Practice Essentials

Paraphimosis is a urologic emergency in which the retracted foreskin of an

uncircumcised male cannot be returned to its normal anatomic position. It is
important for clinicians to recognize this condition promptly, as it can result
in gangrene and amputation of the glans penis. Prompt urologic
intervention is indicated

Background
Paraphimosis occurs when the foreskin of an uncircumcised or partially
circumcised male is retracted for an extended period of time. This in turn
causes venous occlusion, edema, and eventual arterial occlusion. The
foreskin is unable to be reduced easily over the glans owing to this
progressive edema. The condition represents a urologic emergency, as
compromise of the arterial flow to the glans and constriction can cause
gangrene and amputation of the glans penis.
Paraphimosis differs from phimosis, a nonemergent condition in which the
foreskin cannot be retracted behind the glans penis. Paraphimosis occurs
only in uncircumcised or partially circumcised males. [1, 2]

Illustration of paraphimosis. The foreskin is swollen and edematous. A

constricting collar or band is present behind the glans penis.
View Media Gallery
Paraphimosis may occur when the foreskin has been pulled back behind
the head of the penis for an extended period and is often caused by well-
meaning health professionals who have retracted the foreskin to perform
penile examination or urethral instrumentation. Because paraphimosiis is
almost always iatrogenically or inadvertently induced, simple education and
clarification of proper prepuce care to parents, the individuals themselves,
and health care professionals may be all that is required to prevent it.
When paraphimosis is suspected, immediately obtain a urology consult for
proper evaluation and diagnosis. Prompt attention and treatment of this
emergency should lead to a favorable outcome.
Epidemiology
Frequency

Paraphimosis is a relatively uncommon condition and is less common than

phimosis.
Paraphimosis is almost always an iatrogenically or inadvertently induced
condition; however, case reports have described coital paraphimosis
leading to penile necrosis, [3] as well as penile piercings leading to
paraphimosis. [4] Paraphimosis occurs more often in hospitals and nursing
homes than in the private community, where the affected individual or a
parent often retracts the prepuce and then inadvertently leaves it in its
retracted position. In most cases, the foreskin reduces on its own and
therefore precludes paraphimosis; however, if the slightest resistance to
retraction of the prepuce is present, leaving it in this state predisposes it to
paraphimosis. As edema accumulates, the condition worsens.
A large minority of males in the United States are uncircumcised, and thus
are susceptible to paraphimosis. According to the National Hospital
Discharge Survey (NHDS), circumcision rates in the US declined from an
all-time high of 78-80% in the mid-to-late 1960s to 55%-60% in 2003.The
NHDS found that in 2010, 58.3% of newborn boys were circumcised.
Actual rates were presumably somewhat higher, however, as this figure
does not include circumcisions performed in the community

Etiology
Paraphimosis can occur after retraction of the foreskin during detailed
penile examination, cleaning of the glans penis, urethral catheterization, or
cystoscopy. For healthcare providers or patients retracting the patient’s
foreskin for any intervention or examiniation it is of vital importance to
replace the foreskin to the anatomic position covering the glans.
Development of paraphimosis after catheterization is not uncommon.
Before the insertion of a urethral catheter, a health professional retracts the
foreskin to sterilely prepare and drape the glans penis. The retracted
foreskin may be left in that manner for several hours to days. The failure to
restore the prepuce to its original position sometimes leads to the
development of paraphimosis.
More unusual causes of paraphimosis include the following:
 Self-infliction, such as piercing with a penile ring into the glans [6]
 Placement of a preputial bead
 Erotic dancing [7]
 Plasmodium falciparum infection [8]
 Contact dermatitis (eg, from the application of celandine juice to the
foreskin [9])
 Haemophilus ducreyi infection (chancroid) [10]

Pathophysiology
When the foreskin becomes trapped behind the corona for a prolonged
period, it forms a tight band of tissue around the penis. This constricting
ring initially impairs venous blood and lymphatic flow from the glans penis
and prepuce, in turn causing edema of the glans. As the edema worsens,
arterial blood flow becomes compromised. The ensuing tissue ischemia
and vascular engorgement cause painful swelling of the glans and prepuce
and may eventually lead to gangrene or autoamputation of the distal penis.

