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Paraphimosis: Clinical manifestations, diagnosis, and treatment

Paraphimosis: Clinical manifestations, diagnosis, and treatment
Authors:
Matthew Tews, DO
Jonathan I Singer, MD
Section Editors:
Laurence S Baskin, MD, FAAP
Anne M Stack, MD
Jerome P Richie, MD, FACS
Deputy Editor:
James F Wiley, II, MD, MPH
Literature review current through: Jul 2022. | This topic last updated: May 03, 2022.

INTRODUCTION — This topic discusses the clinical features, diagnosis, and treatment of paraphimosis.

Other pathologic conditions of the foreskin (eg, phimosis) and the care of the uncircumcised penis are discussed separately. (See "Care of the uncircumcised penis in infants and children", section on 'Pathologic conditions' and "Care of the uncircumcised penis in infants and children" and "Balanitis in adults".)

DEFINITION — The terms paraphimosis and phimosis are often confused:

Paraphimosis refers to a retracted foreskin in an uncircumcised or partially circumcised male that cannot be returned to normal position (picture 1).

Phimosis is defined as a tight foreskin that cannot be retracted to expose the glans penis. In young children, phimosis is normal or physiologic. In older patients, infections such as balanoposthitis or other inflammatory conditions result in scarring and pathologic phimosis that requires urologic referral. (See "Care of the uncircumcised penis in infants and children", section on 'Physiologic phimosis' and "Care of the uncircumcised penis in infants and children", section on 'Pathologic phimosis' and "Balanitis in adults", section on 'Phimosis'.)

ANATOMY — The penis in the uncircumcised male consists of the penile shaft, glans penis with the coronal sulcus (rim of the glans), and the foreskin (figure 1). The foreskin is a physiologic covering for the glans penis. The foreskin functions to physically and immunologically protect the glans penis and external urethral orifice [1]. It may also function to provide increased male stimulation and lubrication during sexual intercourse.

At birth, the foreskin and glans penis are fused, and the foreskin is not retractable, causing a physiologic phimosis. The epithelial cells of the inner surface of the foreskin desquamate forming white pearly masses, called smegma. The foreskin becomes more retractable with time as the creation of the space between the glans penis and inner foreskin develops. (See "Care of the uncircumcised penis in infants and children", section on 'Normal anatomy and development of the foreskin' and "Care of the uncircumcised penis in infants and children", section on 'Physiologic phimosis'.)

PATHOPHYSIOLOGY — Paraphimosis is caused by foreskin entrapment behind the coronal sulcus (picture 1 and figure 1). Impairment of lymphatic and venous flow from the constricting ring of foreskin causes venous engorgement of the glans penis with swelling. Ultimately, arterial flow to the glans penis becomes compromised over a period of hours to days [2]. Bulbar, urethral, and pudendal vessels may be sequentially impaired. If paraphimosis is not corrected in a timely fashion, the most common outcome is local skin necrosis; although in rare cases, penile necrosis, infarction of the glans, or gangrene may occur, followed by autoamputation [3-5].

EPIDEMIOLOGY — Paraphimosis is a less common emergency department (ED) complaint compared with the more common traumatic injuries (eg, blunt trauma, penile tourniquet syndrome, or zipper entrapment) or infectious penile conditions (eg, balanitis, balanoposthitis) [6,7].

Causes — There are several potential predisposing factors for paraphimosis:

Phimosis – Patients at the greatest risk for developing paraphimosis typically have a partial phimosis (the preputial opening is too small to easily fit over the coronal sulcus of the glans penis). Subsequent retraction of the foreskin leads to entrapment and paraphimosis. (See "Care of the uncircumcised penis in infants and children", section on 'Physiologic phimosis' and "Care of the uncircumcised penis in infants and children", section on 'Pathologic phimosis'.)

In the infant and young boy, this phimosis is usually physiologic. Retraction with paraphimosis typically occurs during cleaning by a caretaker. Self-manipulation in this age range may also cause paraphimosis. (See "Care of the uncircumcised penis in infants and children", section on 'Physiologic phimosis' and "Care of the uncircumcised penis in infants and children", section on 'Routine care and hygiene'.)

