- Matthew Tews, DO
Matthew Tews, DO
- Associate Professor of Emergency Medicine
- Medical College of Wisconsin
- Jonathan I Singer, MD
Jonathan I Singer, MD
- Section Editor — Pediatric Surgical Emergencies
- Professor of Emergency Medicine and Pediatrics
- Wright State University Boonshoft School of Medicine
- Section Editors
- Anne M Stack, MD
Anne M Stack, MD
- Section Editor — Pediatric Procedures
- Associate Professor, Department of Pediatrics
- Harvard Medical School
- Laurence S Baskin, MD, FAAP
Laurence S Baskin, MD, FAAP
- Section Editor — Pediatric Urology
- Frank Hinman, Jr., MD, Distinguished Professorship in Pediatric Urology
- Chief Pediatric Urology
- Professor of Urology and Pediatrics
- UCSF Benioff Children's Hospital
- Allan B Wolfson, MD
Allan B Wolfson, MD
- Section Editor — Adult Procedures
- Professor of Emergency Medicine
- University of Pittsburgh
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Paraphimosis occurs when the foreskin in the uncircumcised or partially circumcised male is retracted behind the glans penis and cannot be returned to its normal position (picture 1). This urologic emergency impedes blood flow to the glans penis with potential for permanent damage and gangrene.
The primary management of paraphimosis consists of timely reduction of the foreskin back over the glans penis and requires appropriate pain control, adjuncts to reduce swelling, and judicious selection of reduction technique. The chosen method depends upon the resources that are available, the degree of penile ischemia present, and the experience of the practitioner. No randomized trials compare the various techniques used for paraphimosis reduction . Successful reduction has been described in case reports or case series with each of the methods discussed below (table 1 and table 2).
The definition, pathophysiology, and clinical manifestations of paraphimosis are discussed separately. (See "Paraphimosis: Definition, pathophysiology, and clinical features".)
The penis in the uncircumcised male consists of the penile shaft, glans penis with the coronal sulcus (rim of the glans), and the foreskin (figure 1).
Paraphimosis is caused by foreskin entrapment behind the coronal sulcus (picture 1 and figure 1). Impairment of lymphatic and venous flow from the constricting ring of foreskin causes venous engorgement of the glans penis with swelling. Ultimately, arterial flow to the glans penis becomes compromised over a period of hours to days [2,3]. Bulbar, urethral, and pudendal vessels may be sequentially impaired. If paraphimosis is not corrected in a timely fashion, penile necrosis, infarction of the glans, or gangrene can occur, followed by autoamputation [4-6].
- Mackway-Jones K, Teece S. Best evidence topic reports. Ice, pins, or sugar to reduce paraphimosis. Emerg Med J 2004; 21:77.
- Reynard JM, Barua JM. Reduction of paraphimosis the simple way - the Dundee technique. BJU Int 1999; 83:859.
- Dubin J, Davis JE. Penile emergencies. Emerg Med Clin North Am 2011; 29:485.
- McCollough M, Sharieff GQ. Abdominal surgical emergencies in infants and young children. Emerg Med Clin North Am 2003; 21:909.
- Hollowood AD, Sibley GN. Non-painful paraphimosis causing partial amputation. Br J Urol 1997; 80:958.
- Raman SR, Kate V, Ananthakrishnan N. Coital paraphimosis causing penile necrosis. Emerg Med J 2008; 25:454.
- Vunda A, Lacroix LE, Schneider F, et al. Videos in clinical medicine. Reduction of paraphimosis in boys. N Engl J Med 2013; 368:e16.
- Cahill D, Rane A. Reduction of paraphimosis with granulated sugar. BJU Int 1999; 83:362.
- Choe JM. Paraphimosis: current treatment options. Am Fam Physician 2000; 62:2623.
- Olson C. Emergency treatment of paraphimosis. Can Fam Physician 1998; 44:1253.
- Turner CD, Kim HL, Cromie WJ. Dorsal band traction for reduction of paraphimosis. Urology 1999; 54:917.
- Little B, White M. Treatment options for paraphimosis. Int J Clin Pract 2005; 59:591.
- Kamat N. Reduction of paraphimosis the simple way--the Dundee technique. BJU Int 1999; 84:890.
- Houghton GR. The "iced-glove" method of treatment of paraphimosis. Br J Surg 1973; 60:876.
- Pohlman GD, Phillips JM, Wilcox DT. Simple method of paraphimosis reduction revisited: point of technique and review of the literature. J Pediatr Urol 2013; 9:104.
- Ganti SU, Sayegh N, Addonizio JC. Simple method for reduction of paraphimosis. Urology 1985; 25:77.
- Kerwat R, Shandall A, Stephenson B. Reduction of paraphimosis with granulated sugar. Br J Urol 1998; 82:755.
- Anand A, Kapoor S. Mannitol for paraphimosis reduction. Urol Int 2013; 90:106.
- Coutts AG. Treatment of paraphimosis. Br J Surg 1991; 78:252.
- Patricia Chambers. Paraphimosis reduction. In: Textbook of Pediatric Emergency Procedures, 2nd edition, King C, Henretig FM. (Eds), Lippincott, Williams & Wilkins, Philadelphia 2008. p.904.
- Barone JG, Fleisher MH. Treatment of paraphimosis using the "puncture" technique. Pediatr Emerg Care 1993; 9:298.
- Hamdy FC, Hastie KJ. Treatment for paraphimosis: the 'puncture' technique. Br J Surg 1990; 77:1186.
- Waters TC, Sripathi V. Reduction of paraphimosis. Br J Urol 1990; 66:666.
- Kumar V, Javle P. Modified puncture technique for reduction of paraphymosis. Ann R Coll Surg Engl 2001; 83:126.
- Fuenfer MM, Najmaldin A. Emergency reduction of paraphimosis. Eur J Pediatr Surg 1994; 4:370.
- Finkelstein JA. "Puncture" technique for treating paraphimosis. Pediatr Emerg Care 1994; 10:127.
- DeVries CR, Miller AK, Packer MG. Reduction of paraphimosis with hyaluronidase. Urology 1996; 48:464.
- Baigrie RJ. Treatment for paraphimosis. Br J Surg 1991; 78:378.
- Raveenthiran V. Reduction of paraphimosis: a technique based on pathophysiology. Br J Surg 1996; 83:1247.
- CONTRAINDICATIONS AND PRECAUTIONS
- Patient counseling/informed consent
- - Minimally invasive reduction
- - Invasive reduction
- General considerations
- Analgesia and sedation
- - Ice
- - Compression bandages
- - Osmotic agents
- Minimally invasive reduction
- - Manual compression and reduction
- - Traction with forceps
- Invasive reduction
- - Puncture technique
- - Glans penis aspiration
- - Dorsal slit procedure
- FOLLOW-UP CARE