emDOCs.net – Emergency Medicine [email protected]: Paraphimosis and Phimosis – emDOCs.net – Emergency Medicine Education

Author: Rachel Bridwell, MD (@rebridwell, EM Resident Physician, SAUSHEC / San Antonio, TX) // Edited by: Brit Long, MD (@long_brit, EM Attending Physician, San Antonio, TX)  and Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)

Welcome to [email protected], an emDOCs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

An 8-year-old male was brought in by his parents for continuous screaming for 12 hours. The parents noted that he is grabbing his groin area but will not let them inspect the area. Review of systems is remarkable for no circumcision.

Triage vital signs (VS): BP 110/61, HR 135, T 98.0 temporal, RR 18, SpO2 100% on room air. He is in distress, and exam demonstrates incarceration of the glans by the foreskin with pronounced glans edema. The testicular lie is normal with positive cremasteric reflex bilaterally. There is no no scrotal edema or erythema.

What’s the diagnosis?

Answer: Paraphimosis1-15

Epidemiology:

  • Risk Factors: Uncircumcised males
  • Paraphimosis: emergency in which foreskin becomes retracted around coronal sulcus, causing vascular congestion and edema of the glans1
    • Can progress to penile necrosis and gangrene2
    • Occurs in 0.7% of uncircumcised boys, which is increasing with rate of declining circumcision3
  • Phimosis: foreskin retracted over the glans
    • Emergency only if causing acute urinary retention
    • The majority of uncircumcised infants have normal phimosis

 

Clinical Presentation:

  • Paraphimosis: in young males, commonly seen during a diaper change, during cleaning of foreskin, or after catheterization1
    • In adolescent and older males—delayed presentation due to embarrassment, may be caused by sexual intercourse, genital piercing, prolonged erotic dancing4
  • Phimosis: foreskin over the glans

 

Evaluation:

  • Assess ABCs and vital signs – tachycardia and hypertension can occur due to pain
  • Perform a complete physical examination
    • Penis
      • Paraphimosis: Glans edema and vascular congestion due to incarceration by retracted foreskin
      • Phimosis: Inability to retract foreskin over glans — check for pain, pruritus, smegma5
    • Scrotum: ensure no concomitant torsion, Fournier’s
  • Laboratory evaluation: can consider
    • POC glucose in DM
    • KOH smears—fungal hyphae can be seen if concomitant balanitis

 

Treatment:

  • ABCs
  • Establish timeframe
  • Paraphimosis
    • Consider and start non-manipulative methods of reduction while mobilizing resources for manual reduction and sedation
    • Non-manipulative reduction: reasonable first option in the absence of ischemia1
      • Osmotic agents, ice water compression2
        • Ideally decrease edema with “iced glove”, topical sugar, of 50% dextrose solution2
        • High solute concentration utilizes gradient to draw fluid from edematous foreskin
        • 1-2 hours to see effect4
      • Depend upon patient and parental cooperation
    • Manual reduction — Consideration of both technique for reduction & analgesia
    • Analgesia: topical EMLA on tegaderm, nerve blocks, IV procedural sedation, midazolam + PO analgesia2
      • Consider local infiltration when Adson forceps or Babcock clamps are utilized to grasp foreskin6
      • Comparison of topical anesthesia vs IV procedural sedation in pediatric paraphimosis
        • No difference in first attempt success, LOS shorter in topical anesthesia, increase in minor adverse events in procedural sedation3
      • Dorsal penile nerve blocks — may perform at 10 and 2 o’clock locations
        • Risk with blind blocks — LAST, urethral injury, failed anesthesia, failed anesthesia
        • Can perform with high frequency linear probe, inject with 25 Ga needle just under Buck’s fascia, 15 min to anesthesia7
        • Successfully described in pediatric and adult populations7,8

 

  • Manual reduction:
    • Classic manual reduction technique: circumferential continuous pressure applied to distal penis to push swelling under constrictive band9
      • Apply both thumbs to glans with countertraction to foreskin with index fingers2
        • Can utilize Adsons or Babcocks to help with countertraction6
      • Colorado CoFlex®: Wrap whole shaft first loosely then next 2 wraps are sequentially tighter, minimizing trauma to prepuce, leave in place for 20 min2
        • Successful reduction in 4/4 patients with range of symptom onset 5-48 hours2
      • Failed manual reduction: urgent surgical consultation
        • If there is no surgeon or transfer available, consider teleconsultation with a surgeon:
          • Place single or multiple needle holes into edematous foreskin with 22-25 G needle10,11
          • Aspiration of blood from glans1
          • Dorsal slit12

 

  • Phimosis
    • Emergency when causing acute urinary retention — consult urology for dorsal slit
    • In the setting of free urinary excretion, education on proper foreskin cleaning and demonstration of forcible retraction of prepuce
      • 3 months of prepuce stretching generated resolution of phimosis in 76% of patients13
    • Topical corticosteroids can be provided for via anti-inflammatory, immunosuppressive, and skin thinning mechanisms of action14
      • Meta-analysis of 12 RCTs showed that topical steroids improved or completely resolved phimosis15
      • Topical triamcinolone 0.025% BID for 4-6 weeks

 

Disposition:

  • Consult Urology urgently for circumcision
    • If urinary retention in phimosis
    • In paraphimosis:
      • Immediately if significant ischemia1
      • After failed manual reduction despite adequate sedation/analgesia1
      • Symptoms > 12 hours1
    • Outpatient urology consult for patient if manual reduction successful in 2-3 weeks1

 

Pearls:

    • After reduction, ensure the patient can pass urine, do not retract foreskin for 2 weeks1

A mother brings her 1-year-old uncircumcised boy to the emergency department after realizing while bathing the child that his foreskin was not retractile. He has no fever and is still having copious wet diapers. Examination reveals a normal, intact foreskin overriding the glans, and urine can be seen coming out of the meatus. Which of the following is the most appropriate next step?