Pathologic phimosis may follow balanoposthitis or other penile inflammation in adolescents and older men, or may relate to loss of skin elasticity and decreased frequency of erection with aging in elderly men [8,9]. The development of candidal balanoposthitis or phimosis in an otherwise healthy man can be the first presentation of undiagnosed diabetes mellitus. (See "Balanitis in adults" and "Balanitis in adults", section on 'Candidal infection'.)

Genitourinary procedures – Paraphimosis can occur because of failure of medical personnel to return a fully retractable foreskin to normal position after cystoscopy or bladder catheterization [2].

Sexual activity – There are numerous case reports in the literature about sexual causes of paraphimosis [10-12]. Activities such as erotic dancing have also caused paraphimosis [13,14].

Penile trauma – Paraphimosis following body piercing of the genitals in which the pierced glans or foreskin is too painful to allow foreskin retraction has been described [15,16].

Other – Paraphimosis may occur in a male who neglects to replace the foreskin after cleaning or after urination [4]. Paraphimosis has also developed in association with Plasmodium falciparum infection [17].

CLINICAL FEATURES

History — Swelling of the penis and penile pain are the two most common complaints in males with paraphimosis. Paraphimosis is also an important but rare cause of irritability in the preverbal infant.

Other features of paraphimosis include dysuria, a decreased urinary stream, and, with prolonged and marked swelling, complete urinary obstruction.

Precipitating factors elicited by history vary by age (see 'Causes' above):

Infants and young boys – Failure or inability to reduce the retracted foreskin after cleaning by the caregiver or after urination, typically due to a physiologic phimosis.

Occasionally, a non-retractable foreskin may be an incidental finding noted when changing a diaper or when giving the boy a bath.

Adolescents and adults – Failure of foreskin reduction after cleaning, urination, sexual intercourse, or a urologic procedure (eg, bladder catheterization or cystoscopy).

Physical examination — On physical examination, the patient is typically in significant pain. The examiner should ensure that no constricting foreign body, including hair, clothing, rubber bands, or metal objects from piercing are present. The following findings are typically evident on inspection of the penis:

Edema and tenderness of the glans penis

Painful swelling of the distal retracted foreskin

A constricting band of tissue proximal to the head of the penis at the coronal sulcus (picture 1 and figure 1)

The penile shaft appears flaccid and unaffected

With ischemia of the glans penis, the skin color will change from the normal pink color to blue or black. In addition, the ischemic glans penis will be firm to palpation rather than soft.

In patients with complete urinary obstruction, bladder distension may also be present.

DIAGNOSIS — Marked penile pain with swelling of the glans penis and distal foreskin due to a constricting band of tissue present at the coronal sulcus (picture 1 and figure 1) establishes the diagnosis of paraphimosis. Blue or black skin discoloration of the glans penis and firmness of the glans to palpation indicate ischemia which is a rare complication. (See 'Clinical features' above.)

DIFFERENTIAL DIAGNOSIS — Paraphimosis usually is easily differentiated from other causes of penile swelling based upon either the marked degree of pain in patients with phimosis or physical examination that demonstrates like of a constricting band at the coronal sulcus (figure 1) as follows:

Tourniquet syndrome – In the infant, a human hair or fiber of clothing may inadvertently wrap around the penis, causing venous congestion and reduced lymphatic flow and is called the hair tourniquet syndrome. Pain, swelling, and edema of the distal penis and foreskin may occur with a constriction of the proximal penis and appears similar to paraphimosis. A careful inspection at the normal to abnormal interface of the penis will reveal the constricting hair and may require magnification to visualize [18]. Rarely, such bands may be intentionally placed on the young as an abusive event [19]. (See "Hair tourniquet and other narrow constricting bands: Clinical manifestations, diagnosis, and treatment".)

