Chapter 127

A paraphimosis is defined as the inability to reduce a proximally positioned foreskin over the glans penis and back to its normal anatomic position. Some confuse a paraphimosis with a phimosis. The latter is a scarring or narrowing of the foreskin in which it cannot be retracted over the glans of the penis. The most common causes for a paraphimosis are iatrogenic. Following examination or instrumentation of the penis, medical personnel often forget to reduce the foreskin over the glans. This is particularly true of patients who are sedated, confused, demented, delirious, or in a nursing home. Patients may fail to reduce their foreskin after intercourse or urination. In infants and toddlers, the foreskin does not become fully mobile until after three years of age. This predisposes them to a paraphimosis when well-meaning caregivers forcibly retract the foreskin during cleaning. A paraphimosis may also occur when a narrowed (phimotic) foreskin is retracted and unable to be reduced.

A patient with a paraphimosis usually presents with severe pain in the distal penis. The process may have a more indolent presentation in persons with impaired pain sensation, such as the elderly or diabetics. As they are often unable to complain of pain, patients with altered mental status are at risk for complications of a paraphimosis. This includes penile ulceration, infection, gangrene, and partial penile autoamputation.1 A careful and complete physical examination is mandatory in these patients. Penile edema secondary to a paraphimosis must be differentiated from edema due to infection, trauma, or allergic reactions.

The foreskin results from epithelial infolding during the gestational growth of the penis. It is composed of a double layer of epidermis overlying subcutaneous tissue. The foreskin is attached to the skin at the base of the glans penis. It covers the glans to a variable degree and can usually be completely retracted over the glans. The arterial supply to the foreskin is derived from branches of the external pudendal artery that originates from the femoral artery. Once these branches reach the preputial ring, they become tortuous, attenuated, and terminate at the coronal sulcus. These superficial arteries do not communicate with the deep arteries of the penis. The foreskin veins are multiple small branches that drain through the inferior external pudendal vein to the saphenous vein of the thigh.

The glans of the penis is supplied by the paired dorsal arteries of the penis that arise from the penile artery. These dorsal penile arteries course deep to Buck’s fascia ventrolaterally to enter the glans at the coronal sulcus. A frenular branch is given off at this point. The blood supply to the glans penis is entirely separate from that of the foreskin.

A retracted foreskin will block lymphatic drainage from the distal penis. As arterial inflow continues, the lack of lymphatic drainage will cause a progressive edema of the penis distal to the retracted foreskin. If the foreskin is not reduced, the ...

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