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Phimosis & Paraphimosis

Background

Phimosis is an inability to retract the tight, distal foreskin over the glans penis (see Picture 1). Paraphimosis is the entrapment of the retracted foreskin behind the coronal sulcus (see Picture 2).

Patients with phimosis rarely require emergency intervention, unless it causes difficulties such as urinary obstruction, haematuria or focal pain. However, paraphimosis is a urological emergency requiring immediate attention.

 

Image 1: (A) Physiologic phymosis; (B) Pathological phymosis

Image 1: (A) Physiologic phymosis; (B) Pathological phymosis

Image 2: Paraphymosis

Image 2: Paraphymosis

Introduction

Almost all boys have physiological non-retractile prepuce (foreskin) at birth but ninety five percent develop a retractile foreskin by 16-17 years of age. However, a pathological phimosis may occur following episodes of prepuce infection (balanoposthitis) due to poor hygiene. These episodes result in scarring of the prepuce which prohibits retraction over the glans. Phimosis usually occurs in the uncircumcised penis but occasionally occurs after circumcision where excessive skin becomes sclerotic.

Patients with physiological or pathological phimosis are at risk of developing paraphimosis when the foreskin is forcibly retracted past the glans or the patient or carer forgets to replace the foreskin after retraction.

*This is particularly important following catheterisation where it is essential to replace the foreskin following completion of the procedure.*

In due course the penis will develop blood and venous congestion. As the swelling worsens, the arterial supply is compromised leading to penile infarction, gangrene and eventually autoamputation.

 Other risk factors for paraphimosis include:

  1. Vigorous sexual activity
  2. Chronic balanoposthitis (inflammation of the foreskin, higher risk in diabetic patients)
  3. Penile piercing
  4. Penile trauma

 

    Clinical History

    Symptoms the patient may report as part of a history include the following:

    1. Penile swelling
    2. Penile pain
    3. Urinary obstruction with/without weak urinary stream
    4. Painful erection
    5. Haematuria
    6. Recurrent Urinary Tract Infections

     

        Clinical Examination

        *Remember to use a chaperone during genitalia examination*

        Typically, patients are in excruciating pain. On inspection, it is important to ensure that no constricting foreign bodies such as rubber bands, piercing, hair and clothing are present. The following findings may be present during the examination of the penis:

        1. Swelling, redness and tenderness of the prepuce with/without purulent discharge.
        2. Constricting band of tissue sited at the coronal sulcus.
        3. Colour of the foreskin turned to blue or black and firm on palpation: ischemia of the glans of the penis which requires immediate urological attention.

         

        Phimosis and paraphimosis are clinically diagnosed; laboratory and imaging studies are not required.

         

        Management

        Surgical Management

          If the glans or prepuce exhibit evidence of colour change to blue or black or appear necrotic as a result of ichaemia, an immediate urological opinion is required. This is a surgical emergency.

           

          If there is no evidence of ischaemia or necrosis then proceed as follows:

           

          Medical Management

          Prescribe analgesia if required. This may be applied topically, injected or given intravenously depending on the individual. Younger patients may require sedation.

          After analgesia is administered the following methods can be used to reduce swelling of the prepuce, as follows:

          • Ice

          The penis should be wrapped in plastic and ice packs can be applied to help reduce oedema.

          • Compression

          The swollen prepuce can be manually compressed to reduce swelling. This is commonly achieved by hand but bandages can also be used. This method is sucessful at decompressing the majority of paraphymoses in children. 

          • Osmotic method:

          A swab soaked in 50 mL of 50% dextrose can be wrapped around the glans and foreskin for an hour prior to attempting reduction via osmotic force. However, the major drawback of this method requires longer period of time for action.

           

          Manual reduction

           *If there is a catheter in situ, determine the indication for its use and remove prior to attempting decompression*

          Once swelling has been reduced by the methods outlined above, manual reduction is performed. This is effected by placing both index fingers on the dorsal border of the penis behind the retracted prepuce and both thumbs on the end of the glans. The glans is pushed back through the prepuce with the help of constant thumb pressure while the index fingers pull the prepuce over the glans.

           

          Puncture method

          If this is not sucessful, another method is to use a 21 to 26 gauge sized needle to puncture multiple openings of the foreskin. This allows the oedematous fluid to escape during manual compression.

          Hyaluronidase method:1 mL of aliquots of hyaluronidase is used to inject into the sites of oedmatous tissue. It is believed that hyaluronidase disperses extracellular edema by modifying the permeability of intercellular substance in connective tissue. The drawback of this method that hyaluronidase solution is not readily available in most wards at the hospital. Secondly, it is contraindicated if the patient is known to have infection or cancer at the local affected site as this technique may result in disseminate the bacteria or malignant cells. The risk of anaphylaxis and shocks also need to be considered.

          If the above methods mentioned do not help reducing the swelling, an urgent urological opinion needs to be sought out. The other more invasive methods are mentioned as below:

          1. Aspiration of blood from the glan penis, using a 20 gauge needle and tourniquet.
          2. Vertical incision or dorsal slit of the foreskin
          3. Emergency circumcision.

           

            Picture 3: Manual reduction

            Summary:

            The single most common cause of paraphimosis in hospital patients is the delay in retracting the foreskin back to its neutral position after urological procedure, e.g. catherisation, cystoscopy etc. When paraphimosis persist in these patients, prompt efforts to reduce the swelling must be made. If minimally invasive reduction methods fail to reduce the paraphimosis, a urological consultation is required.

            Reference(s):

            1. Picture 1 and 2 taken from http://emedicine.medscape.com/article/777539-overview
            2. Picture 3 taken from https://online.epocrates.com/u/2942765/Paraphimosis/Treatment/Tx+Details
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