Urology
A 45 year old man presents to the Emergency Department with a 5 hour history of penile pain and swelling. On examination you note a paraphimosis. You have tried to reduce this using an osmotic agent and direct compression but after 20 minutes this has failed. Which of the following techniques is most appropriate to trial next?
Answer:
- Puncture technique
- This may be used after failed attempts at reduction using minimally invasive procedures. Perforation of the glans at multiple locations (the Dundee technique) allows exudation of the oedematous fluid and reduction in swelling. After appropriate local analgesia and sedation, multiple punctures are made in the oedematous glans using a 22-gauge hypodermic needle. Subsequently, the foreskin is reduced by manual compression and reduction.
Paraphimosis
Urology
Last Updated: 1st February 2022
Definitions
- Phimosis is a condition where the foreskin is too tight to be pulled back over the head of the penis (glans). Physiological adherence of the foreskin to the glans is normal, with up to 10% of foreskins remaining non-retractile up to 3 years of age. This reduces to around 1% at the age of 16 years.
- Paraphimosis is a condition in which the foreskin is left retracted for an extended period. Swelling occurs, causing the foreskin to become trapped behind the glans.
Pathophysiology
The most common aetiology follows retraction of the foreskin of an uncircumcised male penis by a health professional during penile examination, catheterisation, or cystoscopy, who then neglects to return the foreskin back over the glans penis.
Retraction of the foreskin behind the glans penis (in the presence of a phimotic foreskin) leads to the phimotic ring causing constriction of the distal glans. This leads to vascular engorgement as the lymphatic and venous flow from the constricting ring are impaired. This results in secondary oedema. The consequences are further vascular compromise as the arterial flow is impaired, and potential ischaemia of the penis distal to the phimotic ring. Eventual necrosis of the glans penis may be observed.
Diagnosis
Diagnosis is based on history and physical examination.
Adult patients will most often report penile pain. Paediatric patients may present with symptoms of obstructive voiding (i.e. a sensation of incomplete emptying, straining to void, and slow urine stream) or acute urinary obstruction. It is important to determine the duration of the episode of paraphimosis, as manual reducibility may be compromised in those who have had a prolonged course.
On examination, the glans penis is enlarged and congested with a collar of oedematous foreskin. A constricting band of tissue will be observed directly behind the head of the penis. The remainder of the penile shaft will be unremarkable. The glans and foreskin should be evaluated for early signs of necrosis. A soft, pink, pliable glans is reassuring for the presence of a blood flow. Areas that appear black, or the presence of a non-pliable glans, are concerns for the presence of early necrosis.
Management
Paraphimosis should be considered a medical emergency, and steps should be taken to rapidly resolve this painful condition to prevent tissue loss. Careful inspection of the penis should occur to ensure there are no constricting bands or foreign bodies (e.g. piercing studs) present. In the presence of an indwelling catheter, it should be removed before attempting reduction of the paraphimosis.
Paraphimosis can be extremely painful. Therefore, analgesia should be administered before treatment. The amount of analgesia depends on the patient. Some patients can tolerate topical formulations; others may prefer injection of a local anaesthetic. Young boys often require parenteral administration of opioids and sedative agents in addition to local anaesthetics. The local anaesthetic can be used as a single injection at the dorsal midline of the penis or as a ring block at the base of the penis.
Patients with evidence of significant glans penis ischaemia, with necrosis and sloughing of the foreskin and/or glans, require involvement of a consultant in urology. They will require procedural sedation or general anaesthesia, followed by immediate reduction using surgical techniques. Devitalised tissue will require operative debridement.
Techniques to treat acute paraphimosis without ischaemia and necrosis include:
- Manipulation
- The first method of treatment involves manual manipulation of the penis to reduce swelling and to replace the foreskin over the glans penis.
- Analgesia should be administered before treatment.
- Ice, compression, or an osmotic agent is then applied:
- Ice packs: these can be applied to the penis (after the penis has been wrapped in plastic) to help reduce swelling.
- Compression: this is commonly performed using a gloved hand but can also be achieved by a 2 x 2-inch bandage. The oedematous glans and foreskin should be compressed until swelling is noted to improve. This technique is successful in the majority of boys with paraphimosis.
- Osmotic agent: this technique uses the principle that fluid flows down a concentration gradient; in this case the hypotonic fluid in the penis flows to the hypertonic agent on the outside of the skin. The most common agent used is fine granulated sugar, in liberal amounts.
- Once foreskin swelling has been reduced as much as possible, manual reduction is performed by pulling the phimotic ring while pushing down on the glans.
- Puncture technique
- This may be used after failed attempts at reduction using minimally invasive procedures. Perforation of the glans at multiple locations (the Dundee technique) allows exudation of the oedematous fluid and reduction in swelling. After appropriate local analgesia and sedation, multiple punctures are made in the oedematous glans using a 22-gauge hypodermic needle. Subsequently, the foreskin is reduced by manual compression and reduction.
- Hyaluronidase, a natural protein that causes hydrolysis of hyaluronic acid, an extracellular mucopolysaccharide, may be used to augment the puncture technique. Injection of hyaluronidase into the oedematous foreskin leads to degradation of hyaluronic acid and reduction of oedema. Immediate reduction of oedema will be noted and then reduction can be attempted.
- Surgical reduction followed by circumcision
- This is reserved for patients who fail conservative attempts at reduction. Although in very infirm and older people this can be performed at the bedside using a penile block (i.e. local anaesthetic plus procedural sedation), in most patients general anaesthesia will be required.
- For the dorsal slit procedure, the phimotic ring is incised on the dorsal aspect of the penis until release of the foreskin is identified. This allows the swelling to subside. The edges are closed using 4-0 chromic suture or similar. Completion of the circumcision is performed as a second procedure, once the swelling of the foreskin has subsided.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