A) Reassurance and discharge

B) Retraction of the foreskin to expose the distal glans penis

C) Topical hydrocortisone applied to the distal penis

D) Urology consultation

 

 

Answer: A

This patient’s presentation is consistent with physiologic phimosis. Phimosis is the inability to retract the foreskin proximal to the glans. It is important to differentiate phimosis from paraphimosis (inability to reduce the foreskin back over the glans), as paraphimosis is a medical emergency that can lead to necrosis of the glans due to the obstruction of venous flow. Phimosis is most commonly due to stenosis of the distal foreskin. These cases will most often resolve spontaneously by age 5–7 years and do not require additional management unless the stenosis is severe enough to impede urinary flow, causing obstruction or infection. This patient is still having wet diapers, and urinary flow is noted on exam, so in this case, reassurance and discharge is the appropriate management. Additionally, parents should be advised to clean under the foreskin to reduce the risk of local or urinary infections.

Retraction of the foreskin to expose the distal glans (B) should not be attempted, as this will not benefit the patient and can potentially lead to paraphimosis, a much more serious condition. Topical hydrocortisone (C), or other steroid cream, may be used after age five if symptoms persist but is not appropriate in children under five, as this is likely physiologic. Urology consult (D) is not recommended for this benign condition unless symptoms persist past age five.

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Further Reading:

FOAMed:

WikEM – Paraphimosis and Phimosis

EM News – Paraphimosis

Peds EM Morsels – Paraphimosis

Peds EM Morsels – Phimosis

References:

  1. Clifford ID, Craig SS, Nataraja RM, Panabokke G. Paediatric paraphimosis. Emerg Med Australas. 2016;28(1):96-99. doi:10.1111/1742-6723.12532
  2. Pohlman GD, Phillips JM, Wilcox DT. Simple method of paraphimosis reduction revisited: Point of technique and review of the literature. J Pediatr Urol. 2013;9(1):104-107. doi:10.1016/j.jpurol.2012.06.012
  3. Burstein B, Paquin R. Comparison of outcomes for pediatric paraphimosis reduction using topical anesthetic versus intravenous procedural sedation ☆. 2017. doi:10.1016/j.ajem.2017.04.015
  4. Little B, White M. Treatment options for paraphimosis. Int J Clin Pract. 2005;59(5):591-593. doi:10.1111/j.1742-1241.2004.00356.x
  5. Hayashi Y, Kojima Y, Mizuno K, Kohri K. Prepuce: Phimosis, Paraphimosis, and Circumcision.Sci World J. 2011;11:289-301. doi:10.1100/tsw.2011.31
  6. Turner CD, Kim HL, Cromie WJ. Dorsal band traction for reduction of paraphimosis. Urology. 1999;54(5):917-918. http://www.ncbi.nlm.nih.gov/pubmed/10565759. Accessed June 15, 2019.
  7. Flores S, Herring AA. Ultrasound-guided dorsal penile nerve block for ED paraphimosis reduction. Am J Emerg Med. 2015;33(6):863.e3-863.e5. doi:10.1016/j.ajem.2014.12.041
  8. Sandeman DJ, Dilley A V. Ultrasound Guided Dorsal Penile Nerve Block in Children. Anaesth Intensive Care. 2007;35(2):266-269. doi:10.1177/0310057X0703500217
  9. Choe JM. Paraphimosis: current treatment options. Am Fam Physician. 2000;62(12):2623-2626, 2628. http://www.ncbi.nlm.nih.gov/pubmed/11142469. Accessed June 15, 2019.
  10. King PA. Reduction of paraphimosis the simple way–the Dundee technique. BJU Int. 2001;88(3):305. http://www.ncbi.nlm.nih.gov/pubmed/11488759. Accessed June 15, 2019.
  11. Kumar V, Javle P. Modified puncture technique for reduction of paraphymosis. Ann R Coll Surg Engl. 2001;83(2):126-127. http://www.ncbi.nlm.nih.gov/pubmed/11320922. Accessed June 15, 2019.
  12. Waters TC, Sripathi V. Reduction of paraphimosis. Br J Urol. 1990;66(6):666. http://www.ncbi.nlm.nih.gov/pubmed/2265349. Accessed June 15, 2019.
  13. Zampieri N, Corroppolo M, Camoglio FS, Giacomello L, Ottolenghi A. Phimosis: Stretching Methods with or without Application of Topical Steroids? J Pediatr. 2005;147(5):705-706. doi:10.1016/j.jpeds.2005.07.017
  14. Kragballe K. Topical corticosteroids: mechanisms of action. Acta Derm Venereol Suppl (Stockh). 1989;151:7-10; discussion 47-52. http://www.ncbi.nlm.nih.gov/pubmed/2533778. Accessed June 15, 2019.
  15. Moreno G, Corbalán J, Peñaloza B, Pantoja T. Topical corticosteroids for treating phimosis in boys. Cochrane Database Syst Rev. 2014;(9):CD008973. doi:10.1002/14651858.CD008973.pub2

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