In the adolescent or adult, rings, studs or constricting bands intentionally placed to sustain erections, prevent ejaculation, or heighten sexual pleasure should also be visible with inspection [20].

Balanoposthitis – Balanoposthitis, an inflammation of the glans penis and the foreskin, creates complaints of irritation, burning, or itching. Pain is less frequent than in paraphimosis, and discharge is typically present. Physical findings may be similar to paraphimosis with an inflamed surface and a moist, glistening transudate. (See "Balanitis and balanoposthitis in children and adolescents: Clinical manifestations, evaluation, and diagnosis".)

Insect bites – Nonvenomous and venomous insect bites to the glans penis cause penile swelling, erythema, genital itching, and mild discomfort [21]. Causative agents include bed bugs, chiggers, mosquitoes, fleas, spiders, and hymenoptera (eg, bees, wasps). On examination, asymmetric soft tissue swelling that is more lateral or ventral and a small punctate lesion should give clues to the diagnosis. (See "Chigger bites" and "Insect and other arthropod bites" and "Diagnostic approach to the patient with a suspected spider bite: An overview".)

Generalized edematous state – Painless penile edema may occur as a manifestation of an edematous state secondary to cardiac, renal, or hepatic problems. The diagnosis is suggested by evidence of organ dysfunction on the general examination. (See "Evaluation and management of edema in children".)

Angioedema – Painless penile swelling also develops in patients with angioedema. Angioedema generally develops over minutes to hours and resolves in 24 to 48 hours. The skin is either normal in color or erythematous. Pruritus is usually absent, unless the angioedema is associated with urticarial lesions (which are intensely pruritic). Pain and warmth are variably present.

Etiologies include allergy, C1 inhibitor deficiency, and adverse drug effect of angiotensin converting enzyme inhibitors or angiotensin II receptor blockers. (See "An overview of angioedema: Pathogenesis and causes".)

TREATMENT — The primary management of paraphimosis consists of timely reduction of the foreskin back over the glans penis and requires:

Pain control

Manual reduction, which may be facilitated by methods to reduce swelling if time permits (see 'Technique' below and 'Methods to reduce swelling' below)

Use of more invasive techniques, typically by a urologist, if manual reduction is unsuccessful (see 'Dorsal slit reduction' below and 'Other techniques' below)

Successful manual reduction can usually be accomplished by the primary care or emergency physician.

Indications for specialty consultation — Consultation with a urologist or a surgeon with similar expertise is warranted for patients with paraphimosis and [22]:

Penile necrosis

Complete urinary obstruction

Unsuccessful reduction by the manual technique

If subspecialty care is not available in a timely manner, the medical provider should proceed to reduce the paraphimosis with the understanding that minimally invasive techniques may fail and that invasive techniques may be necessary for these patients. (See 'Paraphimosis reduction' below.)

Paraphimosis reduction — The approach and tips for paraphimosis reduction are described in the tables (table 1 and table 2) [23,24].

Paraphimosis reduction is indicated as soon as paraphimosis is identified [22]. Paraphimosis only occurs in the uncircumcised or partially circumcised male. The practitioner should ensure that the penile swelling is due to paraphimosis and not an alternative condition, such as angioedema, insect bite, or constricting band (eg, hair tourniquet). (See 'Differential diagnosis' above.)

The boy or man with paraphimosis is typically anxious and in significant pain. The patient and family should receive an explanation of the problem and the planned approach. Anxiety usually recedes once pain is adequately controlled. A child life specialist or other personnel may help with distraction in children while initial adjuncts aimed at reducing swelling and pain are employed. Successful reduction in young boys may require parenteral analgesia (eg, morphine) and/or procedural sedation. (See 'Methods to reduce swelling' below and "Procedural sedation in children outside of the operating room".)

In general, the benefit of any of the paraphimosis reduction procedures outweighs the risk. The adverse effects of the technique should be disclosed prior to the initiation of the procedure based on the planned approach:

Manual manipulation or paraphimosis reduction with Adson or Babcock clamps (figure 2) may result in minor bruising and superficial abrasions. (See 'Other techniques' below.)

