Paraphimosis

Background

• Retracted foreskin becomes trapped behind glans
  • Acts as constricting band
  • 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
• Constricting band immediately behind glans
• Penile shaft flaccid
• Pediatric patients may present with obstructive urinary symptoms

Differential Diagnosis

Non-Traumatic penile diagnoses

• Phimosis
• Balanoposthitis
• Paraphimosis
• Priapism
• STDs

Penile trauma types

• Penile amputation
• Penile contusion
• Penile fracture
• Traumatic epididymitis
• Zipper injury to penis

Evaluation

• Typically a clinical diagnosis

Management

• Reduction
  • Perform as soon as possible
  • Consider penile block, local anesthetic cream (EMLA) or procedural sedation
  • Use bag of ice (3min intervals) or manual compression before attempting reduction
    • Consider granulated sugar (as an osmotic agent)
    • Wrap glans with 2x2-in. elastic bandage for 5min
  • Use thumbs to push the glans into the foreskin while index fingers pull foreskin back into normal position
• If fails obtain emergent urology consult and/or perform the following:
  • Use 22-25ga needle to make multiple punctures (3-5mm deep) in foreskin (expresses glans edema fluid) and then perform compression
  • Inject hyaluronidase into the swollen foreskin to decrease edema
  • Can also use several evenly spaced, babcock (noncrushing) clamps around foreskin, followed by gentle traction to pull phimotic ring over the glans
  • Dorsal Slit indicated if evidence of impaired perfusion and urologist unavailable

Disposition

• Refer all cases to urology to determine need for circumcision

See Also

• Dorsal Slit (Penis)
• Phimosis