History
Phimosis
• Inability to retract the distal foreskin over the glans penis; “ballooning” of the prepuce during urination; painful erection, preputial pain, weak urinary stream
Paraphimosis
• Pain, swelling of glans w/ entrapment of a retracted foreskin behind the coronal sulcus; a/w vigorous sexual activity & chronic balanoposthitis
• Occurs exclusively in uncircumcised males & is a urologic emergency
• Pediatric: Often seen w/ forceful retraction or forgetting to reduce foreskin after bathing/voiding; irritability may be the only sign in nonverbal children
Physical Exam
Phimosis
• Inability to retract foreskin proximally over glans penis
Paraphimosis
• Foreskin retracted behind the glans & cannot be replaced to nl position; proximal shaft is soft (unless there is accompanying infection) w/ glans appearing erythematous/edematous & eventually blue/black & firm
Treatment
• If significant manipulation is expected, you may perform a penile block. On the dorsal aspect of the penis in the 2- & 10-o’clock positions, deposit 1% lidocaine; subsequently complete a ring block by depositing anesthetic circumferentially around the proximal shaft.
Phimosis
• No acute intervention needed unless infection suspected. Consider topical steroids (0.05–0.1% betamethasone) × 4–6 wk for mild–moderate cases.
Paraphimosis
• Compress the foreskin & glans by snugly grasping it w/ the palm of the hand & apply pressure for several minutes. Other methods to reduce edema include:
• Dundee micropuncture technique: Make ∼20 puncture holes in edematous foreskin tissue w/ a small needle (27 gauge) & express the fluid
• Hyaluronidase technique: Inject 1 cc of hyaluronidase (150 U/mL) using a tuberculin syringe into the site of edematous foreskin
• Sugar technique: Soak a swab of 50 mL of 50% dextrose solution & leave it wrapped around the foreskin for 1 h
• Attempt manual reduction by placing index fingers on dorsal border of glans behind retracted prepuce & thumbs on glans; may facilitate w/ ice, elastic bandage over glans or spreading hyperosmolar agents (such as sugar/dextrose) over glans to reduce swelling
• Consult urology if manual reduction unsuccessful
Disposition
• Home: Phimosis ± abx for accompanying infection; paraphimosis if skin is in the nl position. Urology f/u for all paraphimoses.
• Admit: Paraphimosis not reduced by conservative methods
Pearls
• Educate parents/caretakers of children on importance of avoiding forcible retractions & of gentle reduction of foreskin after bathing & voiding
• Paraphimoses that are not immediately treated are at risk for necrosis & autoamputation