Urologic Emergencies

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Paraphimosis

Paraphimosis occurs when the fold of skin that covers the head (glans) of an uncircumcised penis (i.e., the foreskin) has been retracted and narrows below the glans, constricting the lymphatic drainage and causing the glans to swell. If not corrected, blood flow in the penis becomes impeded by the increasingly constricting band of foreskin, which causes further swelling of the glans. Because lack of oxygen from the reduced blood flow can cause tissue death (necrosis), paraphimosis is considered a medical emergency and requires immediate treatment.

Incidence and Prevalence
In the United States, paraphimosis occurs in about 1% of males over age 16. It can occur at any age but is most common during adolescence. Paraphimosis occurs in the elderly who need frequent catheterizations and those who have a history of poor hygiene or bacterial infections.

Risk Factors

Uncircumcised males are at risk. Piercing the penis increases the risk if the penile ring interferes with foreskin retraction or replacement over the glans, and if infection results from the piercing.

Causes

Causes include the following:

• Bacterial infection (e.g., balanoposthitis)
• Catheterization (i.e., if the foreskin is not returned to its original position after a urethral catheter is inserted, the glans may become swollen, which can initiate paraphimosis)
• Poor hygiene
• Swelling-producing injury
• Vigorous sexual intercourse

Signs and Symptoms

Symptoms include the following:

• Band of retracted foreskin tissue beneath the glans
• Black tissue on the glans (indicates necrosis)
• Inability to urinate (urinary retention)
• Penile pain
• Redness (erythema)
• Swollen glans (the shaft of the penis is not swollen)
• Tenderness

Complications

Tissue death caused by loss of blood supply (gangrene) and spontaneous detachment of diseased tissue (autoamputation) of the glans are possible complications of paraphimosis.

Diagnosis

Paraphimosis is diagnosed during a physical examination.

Treatment

Because paraphimosis can be severely painful, a pain reliever is administered before treatment. The first method of treatment after diagnosis involves manual manipulation of the penis to reduce swelling and to replace the foreskin over the glans. An ice pack may be applied to the penis (after the penis has been wrapped in plastic) to help reduce swelling.

If manual treatment is unsuccessful, the puncture technique uses a needle to drain excess watery fluid in the swollen tissue (edematous fluid) from the glans to reduce swelling.

A third option is to make a small incision in the foreskin to alleviate constriction and allow the swelling to subside. With this procedure, local anesthesia is administered to minimize discomfort.

After reduction of swelling is achieved, antibiotics are prescribed for any underlying infection.

Prognosis
Full recovery from paraphimosis is expected with prompt treatment.

Prevention
Circumcision is recommended after treatment to prevent a recurring episode.

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