Paraphimosis: Difference between revisions

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==Background==
==Background==
*Foreskin trapped behind glans
*Retracted foreskin becomes trapped behind glans
**Acts as constricting band<ref>https://www.aafp.org/afp/2000/1215/p2623.html</ref>
**May result in glans necrosis as venous engorgement leads to arterial compromise
*Urologic emergency
*Urologic emergency
**May result in glans necrosis if not reduced due to venous engorgement causing arterial compromise


==Diagnosis==
==Clinical Features==
*Pain, erythema, swelling distal to constricting ring of foreskin
[[File:PMC2791735 wjem-10-281f1.png|thumb|Paraphimosis with non-retractable foreskin and distal swelling ]]
*Penile pain
*Enlarged and erythematous glans<ref>Choe, J. (2000). Paraphimosis: Current treatment options. American Family Physician, 62(12):2623-2626.</ref>
*Constricting band immediately behind glans<ref>Choe, J. (2000). Paraphimosis: Current treatment options. American Family Physician, 62(12):2623-2626.</ref>
*Penile shaft flaccid<ref>Choe, J. (2000). Paraphimosis: Current treatment options. American Family Physician, 62(12):2623-2626.</ref>
*Pediatric patients may present with obstructive urinary symptoms<ref>Choe, J. (2000). Paraphimosis: Current treatment options. American Family Physician, 62(12):2623-2626.</ref>


==Differential Diagnosis==
==Differential Diagnosis==
{{Nontrauma penile DDX}}
{{Nontrauma penile DDX}}
{{Penile Trauma DDX}}
==Evaluation==
*Typically a clinical diagnosis


==Management==
==Management==
*Reduction
*Reduction
**Perform as soon as possible
**Perform as soon as possible
**Consider penile block, local anesthetic cream (EMLA) or procedural sedation  
**Consider [[Nerve Block: Penile|penile block]], local anesthetic cream (EMLA) or procedural sedation
**Use bag of ice (3min intervals) or manual compression before attempting reduction
 
***Wrap glans with 2x2-in. elastic bandage for 5min
===Manual Reduction===
**Use thumbs to push the glans into the foreskin while index fingers pull foreskin back into normal position
#Wearing gloves, encircle the distal penis and apply circumferential pressure to reduce edema
*If fails obtain emergent urology consult and/or perform the following:
#Maintain pressure for several minutes
**Use 22-25ga needle to make multiple punctures (3-5mm deep) in foreskin (expresses glans edema fluid) and then perform compression
#Release pressure and advance foreskin over glans
**Inject hyaluronidase into the swollen foreskin to decrease edema
#*Use thumbs to push glans toward foreskin while using fingers to pull foreskin over glans
**Can also use several evenly spaced, babcock (noncrushing) clamps around foreskin, followed by gentle traction to pull phimotic ring over the glans
 
===Compressive Bandage Reduction===
#Wearing gloves, wrap the distal penis in the distal to proximal direction with compressive bandage
#Leave bandage for several minutes to allow edema to disperse
#Remove bandage and advance foreskin over glans
#*Use thumbs to push glans toward foreskin while using fingers to pull foreskin over glans
 
===Adjunctive Therapies===
*Apply ice packs in 3 minute intervals to reduce edema (monitor carefully for frostbite)
*Apply granulated sugar to distal penis as an osmotic agent
*Inject hyaluronidase into the swollen foreskin to decrease edema
*Apply several evenly-spaced, Babcock (non-crushing) clamps around foreskin
**Apply gentle traction on clamps to pull foreskin over glans
 
===Reduction Failure===
*If above techniques fail:
#Obtain emergent urology consult
#Proceed to Dundee aspiration or dorsal slit procedure if urology is not immediately available
 
