Continuing Education Activity
Paraphimosis is a common urologic emergency that occurs in uncircumcised males when the foreskin becomes trapped behind the corona of the glans penis. This can lead to strangulation of the glans and painful vascular compromise, distal venous engorgement, edema, and even necrosis. This activity describes the etiology, pathophysiology, evaluation, and management of paraphimosis and highlights interprofessional teams' role in improving outcomes for such patients.
Objectives:
- Describe the pathophysiology of patients with paraphimosis.
- Outline the evaluation in patients with paraphimosis.
- Review the conservative and surgical treatment options available for patients with paraphimosis.
- Summarize interprofessional team strategies for enhancing care coordination to facilitate rapid diagnosis and management of patients with paraphimosis.
Introduction
Paraphimosis is a true urologic emergency that occurs in uncircumcised males when the foreskin becomes trapped behind the corona of the glans penis, leading to strangulation of the glans as well as painful vascular compromise, distal venous engorgement, edema, and even necrosis. By comparison, phimosis is the condition when the foreskin is unable to be retracted behind the glans of the penis.[1]
Etiology
Paraphimosis commonly occurs iatrogenically, when the foreskin is retracted for cleaning, placement of a urinary catheter, a procedure such as a cystoscopy, or for penile examination.[1] Failure to return the retracted foreskin over the glans promptly after the initial retraction can lead to paraphimosis. Other, less common causes include penile coital trauma and self-inflicted injuries.
It is essential that all caregivers who regularly change Foley catheters routinely replace the foreskin at the end of the procedure to prevent the development of a paraphimosis.
Epidemiology
In uncircumcised children, four months to 12 years old, with foreskin problems, paraphimosis (0.2%) is less common than other penile disorders such as balanitis (5.9%), irritation (3.6%), penile adhesions (1.5%), or phimosis (2.6%).[2]
In adults, paraphimosis is most commonly found in adolescents. It will occur in about 1% of all adult males over 16 years of age.
Pathophysiology
If a constricting band of the foreskin is allowed to remain retracted behind the glans penis for a prolonged period, it can lead to impairment of distal venous and lymphatic drainage as well as decreased arterial blood flow to the glans. Arterial blood flow can become affected over the course of hours to days. This change can ultimately lead to marked ischemia and potential necrosis of the glans.[3]
Histopathology
At birth, there is normal physiologic phimosis due to natural adhesions between the glans and the foreskin. During the first 3 to 4 years of life, debris, such as shed skin cells, accumulates under the foreskin, gradually separating it from the glans. Intermittent penile erectile activity, such as nocturnal erections, also contributes to the increased mobility of the foreskin, ultimately allowing it to become completely retractible.
History and Physical
When evaluating a patient with paraphimosis, a pertinent history is important. This history should include any recent penile catheterizations, instrumentation, cleaning, or other procedures.[1] The patient should be asked about his routine cleaning of the penis and if he or a caregiver routinely retracts the foreskin for any reason. It is also important to ask if the patient is circumcised or uncircumcised. It is still possible to develop paraphimosis in a patient who has previously been circumcised. This can be due to the patient believing he was circumcised when he was not or excessive remaining foreskin despite the circumcision.
Typical paraphimosis symptoms include erythema, pain, and swelling of foreskin and glans due to the constricting ring of the phimotic foreskin. It may sometimes be described by patients as "penile swelling" and may be relatively painless. Clinicians are cautioned to be suspicious of any telephone description of "penile swelling" as potentially being a paraphimosis that requires immediate treatment and not to dismiss such descriptions as harmless without actually visualizing the lesion. Sometimes a photo sent from the patient's smartphone may be enough to settle the issue.
The history usually makes the diagnosis, but if not, it will be obvious on direct physical examination. The physical exam should focus on the penis, foreskin, and urethral catheter (if present). A pink color to the glans indicates reasonably good blood supply, whereas a dark, dusky, pale, bluish or black color implies possible ischemia or even necrosis.
