PARAPHIMOSIS

Paraphimosis is a tightening or constriction of the glans penis by the foreskin, which has been retracted behind the corona of the glans penis (Figure 42.2). Prolonged retraction can lead to obstruction of the lymphatics and subsequent lymphedema, which impairs the ability to replace the foreskin to its normal position over the glans penis.

Paraphimosis can occur in children, but is most often seen in uncircumcised adult or elderly men. It is often associated with poor hygiene, chronic balanoposthi-tis, diabetes, phimosis, chronic indwelling foley catheter, or patients who perform intermittent self-catheterization. Patients often experience penile pain and edema of the penile shaft proximal to the glans and corona, where a tight phimotic ring is present. If the constriction is severe, venous congestion of the glans is present, which can cause necrosis of the glans penis or distal urethra.

FIGURE 42.2

Paraphimosis.


Patient Presentation

¦  Penile pain

¦  Edema of the penile shaft proximal to the glans and corona

¦  Presence of a tight phimotic ring proximal to the corona

¦  Late finding of venous congestion of the glans with necrosis at the phimotic ring, which may extend to the glans penis

Treatment

Treatment of paraphimosis is closed manual reduction of the edematous glans penis. If manual compression does not resolve the paraphimosis, then a dorsal slit must be performed. Consider circumcision after the inflammation has resolved. Refer to a urologist.

Contraindications and Relative Contraindications

¦  There are no contraindications to manual reduction of the paraphimosis

¦  Use caution with the dorsal slit procedure in patients with a bleeding diatheses.

¦  Reversal of bleeding disorders, if possible, may be indicated if impending vascular compromise is evident

Special Considerations

Careful examination should be done to rule out any area of necrosis on the phallus, which would need to be debrided.

Procedure Preparation

¦  Gloves

¦  Skin cleanser

¦  Ice

¦  1% lidocaine gel or EMLA cream (2.5% prilocaine and 2.5% lidocaine)

¦  Elastic wrap or Kerlix bandage

¦  25-gauge needle (optional)

¦  4 X 4 gauze

Procedure

¦  Apply ice pack to the distal phallus for 10 to 15 minutes

¦  apply topical anesthetic to the tight phimotic ring, using 1% lidocaine gel or EMLA cream

¦  Manually compress the edematous glans penis using gentle, steady pressure with both thumbs on the glans for 5 minutes (Figure 42.3)

¦  alternatively, an elastic wrap or Kerlix bandage can be wrapped distal to proximal, from the glans to the base of the penis and kept in place for 5 minutes

¦  adjunctive therapy for moderate to severe glanular edema is to make several superficial (2 to 3 mm) puncture wounds using a 25-gauge needle in the glans to promote drainage of edema fluid and/or blood from venous congestion

¦  Holding the penis with one hand on either side, place both thumbs on the glans for stabilization. Using the fingers of both hands, draw the foreskin down over the glans

¦  If the aforementioned procedure does not resolve the paraphimosis, then an emergency dorsal slit or circumcision procedure is required (see phimosis treatment section for dorsal slit procedure)

Postprocedure Considerations

¦  If no definitive treatment, paraphimosis is likely to occur

¦  Debridement of necrotic tissue is rarely indicated

¦  Observe for bleeding for 30 minutes following dorsal slit procedure

Educational Points

Patients and health care providers need to be instructed to replace the foreskin to its normal position over the glans penis after placement of a urinary catheter. Those patients who have a chronic indwelling foley catheter should be taught routine catheter care with gentle soap and water, stressing the importance of returning the foreskin over the glans.

Complications

¦  arterial occlusion with necrosis of the glans penis

¦  Necrosis of the distal urethra

FIGURE 42.3 Manually compress the edematous glans penis.

Source: Image from eMedicine. com,

2010, with permission. Available at: http:// emedicine. medscape. com/article/442883-

Overview


Author’s Pearls

¦  If an indwelling foley catheter is present, remove the catheter to aid in reduction of paraphimosis

¦  A successfully reduced paraphimosis needs definitive treatment to prevent a future phimosis

  • Contact
  • Category: Sundries