Phimosis and paraphimosis

Paraphimosis

Paraphimosis is the inability to replace the retracted prepuce, accompanied by swelling of the glans and pain. This is an emergency, and with time, the swelling increases and ulceration occurs. The rare risk of glans ischaemia also exists, which has been described in literature [1].

Management:

1. Apply a swab soaked in 50% dextrose as a wrap around the site for at least 15 minutes. This acts by osmotic reduction of the swelling as the dextrose draws in the fluid from the tissue, subsequently reducing oedema

2. Ask the patient to squeeze the penis over the swab in an attempt to milk the oedema

3. After steps 1 and 2, attempt to manually reduce the swelling by drawing the prepuce up while pushing the glans inwards (see figure below)

4. Dundee technique - puncturing the oedematous ring with a hypodermic needle after a penile block has been administered is useful if steps 1-3 are unsuccessful. If this is the case, then contact your urology registrar

5. If the above fail, then a dorsal slit is warranted, which should ideally be followed by a delayed formal circumcision

Image 1 - Phimosis and paraphimosis.

Phimosis

-Phimosis is the inability to retract the foreskin (prepuce) over the glans. It is not a urological emergency and can be reviewed in the outpatient setting.

-The prepuce only becomes retractile after 2 years of age and is usually retractile in the vast majority of males at about 10 years of age. This is physiological phimosis and is not concerning unless there is associated pain.

-As a result of phimosis, it is not uncommon for patients to develop balanitis, which is an infection and inflammation of the glans.

Causes of pathological phimosis:

1. Balanoposthitis

2. Balanitis xerotica obliterans

3. Psoriasis

4. Eczema
   
   

Sequelae:

1. Painful erections

2. Painful sexual intercourse

3. Difficulty retracting to pass urine and maintain hygiene

4. Difficulty passing urine with ballooning of the foreskin and a weak stream

5. Urinary retention

6. Recurrent balanoposthitis

7. Balanitis xerotica obliterans

8. Recurrent urinary tract infections

9. Risk factor for penile cancer
   
   

Management:

1. Topical steroids - hydrocortisone for 4 weeks

2. General hygiene advice

3. Surgical - dorsal slit, preputioplasty, circumcision
   
   

References:
[1] Palmisano, F., Gadda, F., Spinelli, M.G. and Montanari, E. (2018). Glans penis necrosis following paraphimosis: A rare case with brief literature review. Urology Case Reports, 16, pp.57–58. doi:https://doi.org/10.1016/j.eucr.2017.09.016.

Images:
Image 1 - Phimosis and paraphimosis. Copyrights - Uromate.