Paraphimosis

Paraphimosis occurs when a retracted tight foreskin becomes trapped behind the coronal sulcus and cannot be returned over the glans.

The constricting ring impairs:

• Lymphatic drainage

then

• Venous drainage

followed eventually by:

• Arterial perfusion

Untreated severe paraphimosis can cause glans ischaemia and necrosis.

It is therefore a urological emergency.

Common causes include failure to replace the foreskin after:

• Catheter insertion
• Examination
• Cystoscopy
• Cleaning
• Sexual activity

Findings include:

• Painful swollen glans
• Retracted oedematous foreskin
• Tight constriction band behind the corona
• Increasing penile oedema

Assess:

• Glans colour
• Temperature
• Capillary refill
• Evidence of necrosis

A dusky, black or insensate glans requires immediate surgical assessment.

Diagnosis is clinical.

No imaging is required.

Analgesia

Provide adequate analgesia.

Options include:

• Oral or IV analgesia
• Penile ring block
• Dorsal penile nerve block

Manual reduction

First reduce oedema.

Use firm circumferential compression of the glans and oedematous foreskin for several minutes.

Then:

• Compress the glans with both thumbs
• Pull the foreskin distally over the glans with the fingers

The glans moves proximally while the preputial ring is brought forward.

This is the preferred first line treatment.

Refractory oedema

Additional techniques can include:

• Compression dressing
• Multiple puncture technique to release oedema
• Osmotic reduction techniques

These should not substantially delay definitive reduction.

Dorsal slit

If manual reduction fails:

Perform a dorsal slit through the constricting preputial band under appropriate anaesthesia.

This immediately releases pressure.

Definitive treatment

After acute swelling and inflammation resolve, treat the underlying pathological phimosis to prevent recurrence.

Options include:

• Circumcision
• Preputioplasty in selected cases

The foreskin must always be returned to its normal position after catheterisation or penile examination to prevent iatrogenic paraphimosis.