Paraphimosis

Introduction

Paraphimosis is the inability to pull forward a retracted foreskin over the glans penis.

By TeachMeSeries Ltd (2024)

Figure 1 – The three anatomical divisions of the penis

It is most often caused due to the presence of a tight constricting band as part of the foreskin that prevents the retraction over the glans

As the paraphimosis remains, the glans becomes increasingly oedematous due to reduced venous return, leading to vascular engorgement of the distal penis and further oedema.

If untreated this may lead to penile ischaemia and worsening infection, including Fournier’s gangrene. Consequently, it is a urological emergency that requires urgent reduction.

Risk Factors

Phimosis, indwelling urethral catheter (due to non-replaced foreskin), poor hygiene, and prior paraphimosis.

Clinical Features

Typical presentation is with progressive pain and swelling in the glans or distal prepuce, following retraction of their foreskin, being unable to retract in back over their glans (Fig. 2).

Patients may have had repeated admissions if the underlying cause has not been addressed.

By Aimee Rowe, TeachMeSurgery [CC-BY-NC-ND 4.0]

Figure 2 – Schematic demonstrating (A) normal prepuce (B) a paraphimosis

Management

Any paraphimosis should be reduced as soon as possible, as delays in management can lead to worsening swelling and a reduced likelihood in successful reduction.

Prior to any reduction, ensure suitable analgesia; a penile block via local anaesthetic (without adrenaline) may be warranted in some cases.

Once reduced, ensure definitive management (such as consideration for circumcision) is arranged urgently as an outpatient.

Methods of Reduction

Various techniques to treat paraphimosis have been described:

• Manual pressure to the glans can aid to reduce oedema, squeezing gently but constantly, before applying force to the glans to reduce it into the prepuce (use of lubricant jelly as required).
• Application of dextrose-soaked gauze to act as an osmotic effect, drawing fluid out of the glans, reducing the oedema present, and allowing for glans reduction as above. Similar technique for reducing oedema can be performed with ice packs
• The “Dundee Technique” involves the use of needle punctures into the glans penis, squeezing the area to allow drainage of oedematous fluid, before attempting reduction of the glans, as discussed above

If manual reduction fails, then a dorsal slit (incision of the prepuce at the 12’o clock position) or an emergency circumcision may be required