Presentation
Adult patients with symptomatic paraphimosis most often report penile
pain. In the pediatric population, paraphimosis may manifest as
acute urinary tract obstructionand may be reported as obstructive voiding
symptoms.
On examination, the glans penis is enlarged and congested with a collar of
edematous foreskin. A constricting band of tissue is noted directly behind
the head of the penis. The remainder of the penile shaft is unremarkable.
An indwelling urethral catheter is often present. Simply removing the
catheter may help treat paraphimosis caused by an indwelling urethral
catheter. The image below depicts mild-to-moderate paraphimosis.
 Mild-to-moderate form of
paraphimosis. The treatment involves manual reduction, puncture
technique, or medical therapy.

View Media Gallery

If paraphimosis is left untreated for too long, necrosis of the glans penis
can occur. Partial amputation of the distal penis has been reported. The
image below depicts severe paraphimosis.

Severe form of
paraphimosis. The distal penis has begun the process of autoamputation.

Relevant Anatomy
The penis is divided into the following three parts:
 The root of the penis lies under the pubic bone and provides stability
when the penis is erect.
 The body of the penis constitutes the major portion of the penis and is
composed of 2 cavernosal bodies (ie, corpora cavernosa) and a
corpus spongiosum (ie, head of the penis). The male urethra traverses
through the corpus spongiosum and exits from the meatus. The
cavernosal bodies produce an erection when filled with blood.
 The glans is the distal expansion of the corpus spongiosum usually
covered by the loose skin of the prepuce in uncircumcised individuals.
 A collar of tissue immediately behind the glans penis is known as the
coronal sulcus.
The penis is innervated by the left and right dorsal nerves (main sensory
nerve supply), which are branches of the pudendal nerve.
The penis is a highly vascular organ supplied by the internal pudendal
artery, which arises from the internal iliac artery and then branches into the
deep penile artery, the bulbar artery, and the urethral artery.
The deep penile artery becomes the cavernosal arteries, which supply the
entire corpus cavernosum. The urethral artery supplies the glans penis and
the corpus spongiosum. The bulbar artery nourishes the bulbar urethra and
the bulbospongiosus muscle

Management
When diagnosed early, paraphimosis can be remedied easily with simple
manual reduction in combination with other conservative measures.
Patients with severe paraphimosis that proves refractory to conservative
therapy will require a bedside emergency dorsal slit procedure to save the
penis. Formal circumcision can be performed in the operating room at a
later date.
Pain control
Paraphimosis is a a painful condition and care should be taken to ensure
patient comfort by providing adequate analgesia and local anesthesia using
a dorsal penile nerve block and circumferential penile ring block with
lidocaine, bupivicaine, or a combination of the two. Epinephrine should
never be injected. In additional, topical application of lidocaine or prilocaine
creams and direct injection of anesthetic into the foreskin can be used.
Reduction
Once pain control is adequate, manual reduction by attempting to
circumferentially compress the foreskin and holding for 2-10 minutes to
“squeeze” the edematous fluid along the penile shaft may be attempted.
After this fluid has passed proximally, the foreskin is reduced by placing
both thumbs on the glans and using the remaining fingers to pull the
foreskin back over the glans into the anatomic location. There are many
variations of this technique, all using the same principle of traction on the
foreskin and countertraction on the glans.
In addition, reduction can include the use of forceps and clamps to pull the
foreskin. Those instruments must be used cautiously, however, as they can
crush the skin and cause necrosis of this tissue due to devascularization.
The use of a 25-gauge needle to make several small stab incisions as an
outlet for edema fluid has also been described [11] .
Adjuncts to reduction
Ice, osmotic agents such as sugar, and compression wrapping with
Coban® have been used as adjuncts to manual reduction and can be
considered. Ice and osmotic agents may require 1-2 hours to take effect,
however, so they should not be used when arterial compromise is
suspected.