Reduction procedures involving needle puncture or incision may cause bleeding or infection.

Hyaluronidase injection has been associated with contusion, allergic reaction, and hypotension.

Injury to the foreskin during manipulation may lead to scarring and phimosis. Ultimately, circumcision may be necessary.

Manual reduction — The approach and tips for paraphimosis reduction are described in the tables (table 1 and table 2) [23,24].

Pain control — Most patients are exquisitely tender to digital manipulation of the glans penis and foreskin. It is imperative to provide analgesia before attempting reduction of the paraphimosis [25]. Degree of analgesia necessary is patient dependent and tends to be inversely related to age; adolescents and adults may tolerate application of topical medications or injection of local anesthetic, while young boys often require intranasal or parenteral administration of opioids and procedural sedation in addition to local anesthesia. (See "Procedural sedation in children outside of the operating room".)

Options for pain control include:

Topical medications – Onset of topical anesthesia can take several minutes to an hour. The effectiveness of the medication should be determined before attempting reduction [26]. These medicines should not be used in infants under three months of age or in patients with predisposition for methemoglobinemia, such as those with glucose-6-phosphate dehydrogenase deficiency. Topical medications containing epinephrine should be avoided. (See "Clinical use of topical anesthetics in children".)

Commonly used medications include 2 percent lidocaine gel or EMLA cream (2.5 percent prilocaine and 2.5 percent lidocaine) applied directly to the skin in the following way [26,27]:

After spreading the topical agent over the swollen foreskin and glans, cover the area for 30 minutes with the cut-off fingertip of a disposable glove or an occlusive dressing to keep the medication in place [26].

Alternatively, wrap a 4x4 gauze bandage impregnated with lidocaine ointment (up to 5 percent) around the penis and foreskin [27].

Local and regional anesthesia – Alternatively, the clinician may provide local or regional anesthesia as follows:

Local infiltration – The use of epinephrine may cause further penile ischemia through vasoconstriction of the penile arteries and is contraindicated when infiltrating the penis. Local infiltration with one percent lidocaine without epinephrine (maximum dose: 4 mg/kg) or with 0.25 percent bupivacaine (maximum dose: 2 mg/kg) can be used before attempting paraphimosis reduction with Adson forceps. This approach complements procedural sedation or may be used alone in the older cooperative patient. The foreskin is anesthetized either in the 12 o'clock position when grasping with a single Adson forceps, or in the nine and three o'clock position when two forceps are applied (figure 2) [28].

The indications, contraindications, and toxicity of infiltrative anesthetics are discussed separately. (See "Subcutaneous infiltration of local anesthetics".)

Dorsal penile nerve block – This technique provides full regional anesthesia to the penis for all paraphimosis reduction methods but is more invasive and has greater potential for morbidity than the other local techniques. The procedure is described separately (figure 3) [29]. (See "Management of zipper entrapment injuries", section on 'Dorsal penile block'.)

Opioid analgesia – Parenteral opioids (eg, morphine, fentanyl) or intranasal fentanyl provide treatment of severe pain.

Procedural sedation – Paraphimosis reduction is a moderate to severely painful procedure that, in young children, frequently warrants procedural sedation. Selection of medications and the safe performance of pediatric procedural sedation are discussed separately. (See "Procedural sedation in children outside of the operating room" and "Selection of medications for pediatric procedural sedation outside of the operating room", section on 'Moderately or severely painful procedures'.)

Methods to reduce swelling such as ice, compression, or use of an osmotic agent can be applied after pain is controlled if time permits. Ice and osmotic agents may be omitted if urgent reduction is necessary or procedural sedation is planned.

