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Paraphimosis
Bradley N. Bragg1; Stephen W. Leslie2.
1 Mayo Clinic Florida
2 Creighton University Medical Center

Last Update: October 20, 2017.

Introduction
Paraphimosis is a true urologic emergency which occurs in uncircumcised males when the foreskin becomes trapped
behind the corona of the glans penis which can lead to strangulation of the glans as well as painful vascular
compromise, distal venous engorgement, edema, and even necrosis. Phimosis, by comparison, is the condition when
the foreskin is unable to be retracted behind the glans of the penis.

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. 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.

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%).

In adults, paraphimosis most commonly is 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, this
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 a marked
ischemia and potential necrosis of the glans.

Histopathology
At birth, there is a 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 contribute 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. The patient should be asked about his routine
cleaning of the penis and if he or a caregiver routinely retract the foreskin for any reason. It is also important to ask if
the patient is circumcised or uncircumcised. It is still possible to develop a 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).

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 Typical paraphimosis symptoms include erythema, pain, and swelling of foreskin and glans due to the constricting
ring of the phimotic foreskin.

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 is indicative of a
reasonably good blood supply; whereas a dark, dusky or black color implies possible ischemia or necrosis.

If a urinary catheter is in place, removing the catheter may aid in the reduction of the paraphimosis. After reduction,
the indication for the catheter should be reviewed, and the catheter should be replaced if necessary.

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, preventing 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 with or without compression
methods, osmotic agents, and puncture-aspiration techniques.

Paraphimosis can often be reduced by simple compression of the glans and the swollen, edematous foreskin for
several minutes allowing 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 upward on the phallus.

The 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.

Another compression technique involves tightly wrapping the penis from the glans to the base with a 1 inch or 2 inch
elastic bandage. A gauze pad is applied first around the edematous foreskin. The compression bandage can remain for
10 to 15 minutes to minimize the edema. Then apply one of the manual reduction methods described above. This is
often a preferred technique as the elastic wrap can be placed by nursing staff while you are travelling to the patient's
location.

Ice packs or surgical gloves filled with ice and applied to edematous areas have been described as possibly being
useful in conjunction with other methods to aid in the reduction of 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) 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,
some believe that it may make the skin a little slippery and harder to manipulate.

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 Reducing the penile edema from a paraphimosis can also be achieved by the injection of hyaluronidase directly into
the edematous foreskin. This has been effective, particularly in children and infants, in resolving the edema which
then allows for easier 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.

Osmotic methods involve the application of 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 aiding in the reduction of the edema from paraphimosis.

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 and 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.

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 by
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 aspiration of blood before injecting.
Ultrasound guidance has been shown to be effective in helping to identify landmarks for this procedure.

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.

If the previous methods are unsuccessful, surgical treatment will be required. 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. After reduction, the incision can be
approximated by a 3-0 or 4-0 absorbable suture.

Other Issues
After successful 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 that contributed 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.

Questions
To access free multiple choice questions on this topic, click here.

References
1. Hayashi Y, Kojima Y, Mizuno K, Kohri K. Prepuce: phimosis, paraphimosis, and circumcision.
ScientificWorldJournal. 2011 Feb 03;11:289-301. [PubMed: 21298220]
2. Khan A, Riaz A, Rogawski KM. Reduction of paraphimosis in children: the EMLA glove technique. Ann R

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 Coll Surg Engl. 2014 Mar;96(2):168. [PMC free article: PMC4474256] [PubMed: 24780686]
3. Wan J, Rew KT. Common penile problems. Prim. Care. 2010 Sep;37(3):627-42, x. [PubMed: 20705203]
4. Little B, White M. Treatment options for paraphimosis. Int. J. Clin. Pract. 2005 May;59(5):591-3. [PubMed:
15857356]
5. Choe JM. Paraphimosis: current treatment options. Am Fam Physician. 2000 Dec 15;62(12):2623-6, 2628.
[PubMed: 11142469]
6. Flores S, Herring AA. Ultrasound-guided dorsal penile nerve block for ED paraphimosis reduction. Am J Emerg
Med. 2015 Jun;33(6):863.e3-5. [PubMed: 25605058]
7. Herzog LW, Alvarez SR. The frequency of foreskin problems in uncircumcised children. Am. J. Dis. Child. 1986
Mar;140(3):254-6. [PubMed: 3946358]
8. Choe JM. Paraphimosis: current treatment options. Am Fam Physician. 2000 Dec 15;62(12):2623-6, 2628.
[PubMed: 11142469]
9. Anand A, Kapoor S. Mannitol for paraphimosis reduction. Urol. Int. 2013;90(1):106-8. [PubMed: 23257575]
10. Clifford ID, Craig SS, Nataraja RM, Panabokke G. Paediatric paraphimosis. Emerg Med Australas. 2016
Feb;28(1):96-9. [PubMed: 26781045]

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