You are in: eMedicine Specialties > Urology > Common Problems of the Penis ParaphimosisArticle Last Updated: Aug 25, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Jeffrey M Donohoe, MD, Assistant Professor of Pediatric Urology, Department of Surgery, Division of Urology, Medical College of Georgia Jeffrey M Donohoe is a member of the following medical societies: American Academy of Pediatrics and American Urological Association Coauthor(s): Hye Kim, RPh, Investigational Drug Pharmacist, Pharmacy Services, Johns Hopkins Hospital; James A Brown, MD, FACS, Associate Professor, Department of Surgery, Medical College of Georgia; Consulting Staff, Head of Urologic Oncology, Veterans Affairs Medical Center Editors: Allen Donald Seftel, MD, Department of Urology, Associate Professor, Case Western Reserve University; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Shlomo Raz, MD, Professor, Department of Surgery, Division of Urology, University of California at Los Angeles School of Medicine; J Stuart Wolf, Jr, MD, FACS, David A Bloom Professor of Urology, Director, Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical Center; Stephen W Leslie, MD, FACS, Founder and Medical Director of the Lorain Kidney Stone Research Center, Clinical Assistant Professor, Department of Urology, Medical College of Ohio Author and Editor Disclosure Synonyms and related keywords: painful swelling of prepuce, swollen foreskin, prepuce swelling, phimosis, penile pain, painful penis, infected penis, foreskin, prepuce, edematous prepuce, manual compression INTRODUCTIONSection 2 of 11
  Paraphimosis is an uncommon condition in which the foreskin, once pulled back behind the glans penis, cannot be brought down to its original position, thus constituting one of the few urologic emergencies encountered in general practice (see Image 1). Like phimosis, paraphimosis occurs only in uncircumcised or partly circumcised males. Paraphimosis is different from phimosis, a nonemergency condition in which the foreskin cannot be pulled back behind the glans penis. Patients with mild forms of paraphimosis have excellent outcomes, but severe paraphimosis can lead to dire consequences; therefore, view paraphimosis as a urologic emergency. Paraphimosis may occur when the foreskin has been pulled back behind the head of the penis for an extended period and is often caused by well-meaning health professionals secondary to penile examination or urethral instrumentation. When paraphimosis is suspected, immediately obtain a urology consult for proper evaluation and diagnosis. Prompt attention and treatment of this emergency should lead to a favorable outcome. FrequencyParaphimosis is a relatively uncommon condition and occurs less often than phimosis. Paraphimosis is almost always an iatrogenically or inadvertently induced condition. The condition occurs more often in hospitals and nursing homes than in the private community. In the private community, either the affected individual or a parent often retracts the prepuce and then inadvertently leaves it in its retracted position. In most cases, the foreskin reduces on its own and therefore precludes paraphimosis; however, if the slightest resistance to retraction of the prepuce is present, leaving it in this state predisposes it to paraphimosis. As edema accumulates, the condition worsens. According to the National Hospital Discharge Survey, a trend in the United States over the last 30-40 years has been toward noncircumcision. Circumcision rates, which were at an all-time high of 78-80% in the mid-to-late 1960s, decreased to 55-60% in 2003. With more uncircumcised individuals, paraphimosis has the potential to become more common. Because paraphimosis is a condition that is almost always iatrogenically or inadvertently induced, simple education and clarification of proper prepuce care to parents, the individuals themselves, and health care professionals may be all that is required to prevent this problem. EtiologyMost frequently, paraphimosis occurs after retraction of the foreskin during detailed penile examination, cleaning, urethral catheterization, or cystoscopy. Being prudent with foreskin manipulation is the most important key in preventing paraphimosis. Development of paraphimosis after catheterization is not uncommon. Before the insertion of a urethral catheter, a health professional retracts the foreskin to sterilely prepare and drape the glans penis. The retracted foreskin may be left in that manner for several hours to days. The failure to restore the prepuce to its original position sometimes leads to the development of paraphimosis. A more unusual cause of paraphimosis is self-infliction, such as piercing with a penile ring into the glans. Paraphimosis secondary to erections has also been reported. PathophysiologyWhen the foreskin becomes trapped behind the corona for a prolonged period, a tight band of tissue forms around the penis. This constricting ring impairs blood and lymphatic flow from the glans penis and prepuce. The ensuing tissue ischemia and vascular engorgement cause painful swelling of the glans and prepuce and may eventually cause gangrene or autoamputation of the distal penis. When diagnosed early, paraphimosis can be remedied easily with simple manual reduction in combination with other conservative measures. Patients with severe paraphimosis that proves refractory to conservative therapy require a bedside emergency dorsal slit procedure to save the penis. At a later date, a formal circumcision can be performed in the operating room. ClinicalAdult patients with symptomatic paraphimosis most often report penile pain. Children may report obstructive voiding symptoms. On examination, the glans penis is enlarged and congested with a collar of edematous foreskin. A constricting band of tissue is noted directly behind the head of the penis (see Image 2). The remainder of the penile shaft is unremarkable. An indwelling urethral catheter is often present. Removing the catheter may help treat paraphimosis. If paraphimosis is left untreated for too long, necrosis of the glans penis can occur. Partial amputation of the distal penis has been reported (see Image 3). In the pediatric population, paraphimosis may manifest as acute urinary obstruction. INDICATIONSSection 3 of 11
Indications for an emergency dorsal slit procedure include phimosis and paraphimosis that have proven refractory to more conservative measures. Emergency dorsal slit procedures are generally reserved for severe or complex paraphimosis. At a later date, a formal circumcision can be performed as an outpatient procedure. Prepuce-sparing procedures have been described and may be appropriate to perform if the individual must retain intact foreskin; however, the best way to ensure that paraphimosis will not recur is to perform circumcision. RELEVANT ANATOMYSection 4 of 11
The penis is divided into 3 parts.
