Phimosis and Paraphimosis In the ED

Up to 10% of males will have physiologic phimosis at 3 years of age, and a larger percentage of children will have only partially retractible foreskins. One to five percent of males will have nonretractible foreskins by age 16 years.[2, 5]

Research shows that in all but a small proportion of boys, the foreskin is retractile by the time boys mature through their teenage years. Studies have revealed that phimosis is present in 8% of 6- to 7-year-olds, 6% of 10- to 11-year-olds, and 1% of 16- to 17-year-olds. In contrast, preputial adhesions remain much more common throughout childhood and adolescence, but by 17 years of age, only 3% of these boys have persisting adhesions.[1]

True pathologic phimosis caused by BXO has a relatively stable incidence across all decades of life, with a spike in the third decade of life. It is relatively rare in children under the age of 5, and peak childhood incidence has been noted between 9 and 11 years of age.[1]

In uncircumcised children 4 months to 12 years of age with foreskin problems, paraphimosis (0.2%) is less common than other penile disorders, such as balanitis (5.9%), irritation (3.6%), penile adhesions (1.5%), or phimosis (2.6%). In adults, paraphimosis is most commonly found during adolescence. It occurs in about 1% of all adult males older than 16 years.[6]

In a Danish study, phimosis was the most frequently reported indication (95.0%) for foreskin surgery in boys younger than 18 years. The remaining 5% underwent surgery because of frenulum breve causing problems during erection. Nine patients needed a second surgery because of recurrent phimosis.[3]

A study of adult patients who underwent circumcision found that the most common indications were phimosis (46.5%), dyspareunia (17.8%), balanitis (14.4%), and concurrent phimosis and balanitis (8.9%). In most older patnts, the reason for adult circumcision was concurrent phimosis and balanitis or cancer, whereas in younger patients, dyspareunia was the most common cause. The complication rate was 3.5%, and there was no significant difference in complication rates between the older patient group and the younger patient group.[20]

Early selection of appropriate treatment for children with phimosis is beneficial for the development of their reproductive organs and significantly improves their prognosis.[21]

The use of steroid cream for physiologic phimosis is associated with decreased risk of recurrent urinary tract infection (UTI) in uncircumcised male infants with normal findings on renal ultrasound.[22]

Circumcision has traditionally been the treatment of choice, but its popularity in cases of non-scarred phimosis has been superseded by more conservative methods such as preputioplasty. Foreskin-conserving methods such as this are a valid option in the treatment of non-scarred pathologic phimosis.[23]

The prognosis with paraphimosis is excellent if it is diagnosed and treated promptly. An alternative to circumcision, especially in an older or sicker patient, is a dorsal slit. Either technique is satisfactory in preventing recurrence of paraphimosis.[6]

Patients with paraphimosis should receive instruction on hygiene, should be sure to return their foreskin to its normal position if it has been retracted, and should avoid wearing penile jewelry if this has contributed to the condition. The patient may wish to consider circumcision to preclude future episodes, particularly with recurrence.[6]

Parents should be educated about the normalcy of congenital phimosis and the time course of its resolution. The dangers of forcibly retracting the foreskin for hygienic purposes should be stressed. If the prepuce does not readily retract, parents should not attempt to clean under it.

Patients and parents of children should be educated on the importance of reduction of the foreskin after each cleaning.

All providers of adult care should be made aware of the risk of paraphimosis associated with bladder catheterization. They should be reminded to always reduce the foreskin after cleaning and catheterization.

Parents of patients with physiologic phimosis may bring in the patient after noting an inability to retract the foreskin during routine cleaning or bathing. Parents may also be alarmed by "ballooning" of the prepuce during urination — a normal finding.

Pathologic phimosis may be detected in males who report painful erections, hematuria, recurrent urinary tract infections, preputial pain, or a weakened urinary stream. (See below.)

Physiologic phimosis versus pathologic phimosis.

Paraphimosis classically presents with a painful, swollen glans penis in the uncircumcised or partially circumcised patient. A preverbal infant may present only with irritability. Occasionally, the paraphimosis may be an incidental finding noted by a caretaker of a debilitated patient. (See below.)

Paraphimosis.

Paraphimosis is classically seen in one of the following populations[24, 25]

• Children whose foreskins have been forcefully retracted or who forget to reduce their foreskin after voiding or bathing

• Adolescents or adults who present with paraphimosis in the setting of vigorous sexual activity[26]

• Men with chronic balanoposthitis

• Patients with indwelling catheters in whom caretakers forget to replace the foreskin after catheterization or cleaning

Urinary obstruction is a late feature.

Phimosis includes the following:

• The foreskin cannot be retracted proximally over the glans penis.

• In physiologic phimosis, the preputial orifice is unscarred and healthy appearing.

