Introduction

Paraphimosis is a true urologic emergency that occurs in uncircumcised males when the foreskin becomes trapped behind the corona of the glans penis, leading to strangulation of the glans as well as painful vascular compromise, distal venous engorgement, edema, and even necrosis. By comparison, phimosis is the condition when the foreskin is unable to be retracted behind the glans of the penis.[1]

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.[1] 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%).[2]

In adults, paraphimosis is most commonly 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 marked ischemia and potential necrosis of the glans.[3]

Histopathology

At birth, there is 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 contributes 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.[1] 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 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.

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 indicates 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 reducing the paraphimosis. After reduction, the indication for the catheter should be reviewed, and the catheter should be replaced if necessary.[1]

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, often preventing the easy manual reduction of the foreskin over the glans. Diagnosis is made clinically by direct visualization, as well as the inability to reduce the retracted foreskin manually easily.

Differential Diagnosis

• Acute angioedema 

• Allergic contact dermatitis 

• Anasarca

• Balanitis

• Balanitis xerotica obliterans

• Cellulitis

• Foreign body tourniquet

• Insect bites

• Penile carcinoma 

• Penile fracture 

• Penile hematoma 

Prognosis

The prognosis with paraphimosis is excellent if diagnosed and treated promptly. There may be some bleeding during skin retraction, but long-term negative outcomes are rare. The condition can common recur; circumcision can preclude recurrence once the inflammation has subsided and the patient is a viable candidate for the procedure.[11]

Complications

Complications that can occur with paraphimosis include pain, infection, and inflammation of the glans penis. If the condition is not relieved in a sufficiently prompt timeframe, the distal penis can become ischemic or necrotic. Operative complications include bleeding, infection, injury to the urethra, and shortened penile skin.

Deterrence and Patient Education

After reduction or surgery, patients should be counseled that their prognosis is quite good. They should receive instruction on hygiene, be sure and return their foreskin to its normal position if it has been retracted, and avoid using any penile jewelry if that has contributed to the condition. The patient may wish to consider circumcision to preclude future episodes, particularly if recurring cases.

Pearls and Other Issues

After a successful manual 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 contributing 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.

Enhancing Healthcare Team Outcomes

Paraphimosis is a urological emergency best managed by an interprofessional team that includes a pediatrician, emergency department physician, urologist, nurse specialist, and a surgeon. Mild cases may be reduced manually, but more complex cases usually require some type of anesthesia.

After a successful manual 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 contributing 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.