The penis is innervated by the left and right dorsal nerves (main sensory nerve supply), which are branches of the pudendal nerve. The penis is a highly vascular organ supplied by the internal pudendal artery, which arises from the internal iliac artery and then branches into the deep penile artery, the bulbar artery, and the urethral artery. The deep penile artery becomes the cavernosal arteries, which supply the entire corpus cavernosum. The urethral artery supplies the glans penis and the corpus spongiosum. The bulbar artery nourishes the bulbar urethra and the bulbospongiosus muscle. CONTRAINDICATIONSSection 5 of 11
Do not consider circumcision in a neonate with hypospadias, a dorsal hood deformity, or a small penis. Refer the neonate to a urologist. TREATMENTSection 6 of 11
Medical therapyMedical therapy involves reassuring the patient, reducing the preputial edema, and restoring the prepuce to its original position and condition. Several methods of reducing the penile swelling have been described. Ice packs, penile wraps, and manual compression mechanically disperse the penile and preputial edema, while granulated sugar1 and hyaluronidase2 have been reported as effective agents to reduce swelling. If a Foley catheter is present, remove it temporarily until the paraphimosis is resolved. The author has never used any management options other than gentle reassurance, local anesthesia (1% lidocaine without epinephrine), intravenous sedation with morphine or midazolam (Versed) (in select cases), and then manual compression with simultaneous manual reduction. The author identifies the location of the cicatricial ring, reduces the edema distal to it, and, as quickly and efficiently as possible, reduces the cicatricial ring with one hand while the second hand has been compressing the glans and forcing out the edema. After 2 or 3 solid attempts, the author resorts to a dorsal slit procedure as described in Surgical therapy. Several other methods to effectively reduce the glanular and prepucial edema prior to reduction of the foreskin have been described in the literature. Some of these methods are described are as follows:
Regardless of the method chosen, when the preputial swelling and edema have subsided, correct the paraphimosis by gentle manual reduction (see Image 4). To reposition the prepuce, place both thumbs on the glans penis and wrap the fingers behind the prepuce. Apply a gentle, steady pressure to the prepuce with counterpressure to the glans penis as the prepuce is pulled down. When performed properly, the constricting band of tissue should come down to completely cover the glans with the prepuce. If the prepuce comes down but the constricting band remains behind, the paraphimosis has not been reduced properly or sufficiently. In patients who are determined to retain the appearance of an uncircumcised phallus, the author has the patient apply triamcinolone cream 0.1% to the affected area to possibly reduce the fibrosis of the ring. This has been described in the treatment for phimosis and has proven efficacy in temporarily preventing recurrent phimosis, decreasing the need for circumcision. After 6 weeks of triamcinolone application, if the prepuce can easily be retracted and reduced, the patient may proceed as such, but the risk for recurrent phimosis and paraphimosis remains. More often than not, the author ultimately performs circumcision. Surgical therapyThe puncture technique,3, 4 a minimally invasive procedure, and blood aspiration are common therapies to decompress the edematous prepuce. To perform the puncture technique, use an 18- or 21-gauge hypodermic needle to puncture the edematous prepuce at multiple sites and release the trapped fluid (see Image 5). External drainage results in rapid resolution of edema, which is followed by manual reduction of the foreskin. Alternatively, blood aspiration of the penis may be attempted after a tourniquet has been applied. If a severely constricting band of tissue precludes all forms of conservative or minimally invasive therapy, an emergency bedside dorsal slit procedure may be performed, followed by a delayed circumcision. The penis is prepared and draped. The cicatricial ring is identified. An assistant may be needed to retract the edematous glans away from the incision site. The ring is crushed with a hemostat at the 12-o'clock position and then cut with scissors. The entire ring must be incised. It is usually no more than 5-10 mm thick. Once this is done, the prepuce can easily be reduced. Sutures, if necessary, are placed to control