Paraphimosis – Causes, Symptoms and Treatment

Paraphimosis is a condition where the retracted foreskin of the penis cannot be returned to its normal position (in an uncircumcised individual). Paraphimosis is a relatively uncommon condition and is most commonly due to iatrogenic reasons or inadvertently caused condition.  Paraphimosis differs from phimosis in that in phimosis the foreskin cannot be retracted beyond the glans penis. Paraphimosis is a clinical emergency as failure to recognise and treat this can lead to loss of the glans penis.

When the foreskin is retracted for a long period of time, it forms a constricting band of tissue around the penis. This will cut off the lymphatic and venous supply initially, which causes oedema of the glans penis. When the oedema worsens the arterial supply gets compromised. If this goes unchecked it will lead to tissue ischemia and vascular engorgement thereby causing gangrene and auto amputation of the penis.

Causes of paraphimosis:

• Infection
• Physical trauma to the genital area
• Contact dermatitis
• Tight foreskin
• Penile piercings
• Retracted foreskin for extended period

Symptoms of paraphimosis:

The main symptom will be the inability to retract the foreskin to its original position. Pain and swelling of the tip of the penis are also common. There might be change in the colour of the tip of the penis which can turn dark red or blue due to lack of blood supply.

Treatment options for Paraphimosis:

Medical treatment: in medical management the patient is reassured, swelling reduced and the prepucal skin is brought to its original position. There are various methods that can be tried for reducing the swelling.

• Ice packs are used around the penis to reduce the swelling
• Mannitol or sugar soaked gauze is also used to wrap the penis. This works on the basis that fluid will move from an area of hypotonicity to an area of hypertonicity and hence the swelling reduces. These are osmotic agents.
• Direct circumferential manual compression (this works and is tolerated better if done after giving local block). In this procedure the foreskin is circumferentially compressed for 2 – 10 min to “squeeze” out the oedematous fluid and then reduction of the foreskin is attempted.
• Hyaluronidase is another substance that can be injected. It breaks down the hyaluronic acid in the connective tissue and hence better tissue diffusion and reduction of swelling.

Prior to reduction, local blocks should be used to minimise pain and ensure better co-operation from the patient. Dorsal penile block and ring block are used either in combination or separately.

Whatever method chosen once the swelling and oedema reduces, manual reduction of the prepuce should be attempted. You place fingers on the glans penis and the prepuce. Counter pressure is applied on the glans penis as the foreskin is pulled down. The constricting band of tissue is pulled down along with entire foreskin otherwise the reduction is not complete.

Using ice and the osmotic agents to reduce the oedema will take one to two hours and should not be attempted when there is an arterial compromise. Instead surgical methods of reducing the oedema are employed.

Surgical treatment:

• Puncture method: This is a minimally invasive procedure where an 18 or 21 gauge needle is used to puncture the prepuce at multiple sites to release the oedematous fluid. This results in a rapid decrease in oedema which is followed by a manual reduction of the foreskin. If a severely constricting band of tissue is present then an emergency procedure is done known as dorsal slit.

• Dosal slit method: After adequate local anaesthesia with or without sedation the dorsal midline portion of the rolled prepucal skin is identified and cut with a vertical incision. This releases the constriction and the foreskin is pulled down and the cut ends can be sewn.

After the procedure petroleum jelly and sterile gauze dressings may be done over the sutures. Oral pain killers are prescribed. Antibiotics if necessary can also be prescribed. The dressing is removed 24 – 48 hours later. The patient is advised to wear loose fitting clothes and refrain from sexual activity for 6 weeks as this may cause breakdown of the sutures or incision line.

• Circumcision: in very severe cases of paraphimosis the entire foreskin is removed. Circumcision prevents it from recurring.

Prior and after the procedures urological evaluation needs to be done for the consideration of circumcision.

Complications of Paraphimosis:

The complications of paraphimosis and its surgical intervention methods are as follows:

• Pain and infection
• Necrosis and ischemia
• Bleeding
• Shortening of penile skin
• Urethral injury

Post operative bleeding being the most common complication and urethral injury being rare and less common. Bleeding can be controlled by direct compression and rarely needs electrocautery or ligation.

The chances of a full recovery are high when treated early. Most people recover without any complications.

Preventing Paraphimosis:

Paraphimosis can be prevented by:

• Practising good hygiene
• Cleaning the tip of the penis regularly
• Making sure the foreskin is pulled back in position after sexual intercourse/ urination or after any procedure by a medical professional.
• Circumcision