Technique — The materials and technique for manual reduction are as follows:

Materials:

Latex-free gloves

Topical local anesthetic agent (2 percent lidocaine gel or EMLA cream [2.5 percent prilocaine and 2.5 percent lidocaine]) OR 1 percent lidocaine without epinephrine for injection

25 gauge or smaller (eg, 27 gauge) needle and 3 to 5 mL syringe for lidocaine injection

Sterile gauze

Adjuncts to reduce swelling: ice, compression dressing (elastic bandage [eg, Ace or Co-flex]), 20 percent mannitol, 50 percent dextrose, or granulated sugar (see 'Methods to reduce swelling' below)

Latex-free surgical glove or condom for application of topical anesthetic, ice, and/or granulated sugar (see 'Pain control' above)

Water soluble lubricant

Manual compression and reduction – Pain control based upon patient age, tolerance, and urgency of the procedure should precede reduction by manual compression. (See 'Pain control' above.)

In patients with marked swelling but adequate penile perfusion in whom manual reduction may be difficult, methods to reduce swelling may be used prior to reduction [23,24]. (See 'Methods to reduce swelling' below.)

The distal penis is grasped with a gloved hand and squeezed circumferentially for several minutes until the swelling has subsided enough to reduce the foreskin over the glans (figure 4).

Once compression is complete and after generous application of water soluble lubricant, the foreskin is peeled over the glans using forefingers and middle fingers placed behind the swollen foreskin on either side while simultaneously pushing with thumbs located on the glans penis [23].

As the glans is pressed through the foreskin opening, the forefingers pull and reduce the constricted foreskin over the glans penis (figure 4).

In some patients, complete reduction is not apparent because of the marked foreskin swelling. Additional compression after reduction can assist in determining if full reduction has occurred. This technique is successful in the majority of boys with paraphimosis. Young boys typically require procedural sedation to tolerate manual reduction. (See "Procedural sedation in children outside of the operating room".)

The reference provides a video that demonstrates the manual compression and reduction technique [22].

Methods to reduce swelling — Methods to reduce swelling may be combined with pain control to facilitate elective reduction of the foreskin [23]. These methods can be time consuming, but with patience, they are rewarding. Although rare, necrosis of the penis is a contraindication to the use of ice or osmotic agents.

If procedural sedation or reduction under anesthesia is planned, then paraphimosis reduction should not be delayed to reduce swelling by these methods.

Of the multiple methods to reduce preputial edema, none is of proven superiority. The health care provider should choose ice packing, compressive dressings, or osmotic agents based on patient preference and operator comfort and experience. Following successful reduction of preputial edema, restoration the foreskin to the appropriate position is typically accomplished by compressive manual reduction. (See 'Manual reduction' above.)

Potential methods for reducing swelling include:

Ice – The use of ice can aid in the manual reduction of paraphimosis as long as signs of ischemia or necrosis are not present [30].

Anesthetic jelly (eg, lidocaine gel) is placed on the penis to lubricate and anesthetize the area. Ice is placed in a rubber glove that is tied off at the end, so the ice and water remain in the glove. The thumb of the glove is placed over the penis and invaginated into the glove to surround the penis with ice.

Alternately, the penis can be wrapped in plastic or the tip of a glove to provide compression followed by placement of ice over the swollen foreskin and glans. (See 'Manual reduction' above.)

Once ice is applied, reevaluate the penis in 15 to 20 minutes to assess for response and to avoid cold injury to the penis.

Compression bandages – Compression of the swollen glans penis and foreskin is frequently done by a gloved hand after appropriate pain control but can also be facilitated by an elastic bandage [31,32]. Wrapping should start distally and progress proximally. Approximately five to seven minutes (Ace wrap) or up to 20 minutes (Co-flex) of pressure facilitates fluid movement through the constricting foreskin to reduce glans swelling prior to manual reduction [29]. Because of the even graded compression they provide, Ace or Co-flex bandages may reduce the risk of shearing or tearing of the prepuce that sometimes occurs with manual compression alone [31]. (See 'Manual reduction' above.)

Osmotic agents – These methods require patience and should not be used if emergency reduction is needed in the face of ischemic changes of the glans.