bleeding from the cut edges of the ring. Long-term management is discussed with the patient. Options include surgical treatment via circumcision or conservative therapy via application of triamcinolone cream for 6 weeks and watchful waiting. Circumcision is the definitive therapy for paraphimosis. Preoperative detailsObtaining a properly informed consent before a circumcision is performed is critical. Inform patients, parents, and/or caregivers of the potential risks of bleeding, infection, suture disruption, urethral injury, and too much or too little skin being removed. Also inform patients that circumcision does not affect the length or girth of the penis. Instruct patients to abstain from genital stimulation for up to 6 weeks after surgery. Inadvertent erections can strain suture lines and cause incisions to break down. Patients having circumcisions for recurrent balanitis should be free of infection before the procedure. Intraoperative detailsPlace the patient in a supine position. Preparation includes a thorough surgical scrub of the genital area with povidone-iodine solution. Shaving or clipping pubic hair is unnecessary. Either general or local anesthetics may be used. General anesthesia is recommended for children, while local anesthesia is recommended for adults. Local anesthesia can be accomplished by a dorsal penile nerve block with a ring block. Equal volumes of 0.5% bupivacaine (Marcaine) and 1-2% lidocaine (Xylocaine) without epinephrine are commonly used. The maximum recommended dose of lidocaine without epinephrine is 4.5 mg/kg or 315 mg for a 70-kg male.
To perform a dorsal slit procedure for emergent reduction of paraphimosis, use the following technique:
When performing a circumcision, either the dorsal slit or sleeve techniques are commonly used. The dorsal slit technique is preferred for patients with severe phimosis and those with paraphimosis in whom intraoperative manipulation of the foreskin is difficult. To perform the dorsal slit, use the following technique:
The sleeve technique is an alternative method for circumcision and may be used as a primary surgical procedure or as a secondary definitive operation after an emergency dorsal slit has been made at bedside.
Postoperative detailsAfter the circumcision, petroleum jelly and sterile gauze or petrolatum gauze dressings may be applied over the sutures, followed by a sterile white gauze dressing. Prescribe oral narcotics and discharge the patient. Some surgeons prescribe oral antibiotics as well. Remove the dressing 24-48 hours after surgery. Advise patients to wear loose-fitting clothes, to gently wash the wound daily for the next 5-7 days, and to refrain from any sexual activity for the next 6 weeks to prevent breakdown of the sutures and incision line. Some surgeons additionally recommend keeping the wound completely dry to avoid inadvertent infection of the suture line. One ampule of amyl nitrate may be used in instances of postoperative erections. Follow-upPatients generally have a follow-up examination in 2-3 weeks to check the wound. Assess the wound for signs of infection and inspect the suture line. For excellent patient education resources, visit eMedicine's Men's Health Center. Also, see eMedicine's patient education articles Foreskin Problems and Circumcision. COMPLICATIONSSection 7 of 11
Complications of paraphimosis include pain, infection, and swelling of the glans penis. The distal portion of the penis can become ischemic and even necrotic. Potential complications involved with any circumcision include bleeding, infection, shortening of penile skin, and urethral injury. Postoperative bleeding is the most common complication. Meticulous hemostasis during the initial surgery is the rule. Bleeding may occur if a scab is pulled off during removal of the dressing. This bleeding can often be controlled with direct pressure. Rarely, electrocautery or ligature may be required. Infection after circumcision is uncommon. If acquired, it may be treated with oral antibiotics. Urethral injury is extremely rare. OUTCOME AND PROGNOSISSection 8 of 11
Paraphimosis does not recur after a proper circumcision. Outcome after a dorsal slit procedure or a circumcision is excellent. Sometimes, patients with a favorable outcome from dorsal slit procedures decline circumcision. ACKNOWLEDGMENTSSection 9 of 11
The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Jong M. Choe, MD, FACS, to the development and writing of this article. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
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