===Dundee Technique<ref>Reynard, J., and Barua, J. (1999). Reduction of paraphimosis the simple way - The Dundee technique. British Journal of Urology, 83(7):859-860.</ref>===
#Apply local anesthetic, perform a penile ring block, or sedate patient
#Prep the foreskin using antiseptic
#Use a 26 gauge needle to make approximately 20 puncture holes in the foreskin
#Use gentle manual pressure to express edema fluid from foreskin
#Advance the foreskin over the glans
#*Use thumbs to push glans toward foreskin while using fingers to pull foreskin over glans
 
===Dorsal Slit Procedure===
 
**[[Dorsal Slit (Penis)|Dorsal Slit]] indicated if evidence of impaired perfusion and urologist unavailable
**[[Dorsal Slit (Penis)|Dorsal Slit]] indicated if evidence of impaired perfusion and urologist unavailable


Latest revision as of 20:18, 15 May 2019

Background

  • Retracted foreskin becomes trapped behind glans
    • Acts as constricting band[1]
    • May result in glans necrosis as venous engorgement leads to arterial compromise
  • Urologic emergency

Clinical Features

Paraphimosis with non-retractable foreskin and distal swelling
  • Penile pain
  • Enlarged and erythematous glans[2]
  • Constricting band immediately behind glans[3]
  • Penile shaft flaccid[4]
  • Pediatric patients may present with obstructive urinary symptoms[5]

Differential Diagnosis

Non-Traumatic penile diagnoses

Penile trauma types

Evaluation

  • Typically a clinical diagnosis

Management

  • Reduction
    • Perform as soon as possible
    • Consider penile block, local anesthetic cream (EMLA) or procedural sedation

Manual Reduction

  1. Wearing gloves, encircle the distal penis and apply circumferential pressure to reduce edema
  2. Maintain pressure for several minutes
  3. Release pressure and advance foreskin over glans
    • Use thumbs to push glans toward foreskin while using fingers to pull foreskin over glans

Compressive Bandage Reduction

  1. Wearing gloves, wrap the distal penis in the distal to proximal direction with compressive bandage
  2. Leave bandage for several minutes to allow edema to disperse
  3. Remove bandage and advance foreskin over glans
    • Use thumbs to push glans toward foreskin while using fingers to pull foreskin over glans

Adjunctive Therapies

  • Apply ice packs in 3 minute intervals to reduce edema (monitor carefully for frostbite)
  • Apply granulated sugar to distal penis as an osmotic agent
  • Inject hyaluronidase into the swollen foreskin to decrease edema
  • Apply several evenly-spaced, Babcock (non-crushing) clamps around foreskin
    • Apply gentle traction on clamps to pull foreskin over glans

Reduction Failure

  • If above techniques fail:
  1. Obtain emergent urology consult
  2. Proceed to Dundee aspiration or dorsal slit procedure if urology is not immediately available

Dundee Technique[6]

  1. Apply local anesthetic, perform a penile ring block, or sedate patient
  2. Prep the foreskin using antiseptic
  3. Use a 26 gauge needle to make approximately 20 puncture holes in the foreskin
  4. Use gentle manual pressure to express edema fluid from foreskin
  5. Advance the foreskin over the glans
    • Use thumbs to push glans toward foreskin while using fingers to pull foreskin over glans

Dorsal Slit Procedure

    • Dorsal Slit indicated if evidence of impaired perfusion and urologist unavailable

Disposition

  • Refer all cases to urology to determine need for circumcision

See Also

References

  1. ↑ https://www.aafp.org/afp/2000/1215/p2623.html
  2. ↑ Choe, J. (2000). Paraphimosis: Current treatment options. American Family Physician, 62(12):2623-2626.
  3. ↑ Choe, J. (2000). Paraphimosis: Current treatment options. American Family Physician, 62(12):2623-2626.
  4. ↑ Choe, J. (2000). Paraphimosis: Current treatment options. American Family Physician, 62(12):2623-2626.
  5. ↑ Choe, J. (2000). Paraphimosis: Current treatment options. American Family Physician, 62(12):2623-2626.
  6. ↑ Reynard, J., and Barua, J. (1999). Reduction of paraphimosis the simple way - The Dundee technique. British Journal of Urology, 83(7):859-860.
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