Medical Therapy
Medical therapy for paraphimosis involves reassuring the patient, reducing
the preputial edema, and restoring the prepuce to its original position and
condition. Several methods of reducing the penile swelling have been
described. Ice packs, penile wraps, and manual compression mechanically
disperse the penile and preputial edema, while osmotic agents, such as
granulated sugar or mannitol [13]have been reported as effective agents to
reduce swelling. Hyaluronidase has been effectively used in the pediatric
population as a method of increasing fluid diffusion, thus decreasing local
edema. [14] If a Foley catheter is present, remove it temporarily until the
paraphimosis has resolved.
Reduction
Prior to reduction, consider the use of local anesthesia
 Dorsal penile block: Insert a short 25-gauge needle anterior to the
pubic arch at the 10-o'clock position until the Buck fascia is
encountered. Insert the needle through the Buck fascia, but remain
outside of the corporal bodies. Aspirate to make sure the needle is not
in a corporal body. Inject 10 mL of 1% lidocaine solution. Repeat the
process at the 2-o'clock position.
 Ring block: Insert a short 25-gauge needle at the base of the penis
until the Buck fascia is encountered. Remain outside of the corporal
bodies. Inject the anesthetic into the Buck fascia circumferentially
around the base of the penis.
 A combination of dorsal penile and ring blocks should provide
adequate local anesthesia. If not, inject additional anesthetic directly
into the incision line.
Once pain control is adequate, manual reduction by attempting to
circumferentially compress the foreskin and holding for 2-10 minutes to
“squeeze” the edematous fluid along the penile shaft should be attempted.
After this fluid has passed proximally, the foreskin is reduced by placing
both thumbs on the glans and using the remaining fingers to pull the
foreskin back over the glans into the anatomic location. There are many
variations of this technique with the same principal of traction on the
foreskin and counter traction on the glans. In addition, reduction can
include the use of the forceps and clamps to pull the foreskin. Caution
should be used as the use of an instrument which crushes the skin will
result in necrosis of this tissue due to revascularization. The use of a 25
gauge needle to make several small stab incisions as an outlet for edema
has also been described After two or three solid attempts, the authors
resort to a dorsal slit procedure as described in Surgical therapy.
Several other methods to effectively reduce the glanular and prepucial
edema prior to reduction of the foreskin have been described in the
literature. Some of these methods are described are as follows:
 Wrap the penis in plastic and apply ice packs.
 Use compressive elastic dressings.
 Apply direct circumferential manual compression. (Application of a
topical anesthetic such as 2% lidocaine gel or eutectic mixture of local
anesthetics cream [2.5% prilocaine, 2.5% lidocaine;
see lidocaine/prilocaine] to the penile skin a few minutes to an hour
before penile manipulation reduces pain and helps patients,
particularly children, tolerate the procedure. [15] )
 Apply granulated sugar or mannitol-soaked gauze to the surface of the
edematous prepuce and cover it with a condom or a finger of a rubber
glove. The hypotonic fluid from the swollen foreskin moves down the
osmotic gradient into the hypertonic agent, which results in a reduction
of the preputial edema. This treatment is based on the principle that
fluid transfer occurs via an osmotic gradient.
 Using a tuberculin syringe, inject 1 mL of hyaluronidase (150 U/mL
Wydase) directly into several sites of the edematous prepuce.
Hyaluronidase breaks down hyaluronic acid in connective tissue and
enhances fluid diffusion between tissue planes, decreasing preputial
swelling and resulting in almost immediate resolution of the edema.
(The use of hyaluronidase in the pediatric population has been well
documented.)

Using ice and osmotic agents might take 1-2 hours to have an effect and
should not be used when arterial compromise is suspected.
Regardless of the method chosen, when the preputial swelling and edema
have subsided, correct the paraphimosis by gentle manual reduction (see
image below).

This demonstrates the

technique of manually reducing the paraphimotic foreskin.

View Media Gallery

To reposition the prepuce, place both thumbs on the glans penis and wrap
the fingers behind the prepuce. Apply gentle steady pressure to the
prepuce with counterpressure to the glans penis as the prepuce is pulled
down.
When performed properly, the constricting band of tissue should come
down to completely cover the glans with the prepuce. If the prepuce comes
down but the constricting band remains behind, the paraphimosis has not
been reduced properly or sufficiently.
For more information, see Paraphimosis Reduction Procedures.
In patients who are determined to retain the appearance of an
uncircumcised phallus, the authors have the patient
apply triamcinolone cream 0.1% to the affected area to possibly reduce the
fibrosis of the ring. This has been described in the treatment of phimosis
and has proven efficacious in temporarily preventing recurrent phimosis,
decreasing the need for circumcision. After 6 weeks of triamcinolone
application, if the prepuce can easily be retracted and reduced, the patient
may proceed as such, but the risk for recurrent phimosis and paraphimosis
remains. More often than not, the authors ultimately perform circumcision.