This technique applies the physiologic principle that fluid flows down its concentration gradient, in this case from the hypotonic fluid in the penis to the hypertonic agent placed on the skin. Potential osmotic agents used successfully in small case series or case reports include fine granulated sugar, gauze soaked in 50 percent dextrose, or gauze soaked in 20 percent mannitol [33,34].

The approach and time to reduction differs by the agent used as follows [29]:

Granulated sugar – Place granulated sugar on the swollen glans penis and foreskin. Cover the penis with the finger of a rubber glove or a condom and observe for reduction, which may require up to two hours [33].

50 percent dextrose – Apply 50 percent dextrose to gauze dressings and wrap them around the swollen foreskin and penis [35]. Leave the gauzes in place for approximately one hour, periodically re-soaking them with 50 percent dextrose, and then perform manual reduction. (See 'Manual reduction' above.)

20 percent mannitol Apply 20 percent mannitol to gauze dressings and wrap them around the swollen foreskin and penis [34]. Leave the gauzes in place for approximately 30 to 45 minutes, periodically re-soaking them with the mannitol solution, and then perform manual reduction.

Dorsal slit reduction — Incision of the constricting band of foreskin in paraphimosis is sometimes necessary if manual reduction fails. A dorsal penile block may be employed for regional anesthesia in conjunction with procedural sedation. (See 'Pain control' above.)

General anesthesia may also be appropriate for the rare patients with significant ischemia and penile necrosis who will require immediate reconstructive surgery.

Materials — The equipment needed is as follows:

Sterile surgical gloves

Betadine or other antiseptic solution

Sterile gauze

Sterile surgical towels

Dorsal slit procedure:

-Scalpel (dorsal slit procedure)

-Suture material: 4-0 rapidly absorbing suture (eg, 4-0 chromic or similar suture)

Dorsal slit procedure — The penis and foreskin are prepped in sterile fashion using liberal amounts of antiseptic solution (eg, Betadine) and sterile drapes. The dorsal slit procedure is usually performed by a urologist, but can also be performed by a knowledgeable clinician if no urologist is available and emergency reduction is necessary (table 1 and table 2).

Two methods have been described for the dorsal slit procedure (figure 5) [27,29]:

An incision is made along the dorsal skin longitudinally for a length of 1 to 2 cm over the constriction. This will allow edema to flow past the constricting ring and decrease glans edema so that the foreskin can be returned to its normal position. Following reduction, sutures are placed transversely and perpendicular to the longitudinal incision with 4-0 rapidly absorbing suture (eg, 4-0 chromic or similar suture) (figure 5) [29].

Alternatively, two hemostats are inserted in the 12 o'clock position in order to crush the skin to decrease the blood supply. After one minute, an incision is made through the skin between the two hemostats, and the foreskin is reduced. Before removing the hemostats, the two edges are closed with a rapidly absorbing suture (eg, 4-0 chromic or similar suture) [26].

Patients who require a dorsal slit procedure for paraphimosis reduction should undergo delayed circumcision after full resolution of foreskin edema. (See 'Aftercare' below.)

Other techniques — Other techniques for paraphimosis reduction have been described but are less commonly used:

Traction with forceps – If manual reduction fails, paraphimosis reduction may be attempted using blunt Babcock forceps or sharp Adson forceps (figure 2) [24]. In either case, adequate measures must be taken to ensure patient cooperation and analgesia. Young boys typically require procedural sedation although local analgesia alone may suffice for older boys and adolescents [24]. (See 'Pain control' above.)

Babcock forceps – Non-crushing Babcock forceps can be placed in each of four quadrants of the swollen foreskin, followed by continuous, gentle, symmetrical traction until reduction of the foreskin has occurred (figure 2) [24].

Adson forceps – Topical analgesia using EMLA applied for 45 to 60 minutes and held in place with an occlusive dressing or local injection of one percent lidocaine without epinephrine at the site of sharp Adson forceps application complements procedural sedation, One tine of the Adson forceps is placed under the constricting band and one on the superficial skin. A secure grasp is obtained and constant, steady traction is applied distally until reduction of the band over the glans occurs. This can be modified by using two forceps at the nine and three o'clock positions (figure 2) [28].

