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
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 ...