Surgical Therapy
The puncture technique, [16, 17] a minimally invasive procedure, and blood aspiration
are common therapies used to decompress the edematous prepuce.
To perform the puncture technique, commonly referred to as the Perth-Dundee
method, an 18- or 21-gauge hypodermic needle is used to puncture the edematous
prepuce at multiple sites and to release the trapped fluid (see image below). External
drainage results in rapid resolution of edema, which is followed by manual reduction
of the foreskin.

The puncture method to relieve preputial edema resulting from

paraphimosis. Using a needle, several punctures are made in the foreskin
to relieve the trapped fluid.
View Media Gallery

Alternatively, blood aspiration of the penis may be attempted after a

tourniquet has been applied.
If a severely constricting band of tissue precludes all forms of conservative
or minimally invasive therapy, an emergency bedside dorsal slit procedure
may be performed, followed by a delayed circumcision.
Dorsal Slit
After adequate local anesthesia with or without sedation or general
anesthesia, the plane between the dorsal foreskin and the corona is
identified. Normally when performing a dorsal slit, a hemostat is then used
to crush the foreskin at the 12 o’clock position which is also the midline of
the dorsal foreskin. This is left in place for hemostasis for 30-60 seconds.
The crushed area is then sharply incised with scissors. The edges are often
over sewn with an interrupted or running dissolvable suture such as
chromic.
However, when performing a dorsal slit for paraphimosis, one should
identify the dorsal midline of the rolled preputial skin. Make a vertical
incision at the junction of the rolled foreskin (identified as the point between
the mucosal, smooth skin and the preputial thicker, dull skin. This should
release the contricting tissue. Mobilize the foreskin so that it can slide over
the glans and back and then oversew the cut edges.

Regardless of the method used, urologic evaluation acutely in the

emergency room setting and then following the acute interaction for
consideration of circumcision are crucial.

Preoperative Details
Obtaining properly informed consent before performing circumcision is
critical. Inform patients, parents, and/or caregivers of the potential risks of
bleeding, infection, suture disruption, urethral injury, and too much or too
little skin being removed. Also inform patients that circumcision does not
affect the length or girth of the penis.
Instruct patients to abstain from genital stimulation for up to 6 weeks after
surgery. Inadvertent erections can strain suture lines and cause incisions to
break down.
Patients undergoing circumcision for recurrent balanitis should be free of
infection before the procedure.

Adequate anesthesia for emergency department management of

paraphimosis is technically challenging using a landmark-based technique
of a dorsal penile block (DPB). The landmark-based DPB is not
standardized and options include “10 o'clock and 2 o'clock” infrapubic
injections with or without ventral infiltration or a ring block. Given the
inherent technical imprecision, large dosage of a local anesthetic (up to 50
mL) can be required to achieve an adequate block. Successful use of an
ultrasound-guided approach has been reported wherevy the dorsal penile
nerves were precisely targeted in the fascial compartment just deep to
Buck fascia, reducing the need for large local anesthetic.

Postoperative Details
After the dorsal slit, petroleum jelly and sterile gauze or petrolatum gauze
dressings may be applied over the sutures, followed by a sterile white
gauze dressing. Prescribe oral narcotics and discharge the patient. Some
surgeons also prescribe oral antibiotics. the patient should apply bacitracin
or vasoline to the suture 2-3 times daily for the next 1-2 weeks or per the
preference of the performing physician
Remove the dressing 24-48 hours after surgery. Advise patients to wear
loose-fitting clothes, to gently wash the wound daily for the next 5-7 days,
and to refrain from any sexual activity for the next 6 weeks to prevent
breakdown of the sutures and incision line. Some surgeons additionally
recommend keeping the wound completely dry to avoid inadvertent
infection of the suture line.

Follow-up
Patients generally undergo follow-up examination in 2-3 weeks to check the
wound. Assess the wound for signs of infection and inspect the suture line.
For excellent patient education resources, visit eMedicineHealth's Men's
Health Center. Also, see eMedicineHealth's patient education
articles Foreskin Problemsand Circumcision.