If a Foley catheter is in place, it's recommended to review the reason why the catheter was needed and whether any difficulties were encountered in placing it, prior to its removal. While removing the Foley will almost certainly aid in reducing the paraphimosis, in some circumstances it may prove to be impossible to replace the catheter and now the caregiver is faced with a new problem. Most of the time, removal of the Foley is not necessary to successfully reduce the paraphimosis.[1]
Evaluation
The patient typically presents with acute, distal, penile pain and swelling, but the pain is not always present. The glans and foreskin typically are markedly enlarged and congested, but the proximal penile shaft is flaccid and unremarkable. A tight band of constrictive tissue is present, often preventing the easy manual reduction of the foreskin over the glans. Diagnosis is made clinically by direct visualization, as well as the inability to easily reduce the retracted foreskin manually.
Treatment / Management
Mild, uncomplicated paraphimosis may be reduced manually, usually without the need for sedation or analgesia. More difficult or complicated cases may require local anesthesia with a dorsal penile block, systemic analgesia, or procedural sedation.
Several methods of reduction are available and can be classified into manual reduction or surgical repair.
Manual, non-surgical reduction of the paraphimosis is possible with or without compression methods, using osmotic agents and puncture-aspiration techniques.
Manual reduction of paraphimosis can often be facilitated by simple compression of the glans and the swollen, edematous foreskin for several minutes before attempting the reduction. This allows the edematous swelling of the retracted foreskin to diminish before attempting repositioning of the foreskin to its usual position. One simple method involves manually compressing the edematous foreskin while pulling slowly upward on the phallus.
Manual reduction can also be attempted by placing both thumbs over the glans with both index and long fingers surrounding the trapped foreskin. Then slow, steady pressure is applied to advance the phimotic portion of the foreskin outwards slowly, back over the glans. This can be facilitated with a little lubricant. Excessive lubricant should be avoided as it may make the skin too slippery for reliable grasping.[4]
Another compression technique involves tightly wrapping the swollen portion of the penis from the glans towards the base with a 1-inch or 2-inch elastic bandage. A gauze pad should be applied first around the edematous foreskin. The compression bandage can remain for 10 to 20 minutes to minimize the edema. Then apply one of the manual reduction methods described above.[5]
Ice packs or surgical gloves filled with ice and applied to edematous areas have been described as possibly useful in conjunction with other methods to reduce the paraphimotic swelling. However, since the main issue in paraphimosis is distal penile vascular compromise from a constricting fibrous band of the phimotic foreskin, many experts recommend against using ice in these situations as it may further compromise arterial inflow to the possibly ischemic portion of the penis.
Another possible compressive treatment method involves cutting the thumb from a surgical glove to make a "sleeve" and emptying a tube of EMLA cream (2.5% lidocaine and 2.5% prilocaine; AstraZeneca, London, UK) or similar into the sleeve. This is then placed over the penis and left for approximately 30 minutes. This allows for local anesthesia and softening of affected skin to aid in foreskin reduction. However, while it does provide some analgesic relief, it may make the skin a little more slippery and harder to manipulate.[6]
Reducing the penile edema from paraphimosis can also be achieved by directly injecting hyaluronidase into the edematous foreskin. This has been effective, particularly in children and infants, in resolving the edema, allowing for an easier manual reduction of the paraphimosis. The hyaluronidase increases the diffusion of trapped fluid within the tissue planes of the malpositioned foreskin, which reduces the swelling and edema.[7]
Osmotic methods involve applying substances with a high solute concentration on the external skin surfaces of the edematous tissue. This would tend to draw water along an osmotic gradient and thereby reduce the edema. For example, a generous topical application of granulated sugar to the affected glans and foreskin has been shown to be effective in helping reduce edema from paraphimosis.[8]
Gauze soaked in 20% mannitol solution has also been used as an osmotic agent to reduce the edema from paraphimosis. The gauze is left in place for 30 to 45 minutes. It has been reported to completely eradicate the troublesome edema allowing for easy resolution of the paraphimosis with manual techniques, as described above. This technique is relatively painless and is well suited for children.[9]
In many cases, no additional local anesthetic or analgesia is needed, but if the paraphimosis is long-standing, extremely painful, or severe, then a formal penile anesthetic block can be used. A dorsal penile block is performed using a 25-gauge or 27-gauge needle, infiltrating approximately 2.5 mL of 1% lidocaine without epinephrine into the base of the penis at the junction of the penis and suprapubic skin at the 10 o'clock position, off the midline to avoid the superficial dorsal vein. Another 2.5 mL is injected at the 2 o'clock position. Inject the lidocaine just deep to Buck's fascia, approximately 3 mm to 5 mm beneath the skin, ensuring negative blood aspiration before injecting. Ultrasound guidance has been shown to be effective in helping to identify landmarks for this procedure.[10]
Puncture and aspiration methods are more invasive and should be reserved for cases refractory to other less-invasive techniques. The puncture technique involves puncturing the edematous foreskin several times with a hypodermic needle followed by manual expression of edematous fluid through the puncture holes. Experienced emergency practitioners can consider penile corporal aspiration of blood.
