Contents
Urologic emergency, occurring in uncircumcised males, in which the foreskin becomes trapped behind the corona and forms a tight band of constricting tissue.
- Phimosis (differential): Nonemergency condition in which the foreskin cannot be pulled back.
Aetiology
Iatrogenic cause:
Most common cause
- Urethral catheterization: Paraphimosis typically occurs after Foley catheter placement. During the insertion of a urethral catheter, the foreskin is retracted to prepare and drape the glans penis. After insertion of the catheter, the practitioner may not return the retracted foreskin to its normal position.
- Following penile examination
- Cystoscopy
Rare causes:
- Self-inflicted injury to the penis (eg. penile ring piercing into the glans)
- Secondary to penile erections
Pathophysiology
When the foreskin becomes trapped behind the corona for a prolonged time, it may form a tight, constricting band of tissue. This circumferential ring of tissue can impair the blood and lymphatic flow to and from the glans and prepuce. As a result of penile ischemia and vascular engorgement, the glans and prepuce may become swollen and edematous. If left untreated, penile gangrene and autoamputation may follow in days or weeks.
Diagram illustrating paraphimosis | From the collection of Dr Ranjiv Mathews Paraphimosis, the foreskin constricting the penis at the coronal sulcus. The distal glans is necrotic and the area is dry and well-demarcated. | Palmisano, F., Gadda, F., Spinelli, M. G., & Montanari, E. (2017). Glans penis necrosis following paraphimosis: A rare case with brief literature review. Urology case reports, 16, 57–58. https://doi.org/10.1016/j.eucr.2017.09.016
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.
Penile nerve block:
Because of extreme pain, patients may require a penile nerve block, topical analgesic or oral narcotics before penile manipulation.
Manual reduction:
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.
Circumcision:
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.