The potential to inadvertently tear the foreskin is a major drawback of this approach.

Puncture technique — The puncture technique (the Dundee technique) may be used after failed attempts at reduction using minimally invasive methods [2,7,36-39]:

After appropriate local analgesia and sedation as needed, the patient is prepped with antiseptic solution.

Multiple punctures are then made in the edematous foreskin using a 25 gauge or smaller needle (figure 6) [2,12].

Subsequently, the foreskin is reduced using manual compression and reduction (figure 4).

Hyaluronidase, a natural protein that causes hydrolysis of hyaluronic acid, an extracellular mucopolysaccharide, may be used to augment the efficacy of the multiple puncture technique [40,41]. When injected using a tuberculin syringe into one or more sites of the edematous foreskin as 1 mL of 150 units/mL (Wydase), hyaluronidase causes a rapid decrease in preputial swelling that allows manual reduction to proceed [40].

Hyaluronidase is contraindicated in the presence of cancer or infection because spread of bacteria or malignant cells may result. Adverse effects are uncommon and include ecchymosis, anaphylaxis, shock, and hypovolemia, especially if inadvertent intravascular injection occurs. Hyaluronidase may have limited availability in some health care settings and is not typically required for the puncture method to be successful.

Previous reports have described successful reduction even after prolonged paraphimosis lasting up to 168 hours [2]. In some instances of delayed reduction of paraphimosis, a fibrotic band forms, and incision of the band is still necessary similar to the dorsal slit procedure [42]. (See 'Dorsal slit reduction' above.)

Glans penis aspiration — Aspiration of the glans penis is another invasive method of reduction that may be utilized if minimally invasive techniques fail [43]:

After performing a penile block, the clinician applies a tourniquet to the penile shaft proximal to the paraphimotic foreskin.

The glans penis is prepped sterilely, and a 20 gauge needle, attached to a 10 mL syringe, is inserted into the glans penis parallel to the urethra (figure 7).

Approximately 3 to 10 mL of blood are aspirated resulting in marked shrinkage of the glans penis.

The needle is removed and a firm, squeezing pressure to the glans is applied, just as in manual reduction. While holding this pressure, the tourniquet is released, and the constricted foreskin is reduced over the shrunken glans. Without the tourniquet, the glans will rapidly refill.

Potential urethral injury is the major drawback to this technique.

Complications — In general, the benefit of any of the paraphimosis reduction procedures outweighs the risk of ischemia to the penis. The adverse effects depend on the technique.

Injury to the foreskin during manipulation may lead to scarring and phimosis. Ultimately, circumcision may be necessary.

Manual manipulation or paraphimosis reduction with Adson or Babcock clamps may result in minor bruising and abrasion to the foreskin and glans penis.

Adson or Babcock clamps have the potential to tear the foreskin.

Reduction procedures involving dorsal slit incision or needle puncture may cause bleeding or infection.

Hyaluronidase injection has been associated with contusion, allergic reaction, and hypotension.

AFTERCARE — Additional care and follow-up depends upon how the paraphimosis was reduced:

Reduction by minimally invasive technique – Following successful reduction of the paraphimosis by minimally invasive techniques, the patient and/or parent should be instructed as follows:

Do not retract the foreskin for approximately one week [22].

Wash the foreskin with water. Do not forcefully retract the foreskin, and avoid irritants (eg, bubble bath or strong soaps). (See "Care of the uncircumcised penis in infants and children", section on 'Routine care and hygiene'.)

Patients with minor tears to the foreskin after reduction should apply bacitracin to the foreskin without performing retraction and should be advised to seek attention promptly if signs of infection (eg, redness, swelling, pain, or drainage) appear.

Adolescents and adults who sustain paraphimosis secondary to body piercing apparatus should be instructed not to reinsert these foreign bodies.

Those who sustain paraphimosis following intercourse should be cautioned to refrain from sexual activities for several days.

