This man is presenting with a paraphimosis. This is a true urologic emergency. Failure to make the diagnosis and resolve the problem can lead to necrosis and gangrene of the glans penis.
Paraphimosis is defined as the inability to reduce the proximally positioned foreskin over the glans penis. The foreskin forms a constricting band referred to as the phimotic ring. This phimotic ring impairs venous and lymphatic drainage. The result is swelling of the foreskin and glans penis. If the condition persists, arterial compromise may result with subsequent ischemia and skin necrosis. Gangrene of the penis can ultimately result.
Paraphimosis may be the result of infectious processes, trauma, or sexual activity. There are several case reports where it resulted from vaginal intercourse. The patient’s foreskin gets retracted during activity, and he subsequently falls asleep. In the morning, he wakes up with a swollen glans and foreskin which now cannot be reduced distally. Iatrogenic causes are one of the more common causes of paraphimosis. It occurs if the health professional forgets to move the foreskin back into its normal position after urinary catheterization or physical exam.
The diagnosis of paraphimosis is a clinical one. In the awake and oriented patient, it is often straightforward, but in the patient unable to give an accurate history, the diagnosis may be more difficult. The differential diagnosis includes hair tourniquet, allergic reaction, traumatic changes, and infection. Often the patient will have a history of phimosis. Phimosis is the inability to retract the foreskin proximally. In the newborn and infant, this is often physiologic and will improve over time without treatment. In the older patient, it occurs secondary to a traumatic event, infection, or inflammation.
The emergency treatment of a paraphimosis is immediate foreskin reduction. Before beginning any procedure, the patient will require anesthesia. Topical, nonirritating anesthetic gel can be placed on the inner surface of the foreskin. This will aid in pain control and help reduce friction when attempting reduction. In more severe cases, a penile nerve block may be needed. Parenteral medication also is helpful.
The first thing that needs to be done is decrease the swelling of the phimotic ring. In the literature, there are several interesting ways to accomplish this. The most common initial approach is manual compression. The distal penis is gripped with one hand for approximately five minutes to reduce the swelling. Alternately a compressive elastic bandage can placed on the distal penis. Other ways to help decrease swelling of the phimotic ring is to inject the ring with hyaluronidase once or twice using a tuberculin syringe. Hyaluronidase is an enzyme that hydrolyses extracellular mucopolysaccharide. It modifies the permeability of intercellular ground substance in connective tissue, which subsequently enhances diffusion between tissue planes and therefore decreasing edema.
There are some experts who believe that puncturing the phimotic ring and not the hyaluronidase that decreases the swelling, and they recommend multiple pin prinks only into the ring. Finally, there are case reports of the application of sugar and ice packs onto the edematous foreskin to reduce edema. To the best of my knowledge, there have been no randomized studies to evaluate any of these strategies.
The next step in treatment is reduction of the proximally placed foreskin. Manual reduction should be attempted first. The thumbs are placed on the glans of the penis, exerting pressure proximally. The index and middle fingers are placed on the foreskin, pushing the foreskin distally to cover the glans penis. If successful, the penis should appear as it normally would uncircumcised.
If this procedure is unsuccessful, nonserrated clamps can be used to grasp the foreskin and reduce it over the glans penis. If this is unsuccessful, a dorsal slit procedure will need to be done. In this procedure, a linear incision is made though the dorsal foreskin after being crushed with a hemostat. The edges are drawn back around the glans penis and sutured, reapproximating the two flaps of skin.
After reduction, the patient may be discharged with follow-up arranged with urology. A circumcision may ultimately be performed once the swelling and inflammation have subsided because recurrence is not uncommon.