Surgical treatment of the paraphimosis will be required if the previously described manual reduction methods are unsuccessful. Prepare the penis and prepuce with a povidone-iodine or similar antiseptic solution. This can be achieved after the previously-described penile block. One method involves applying two straight hemostats to grab the dorsum of the constricting foreskin at the 12 o'clock position. This is followed by making a 1 cm to 2 cm longitudinal incision of the constricting band of edematous foreskin between the hemostats, which allows for passage over the glans. The incised foreskin is not reapproximated after reduction, but the edges are oversown with a 3-0 or 4-0 absorbable suture. This will leave the phimotic portion of the foreskin widely separate and open to prevent recurrences.
Ischemia leading to necrosis and gangrene of the glans and distal urethra can occur. Management of such a severe complication of paraphimosis is typically partial penectomy, resection of the glans and/or excision of the necrotic penile tissue. Recently, conservative management of a case of necrosis of the glans from paraphimosis in a 25 year old was described with suprapubic tube drainage and careful surgical debridement which provided a reasonably good result without penile amputation.[11]
An elective circumcision or dorsal slit procedure is strongly recommended in all patients who have had a significant paraphimosis due to the very great risk of a recurrence.
Differential Diagnosis
- Allergic contact dermatitis
- Balanitis xerotica obliterans
Prognosis
The prognosis with paraphimosis is excellent if diagnosed and treated promptly. There may be some bleeding during skin retraction, but long-term negative outcomes are rare. The condition can commonly recur; circumcision can preclude recurrence once the inflammation has subsided and the patient is a viable candidate for the procedure.[12] An alternative to a circumcision, especially in an older or sicker patient, would be a dorsal slit. Either is satisfactory in preventing a recurrence of the paraphimosis.
Complications
Complications that can occur with paraphimosis include pain, infection, and inflammation of the glans penis. If the condition is not relieved in a sufficiently prompt timeframe, the distal penis can become ischemic or necrotic. Operative complications include bleeding, infection, injury to the urethra, and shortened penile skin.
Deterrence and Patient Education
After reduction or surgery, patients should be counseled that their prognosis is quite good. They should receive instruction on hygiene, be sure and return their foreskin to its normal position if it has been retracted, and avoid using any penile jewelry if that has contributed to the condition. The patient may wish to consider circumcision to preclude future episodes, particularly if recurring cases.
Pearls and Other Issues
After a successful manual reduction, the foreskin should carefully be cleaned. Any superficial abrasions or tears to the foreskin should be treated with a topical antibiotic ointment such as bacitracin. Patients should be instructed to avoid retracting the foreskin for one week and avoid any offending activities contributing to the paraphimosis.
Reducing the paraphimosis successfully is insufficient long-term therapy. All such patients should be evaluated for further treatment involving a dorsal slit or circumcision procedure to definitively deal with the tightened foreskin and permanently prevent any recurrences of the paraphimosis.
Enhancing Healthcare Team Outcomes
Paraphimosis is a urological emergency best managed by an interprofessional team that includes a pediatrician, emergency department physician, urologist, nurse specialist, and a surgeon. Mild cases may be reduced manually, but more complex cases usually require some type of anesthesia.
After a successful manual reduction, the foreskin should carefully be cleaned. Any superficial abrasions or tears to the foreskin should be treated with a topical antibiotic ointment such as bacitracin. Patients should be instructed to avoid retracting the foreskin for one week and avoid any offending activities contributing to the paraphimosis.
Reducing the paraphimosis successfully is insufficient long-term therapy. All such patients should be evaluated for further treatment involving a dorsal slit or circumcision procedure to definitively deal with the tightened foreskin and permanently prevent any recurrences of the paraphimosis.
Paraphimosis