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Paraphimosis

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Urology

Related Subjects: |Testicular Torsion |Paraphimosis

It is important to return the retracted foreskin to the normal position after catheterisation or other procedures. Paraphimosis is a urological emergency as failure to remove the constricting band of paraphimosis will result in necrosis of the glans.

Severe Paraphimosis: Get Urological help if not quickly settling
Pain Relief: Administer effective analgesia and/or sedation before attempting manual reduction. Low threshold for opiates. Manual Reduction involves a steady firm compression of the glans with the aim of reducing swelling. Use fingers with gauze and/or special compression dressing. Apply a lubricant e.g. anaesthetic jelly to reduce friction and pain. Once the swelling has decreased, gently attempt to pull the foreskin forwards over the glans. Ice packs can help reduce swelling before attempting manual reduction. Osmosis can help reduce swelling: Mix 50 mL of 50% dextrose solution with 2% lidocaine jelly. Place a gauze into the solution. Place soaked gauze on the glans of penis. Cover with condom or condom foley. Wait 1 hour. Attempt to reduce the paraphimosis. One can simply cover the affected area with granulated sugar and a sugar paste. Surgical Intervention: Urology call. If manual reduction fails, a dorsal slit may be performed. This involves making a small incision in the tight band of the foreskin to relieve constriction and allow the foreskin to be repositioned. Circumcision can prevent recurrence, especially if there is a history of recurrent paraphimosis or phimosis.

Severe Paraphimosis: Get Urological help if not quickly settling

Pain Relief: Administer effective analgesia and/or sedation before attempting manual reduction. Low threshold for opiates.
Manual Reduction involves a steady firm compression of the glans with the aim of reducing swelling. Use fingers with gauze and/or special compression dressing. Apply a lubricant e.g. anaesthetic jelly to reduce friction and pain. Once the swelling has decreased, gently attempt to pull the foreskin forwards over the glans. Ice packs can help reduce swelling before attempting manual reduction.
Osmosis can help reduce swelling: Mix 50 mL of 50% dextrose solution with 2% lidocaine jelly. Place a gauze into the solution. Place soaked gauze on the glans of penis. Cover with condom or condom foley. Wait 1 hour. Attempt to reduce the paraphimosis. One can simply cover the affected area with granulated sugar and a sugar paste.
Surgical Intervention: Urology call. If manual reduction fails, a dorsal slit may be performed. This involves making a small incision in the tight band of the foreskin to relieve constriction and allow the foreskin to be repositioned. Circumcision can prevent recurrence, especially if there is a history of recurrent paraphimosis or phimosis.

About

Paraphimosis: the foreskin becomes retracted behind the glans penis and cannot be reduced. This may occur after failing to pull the foreskin forward to its natural position after cleaning or catheterization

Aetiology

Paraphimosis can be seen at all ages when the foreskin retracted
May be iatrogenic during catheter change or cleaning
Also seen after vigorous sexual activity
Chronic balanoposthitis (typically in patients with diabetes)
Penile piercing
Scarring of the prepuce after repeated forcible retraction in an attempt to 'cure' a physiological phimosis

Clinical

A tight prepuce causes swelling when it is retracted.
There is acute penile pain, swelling and discomfort
Infants may present just with irritability
There is oedema around the constricting band that is usually the prepuce
A carer may discover the condition incidentally in a debilitated patient
In later stages, the glans may develop a blue or black colour due to necrosis

Management

Paraphimosis is seen in all ages but often in older men and can be iatrogenic when the foreskin is not reduced following urinary catheterisation
Removing the catheter usually helps with penile manipulation which involves reduction is with a very tight grip for 20-30 minutes with some ice and KY jelly to reduce inflammation and oedema.
Gentle compression with a saline-soaked swab followed by reduction of the prepuce over the glans is usually successful. Gradual manual reduction of the prepuce over the glans is done by placing both index fingers on the dorsal border of the penis and thumbs on the glans. The glans is pushed back while the index fingers pull the prepuce back over the glans
This technique can be facilitated by trying to achieve the reduction of swelling first. Ice may be applied. Manual compression is achieved by asking the patient to squeeze the glans for anything from 5 to 30 minutes or the doctor may do this if the patient cannot. Osmotic reduction involves the application of a swab soaked in 50% dextrose to the swollen area for an hour. If simple measures fail refer urgently to urology. Urgent surgical care is usually an emergency dorsal slit procedure and consideration for circumcision
The catheter may then be replaced after successful reduction if the indication for it still remains.
Injection of hyaluronidase into the oedematous prepuce can be useful in babies and children

Comparison Between Phimosis and Paraphimosis
Criteria	Phimosis	Paraphimosis
Definition	Inability to retract the foreskin over the glans penis	Inability to pull the retracted foreskin back over the glans, leading to constriction
Causes	Congenital, poor hygiene, recurrent infections (e.g., balanitis), scarring	Usually caused by forceful retraction of a tight foreskin, trauma, or after catheterization
Clinical Features	Tight foreskin, difficulty urinating, discomfort, ballooning of the foreskin during urination	Pain, swelling, erythema of the glans, venous congestion, restricted blood flow
Complications	Urinary retention, recurrent infections, increased risk of penile cancer	Ischemia, necrosis of the glans, and possible gangrene if untreated
Management	Topical steroids, gentle stretching, circumcision in severe cases	Manual reduction, application of ice, dorsal slit if reduction fails, emergency circumcision if ischaemia is present

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