Emergency Department Care
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.)
Emergent circumcision
Emergency circumcision is a last resort that is 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.
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
Complications of phimosis or paraphimosis may include the following:
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Recurrence
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Posthitis
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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]
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Anatomy of the penis.
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Physiologic phimosis versus pathologic phimosis.
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Paraphimosis.
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Dorsal slit procedure.
