Definitions
Phimosis is a condition where the foreskin is too tight to be pulled back over the head of the penis (glans). Physiological adherence of the foreskin to the glans is normal, with up to 10% of foreskins remaining non-retractile up to 3 years of age. This reduces to around 1% at the age of 16 years.
Paraphimosis is a condition in which the foreskin is left retracted for an extended period. Swelling occurs, causing the foreskin to become trapped behind the glans.
Pathophysiology
The most common aetiology follows retraction of the foreskin of an uncircumcised male penis by a health professional during penile examination, catheterisation, or cystoscopy, who then neglects to return the foreskin back over the glans penis.
Retraction of the foreskin behind the glans penis (in the presence of a phimotic foreskin) leads to the phimotic ring causing constriction of the distal glans. This leads to vascular engorgement as the lymphatic and venous flow from the constricting ring are impaired. This results in secondary oedema. The consequences are further vascular compromise as the arterial flow is impaired, and potential ischaemia of the penis distal to the phimotic ring. Eventual necrosis of the glans penis may be observed.
Diagnosis
Diagnosis is based on history and physical examination.
Patient Presentation
- Adult patients will most often report penile pain
- Paediatric patients may present with symptoms of obstructive voiding (i.e. a sensation of incomplete emptying, straining to void, and slow urine stream) or acute urinary obstruction
- Important to determine duration of the episode as manual reducibility may be compromised in prolonged cases
Physical Examination
- Glans penis is enlarged and congested with a collar of oedematous foreskin
- Constricting band of tissue observed directly behind the head of the penis
- Remainder of penile shaft unremarkable
- Evaluate for early signs of necrosis
- Soft, pink, pliable glans indicates blood flow
- Black appearance or non-pliable glans suggests early necrosis
Management
Paraphimosis should be considered a medical emergency, and steps should be taken to rapidly resolve this painful condition to prevent tissue loss.
- Careful inspection of the penis to ensure no constricting bands or foreign bodies (e.g. piercing studs) present
- Remove any indwelling catheter before attempting reduction
Analgesia
Paraphimosis can be extremely painful. Therefore, analgesia should be administered before treatment:
- Some patients tolerate topical formulations
- Others may prefer injection of local anesthetic
- Young boys often require parenteral opioids and sedative agents plus local anesthetics
- Local anesthetic can be used as:
- Single injection at dorsal midline of penis
- Ring block at base of penis
Severe Cases
Patients with evidence of significant glans penis ischaemia, with necrosis and sloughing of the foreskin and/or glans:
- Require involvement of consultant urologist
- Need procedural sedation or general anesthesia
- Immediate reduction using surgical techniques
- Devitalized tissue requires operative debridement
Treatment Techniques
Manipulation
- First method involves manual manipulation to reduce swelling and replace foreskin over glans
- Apply ice, compression, or osmotic agent:
- Ice packs: Apply to penis (after wrapping in plastic) to reduce swelling
- Compression: Use gloved hand or 2 x 2-inch bandage to compress oedematous glans and foreskin until swelling improves (successful in majority of cases)
- Osmotic agent: Use fine granulated sugar in liberal amounts (hypotonic fluid in penis flows to hypertonic agent outside)
- Once swelling reduced, perform manual reduction by pulling phimotic ring while pushing down on glans
Puncture Technique
- Used after failed attempts at minimally invasive reduction
- Dundee technique: Multiple perforations of glans with 22-gauge needle allows exudation of oedematous fluid
- After local analgesia and sedation, make multiple punctures in oedematous glans
- Then reduce foreskin by manual compression
- May augment with hyaluronidase injection into oedematous foreskin to degrade hyaluronic acid and reduce oedema
Surgical Reduction Followed by Circumcision
- Reserved for patients who fail conservative attempts
- In very infirm/older patients: Can be performed at bedside using penile block (local anesthetic + procedural sedation)
- Most patients require general anesthesia
- Dorsal slit procedure:
- Incise phimotic ring on dorsal aspect of penis until foreskin release identified
- Allows swelling to subside
- Close edges with 4-0 chromic suture or similar
- Complete circumcision as second procedure after swelling subsides
Clinical Pearls
- True urological emergency
- Common in children and older people
- Can be prevented with circumcision
- Key clinical features:
- Penile pain
- Band of retracted foreskin tissue beneath glans
- Swollen glans penis
- Erythema
- Black tissue on glans (sign of necrosis)
- Diagnosis is clinical
Prevention Strategies
- Always return foreskin to anatomical position after any penile procedure
- Educate patients and caregivers about proper foreskin care
- Document foreskin position after catheterization
- Consider elective circumcision for recurrent cases
- Proper training for healthcare staff on penile procedures