Regardless of the method used, urologic evaluation acutely in the emergency department and then following the acute interaction for consideration of circumcision are crucial.

Contraindications

Do not consider circumcision in a neonate with hypospadias, a dorsal hood deformity, or a small penis. Refer the neonate to a urologist.

 

Treatment

Medical Therapy

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[13] 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.[14] If a Foley catheter is present, remove it temporarily until the paraphimosis has resolved.

Reduction

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.[15] )

  • 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).

This demonstrates the technique of manually reduci This demonstrates the technique of manually reducing the paraphimotic foreskin.

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.

Surgical Therapy

The puncture technique,[16, 17] 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.

The puncture method to relieve preputial edema res The puncture method to relieve preputial edema resulting from paraphimosis. Using a needle, several punctures are made in the foreskin to relieve the trapped fluid.

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.

Dorsal Slit

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[12] .

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.

Preoperative Details

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.

Anesthesia

Adequate anesthesia for emergency department management of paraphimosis is technically challenging using a landmark-based technique of a dorsal penile block (DPB). The landmark-based DPB is not standardized and options include “10 o'clock and 2 o'clock” infrapubic injections with or without ventral infiltration or a ring block. Given the inherent technical imprecision, large dosage of a local anesthetic (up to 50 mL) can be required to achieve an adequate block. Successful use of an ultrasound-guided approach has been reported wherevy  the dorsal penile nerves were precisely targeted in the fascial compartment just deep to Buck fascia, reducing the need for large local anesthetic.[18]

Postoperative Details

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.

Follow-up

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 eMedicineHealth's Men's Health Center. Also, see eMedicineHealth's patient education articles Foreskin Problems and Circumcision.

Complications

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.