• In pathologic phimosis, a contracted white fibrous ring may be visible around the preputial orifice

  Physiologic phimosis versus pathologic phimosis.

Paraphimosis includes the following:

• The foreskin is retracted behind the glans penis and cannot be replaced to its normal position.

• The foreskin forms a tight, constricting ring around the glans.

• Flaccidity of the penile shaft proximal to the area of paraphimosis is seen (unless there is accompanying balanoposthitis or infection of the penis).

• With time, the glans becomes increasingly erythematous and edematous.

• The glans penis is initially its normal pink hue and soft to palpation. As necrosis develops, the color changes to blue or black and the glans becomes firm to palpation.

Patients with phimosis rarely require any emergency intervention and should be referred to a urologist 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 in case studies, though none have been tested in randomized control trials.[27] 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[9] using lidocaine hydrochloride without epinephrine, or, especially in children, conscious sedation. Sterile technique should be used for all invasive procedures.[10, 11]

In a retrospective analysis comparing a topical anesthetic (TA) to procedural sedation (PS) in 46 patients with paraphimosis requiring urgent manual reduction, first-attempt success for TA was 91.4% (32/35) and 81.8%  for PS (9/11). The mean length of stay in the emergency department was shorter for TA patients (148 min vs. 357 min) and remained significantly shorter after controlling for age and duration of paraphimosis.[28]

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. Soaking the penis in a glove full of ice for 5 minutes before attempting manual reduction has been reported to be effective 90% of the time.[27]

An elastic bandage can also be wrapped from the glans to the base of the penis for 5-7 minutes to minimize edema.[29]

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.[30]

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.[30] 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.[30] 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.[30]

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

For aspiration of blood, a tourniquet is applied to the shaft of the penis. A 20-gauge 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.[29] 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 Dorsal Penile Nerve Block. (See the image below.)

Dorsal slit procedure.

Emergent circumcision

Emergency circumcision is a last resort that is performed by a urologist to achieve the necessary reduction of a paraphimosis.

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.

Referral to outpatient urology follow-up is required in cases of pathologic phimosis.[2] Not all cases of phimosis require circumcision. Prepuce sparing surgery using Z-plasty for the treatment of phimosis and scarred foreskin has been reported.[31]  The urologist, in consultation with the patient and his family, may try a course of topical steroids or preputioplasty.

A paraphimosis that is reduced with minimal intervention by the ED physician still requires outpatient urology follow-up in anticipation of recurrences and evaluation for possible circumcision. Trauma to the foreskin during reduction of a paraphimosis may lead to the development of phimosis in up to 30% of patients.[30]

Complications of phimosis or paraphimosis may include the following:

• Recurrence

• Posthitis

• Necrosis and gangrene of the glans[26, 32]

• Autoamputation

In a study by Afonso et al of 30 patients who underwent circumcision due to phimosis, human papillomavirus (HPV) was present in 46.7% of patients, of whom 50% had high-risk HPV genotypes. Only 16.4% of 100 asymptomatic patients were found to be positive for HPV, and only 1 showed high-risk HPV.[33]

According to a study by Huang et al, phimosis with preputial fissures may be a sign of undiagnosed diabetes mellitus. In 28 patients with acquired phimosis and preputial fissures, diabetes was confirmed in all 28 patients, as compared to only 2 patients out of 28 with acquired phimosis without preputial fissures. Statistically significant differences were found in body mass index, random plasma glucose, glucosuria, and glycosylated hemoglobin levels, but not in age, family history of diabetes, hypertension, or classic hyperglycemic symptoms.[34]

Up to 95% of cases of phimosis have been shown to respond to application of topical steroids to the preputial orifice,[12] although some studies have suggested that this response rate may decline several months after the regimen is completed.[13] An initial attempt at medical intervention has been shown to reduce costs by 27.3% in comparison to primary circumcision as a treatment of phimosis in infants and children.[35] Complications of medication use are limited to preputial pain and hyperemia.

The ED physician may choose to recommend 0.05% betamethasone dipropionate applied to the preputial orifice twice a day for 4-6 weeks.[13]

Betamethasone valerate 0.1%, 0.2%, and 0.2% in combination with hyaluronidase has also been shown to be effective. In one study, patients who initially had partial or no response to this regimen reached complete response after 60 days of treatment.[14]

Anand and Kapoor reported on the use of the osmotic diuretic mannitol to reduce paraphimosis. The procedure required no anesthesia and was associated with minimal or no patient discomfort, according to the authors. They compared it to multiple needle punctures and other nonosmotic methods of reducing paraphimosis. A complete reduction of paraphimosis occurred after mannitol-soaked gauze had been placed over the edematous prepuce for about 30-45 minutes in 6 patients.[15]