Paraphimosis, entrapment of the foreskin in the retracted position, is a urologic emergency requiring reduction of the foreskin to its normal distal position enveloping the glans penis, in order to prevent necrosis of the glans.
(See also Phimosis and Paraphimosis.)
Paraphimosis can occur in uncircumcised males and often results from failure to reduce the foreskin after retracting it during a urologic examination or procedure such as urethral catheterization.
Manual methods of reduction are tried before more invasive methods, such as the dorsal slit, and include
Compressing the edematous glans and foreskin, then pushing the glans back through the constricting foreskin ring (phimotic ring)
Traction upon multiple Babcock clamps (noncrushing) placed about the circumference of the foreskin, to pull the foreskin back over the glans
Indications for Paraphimosis Reduction
Paraphimosis requires immediate reduction.
Contraindications to Paraphimosis Reduction
Absolute contraindications
There are no absolute contraindications to paraphimosis reduction.
Relative contraindications
Invasive adjuncts for dispersing foreskin edema (eg, involving needle puncturing of the foreskin) should be avoided if local infection, ulceration, or penile cancer is present.
Complications of Paraphimosis Reduction
Complications include
Laceration or tearing of penile skin or foreskin
Phimosis due to injury of the foreskin
Equipment for Paraphimosis Reduction
Routine
Sterile drapes and gloves
Povidone iodine
Sterile gauze, 4" x 4" squares
Water-soluble lubricant
2% lidocaine jelly
Local anesthetic (eg, 1% lidocaine or 0.5% bupivacaine without epinephrine)
Adjunctive (sometimes used)
Roll of elastic bandage (2" wide)
Babcock clamps (6 to 8)
Ice, crushed, placed inside surgical gloves
Small needle (21 to 27 gauge), to place punctures in the edematous foreskin
Hyaluronidase, 1 mL (150 U), 27-gauge needle, tuberculin syringe
Salt or sugar for osmotic treatment (1)
Additional Considerations for Paraphimosis Reduction
Consult a urologist urgently if there are concerns about glans necrosis or penile cancer.
Although most adults tolerate noninvasive reduction methods with only calm reassurance and a topical anesthetic, penile anesthesia—such as a penile ring block (subcutaneous lidocaine circumferentially about the base of the penis) and/or dorsal block—may be required in some cases (eg, aggressive manual reduction, use of Babcock clamps, or needle insertions into the foreskin).
Procedural sedation or general anesthesia may be required in some cases (eg, children).
Positioning for Paraphimosis Reduction
Position the patient supine.
Position yourself (operator) seated next to the stretcher at a height where your elbows rest comfortably on the stretcher.
Step-by-Step Description of Paraphimosis Reduction
Place all equipment within easy reach on a bedside tray.
Apply anesthetic jelly to the glans and foreskin and enclose and compress with an occlusive dressing (eg, plastic wrap or gauze) or a cut-off fingertip of a disposable glove. Allow 20 to 30 minutes for the anesthetic to take effect.
Remove any foreign bodies from the affected area.
Cleanse the region. Swab in concentric circles from the tip of the penis down to its base and several centimeters beyond, using povidone iodine.
Provide appropriate pain control to allow for patient cooperation. Anesthetize the penis using a ring or dorsal block, if any of the following is anticipated: aggressive manual reduction, needle punctures or hyaluronidase injections of the foreskin, or retraction of the foreskin using the Babcock clamp method. If needed, also use oral or intravenous pain medications, sedation, or other anesthesia.
Decrease local edema by compressing the glans and foreskin. Grasp the distal penis in the palm of a gloved hand and squeeze snugly for 5 to 10 minutes or more. Alternatively, in an adult, wrap a strip of gauze or elastic bandage around the area, beginning distally and wrapping most tightly distally and less tightly proximally. Be patient; edema decreases gradually. Remove any bandages before doing manual reduction.
Push the glans proximally through the phimotic ring. Using both hands, hold the penis securely between the index and middle fingers bilaterally, just proximal to the phimotic ring. Then, with your thumbs, use slow, steady pressure to push the glans proximally through the ring, while milking the foreskin distally to reduce it fully over the glans. Alternatively, in an adult, grasp and apply traction to the shaft of the penis with one hand while using the thumb of the other hand to push the glans through the phimotic ring.
A successful reduction will appear as a foreskin reduced over a swollen glans.
Additional methods to decrease the edema of the glans and foreskin and facilitate manual reduction include
Application of ice: Place water and ice chips into a surgical glove, then remove any air and tie off the glove. Invaginate the thumb of the glove, place the penis into it, and then hold the glove in place and compress for 5 to 10 minutes. To prevent cold injury to the penis, remove the pack after 10 minutes.
Circumferential needle punctures of the edematous foreskin: First, anesthetize the penis. Then use a 21- to 27-gauge needle to make multiple punctures (about 10 to 20) in the edematous foreskin, to allow the edema to seep out during manual compression of the area. During compression, use gauze around the foreskin to absorb the seeping fluid and blood.
Hyaluronidase injections into the foreskin: Inject 1 mL (150 U) total in 1 or 2 subcutaneous injections using a tuberculin syringe (avoid intravascular injection, which can cause anaphylaxis). The hyaluronidase causes rapid dispersal of edema into surrounding tissues. During compression, use gauze around the foreskin to absorb any seeping fluid and blood.
Application of osmotic agents to the foreskin: Sugar and salt are hypertonic agents, which will draw out the hypotonic edema when applied to the glans and foreskin. This process may take hours and should not be used in acute paraphimosis (1).
After doing any of these maneuvers, manually reduce the foreskin as described above.
The Babcock clamp method of reduction
Place 6 to 8 Babcock (noncrushing) clamps on the outer edge of the phimotic ring, circumferentially and evenly spaced.
Grasp the clamps simultaneously and apply slow, distal traction to pull the phimotic ring over the glans. Be careful not to tear the foreskin.
Aftercare for Paraphimosis Reduction
Promptly consult a urologist if manual reduction attempts fail.
Arrange follow-up with a urologist after successful manual reduction, to evaluate whether surgical treatment (circumcision or dorsal slit) is required.
Most dermal injuries will not require suturing after manual reduction.
Oral or topical antibiotics may be given to help decrease the risk of infection, especially in high-risk patients (eg, those who are immunocompromised, those who have diabetes).
Ask patients not to retract the foreskin until they have been reevaluated, at which time retraction can be done with physician supervision.
Warnings and Common Errors for Paraphimosis Reduction
Impatience could lead to failure to compress the foreskin and glans for an adequate time before attempting reduction.
Tips and Tricks for Paraphimosis Reduction
Patient cooperation is essential in order to have any attempt at successful reduction of paraphimosis. Children and even anxious adults may require local anesthesia and sometimes sedation to undergo treatment.
Джерела літератури
1. Kerwat R, Shandall A Stephenson B: Reduction of paraphimosis with granulated sugar. Br J Urol 82(5):755, 1998. doi: 10.1046/j.1464-410x.1998.00902.x
