Dorsal Slit of the Foreskin

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, 3, 4]}  A retrospective study comparing elective circumcision versus dorsal slit for elective management of phimosis found no differences between the groups in terms of stenosis, postoperative pain, need for reoperation, parental appreciation of postoperative pain, or functional and esthetic satisfaction. Bleeding was more frequent in the circumcision group (1.7%; P = .03). ^[5]

Phimosis

Phimosis is the inability of the foreskin to retract and expose the glans. ^[6] 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. ^{[7, 8]} See image below.

Paraphimosis

Paraphimosis is the inability to replace the retracted foreskin. ^{[9, 10]} Dorsal slit of the foreskin should only be performed on patients whose paraphimosis could not be reduced with manual techniques. ^[11] See image below.

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 Medscape Reference article Paraphimosis Reduction Procedures.

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. ^{[12, 13]}

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. ^[14]

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.

Alternatively, local anesthesia can be achieved by doing a dorsal nerve block with or without a ring block. ^[15] For more information, see Nerve Block, Dorsal Penile.

Equipment includes the following:

• 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

The patient should lie supine with his genitalia exposed.

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.

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.

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.

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.

An alternative is to use a simple running absorbable suture to ensure hemostasis of the incised edges. See image below.

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 day) follow-up with a urologist should be arranged for aftercare and consideration of elective circumcision. ^{[16, 17]}

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 include the following:

• 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.