In patients for whom paraphimosis reduction is uneventful, follow-up may occur with the primary care provider in one to two weeks in order to evaluate for secondary infection and to reinforce proper hygiene [22].

Referral to a urologist to determine the need for circumcision is appropriate in patients with a repeated episode of paraphimosis and those with sustain significant trauma to the foreskin during reduction with the potential for scarring with phimosis.

Reduction by invasive technique – In addition to aftercare as described above, follow-up evaluation with a urologist is indicated for all patients who have undergone paraphimosis reduction by invasive methods. Elective circumcision is typically recommended.

PREVENTION — Parents of young, uncircumcised boys should be educated not to forcefully retract the phimotic foreskin. (See "Care of the uncircumcised penis in infants and children", section on 'Routine care and hygiene'.)

Adolescents and adults should be reminded to return the foreskin to normal position after cleaning and sexual activity.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Care of the uncircumcised penis in babies and children (The Basics)")

SUMMARY AND RECOMMENDATIONS

Definition and causes – Paraphimosis refers to a retracted foreskin in an uncircumcised male that cannot be returned to normal position (picture 1). (See 'Definition' above and 'Anatomy' above and 'Pathophysiology' above.)

In infants and young children, paraphimosis usually results from inadvertent or forcible retraction of the physiologically phimotic foreskin by the caretaker during penile cleaning. In the sexually active adolescent or adult, intercourse is a common precipitant. (See 'Causes' above.)

Diagnosis – The diagnosis of paraphimosis is based upon clinical findings. Swelling of the penis and severe penile pain are the two most common complaints in uncircumcised males with paraphimosis. On inspection, the glans penis and distal foreskin appear swollen with a constricting band present at the coronal sulcus (picture 1 and figure 1). Blue or black skin discoloration of the glans penis and firmness of the glans during palpation indicate ischemia. (See 'Physical examination' above and 'Diagnosis' above.)

Management – The primary management of paraphimosis consists of timely reduction of the foreskin back over the glans penis and requires (see 'Treatment' above):

Pain control – Pain control is patient dependent and tends to be inversely related to age; adolescents and adults may tolerate application of topical medications or injection of local anesthetic (figure 3), while young boys often require intranasal or parenteral administration of opioids and procedural sedation in addition to local anesthesia. (See 'Pain control' above and "Procedural sedation in children outside of the operating room".)

Reduction – Manual reduction may be facilitated by methods to reduce swelling if time permits (see 'Methods to reduce swelling' above).

For patients without signs of penile ischemia or urinary obstruction, the practitioner should start with manual reduction (figure 4 and table 1 and table 2). (See 'Manual reduction' above.)

If manual reduction is unsuccessful, the provider should advance to more invasive techniques, typically in consultation with a urologist. (See 'Dorsal slit reduction' above and 'Other techniques' above.)

Specialty consultation – Consultation with a urologist or a surgeon with similar expertise is warranted for patients with paraphimosis and (see 'Indications for specialty consultation' above):

Penile necrosis

Complete urinary obstruction

Unsuccessful reduction by the manual technique

If subspecialty care is not available in a timely manner, the medical provider should proceed to reduce the paraphimosis with the understanding that minimally invasive techniques may fail and that invasive techniques may be necessary for these patients.

Aftercare – Key components of aftercare following paraphimosis reduction include (see 'Aftercare' above):

No retraction of the foreskin for one week

Reinforcement of proper hygiene, avoidance of forced retraction of the foreskin in the young boy, and avoidance of irritants

For patients with minor tears to the foreskin after reduction, application of triple antibiotic ointment to the foreskin without performing retraction and prompt return for medical treatment if signs of infection (eg, redness, swelling, pain, or drainage) appear

In adolescents and adults, avoidance of sexual intercourse for several days

Follow-up with a urologist after paraphimosis reduction is indicated for patients with the following:

-Significant trauma during minimally invasive reduction

-Recurrent paraphimosis

-Required invasive paraphimosis reduction

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Topic 6482 Version 16.0

References