Chapter 129

A dorsal slit of the prepuce or foreskin is performed primarily in the Emergency Department. This technique is used to relieve strangulation of the glans by a paraphimosis, to release a paraphimosis, or to aid in the visualization of the urethral meatus in patients with a phimosis.1 This technique is easy to learn, simple to perform, and takes approximately 10 minutes. Performing a dorsal slit of the foreskin requires complete anesthesia of the foreskin and/or penis (Chapter 125).

The prepuce, or foreskin, is the skin originating just proximal to the corona that encircles the glans and often extends beyond it.2 It may be incomplete, primarily at the ventral midline or the frenulum. The frenulum is the fusion site of the preputial and urethral folds. The glans is composed of the corpus spongiosum that enlarges to cover the tips of the corpora cavernosa. It has less erectile tissue than the cavernosa and contains the urethra.2

The blood supply to the foreskin and glans is from the left and right superficial penile arteries. The arteries are derived from the inferior external pudendal arteries, which are branches of the femoral arteries. The penile arteries travel in the superficial fascia of the penis and above Buck’s fascia.3 The left and right superficial penile arteries freely communicate over the midline.4 Superficial veins accompany the arteries and ultimately drain to the saphenous veins in the thighs. The lymphatics travel deep to Buck’s fascia and ultimately empty into the inguinal chain of lymph nodes. The somatic nerves to the foreskin are derived from the pudendal nerves.

A more detailed description of the anatomy and pathophysiology of the penis, a paraphimosis, and a phimosis can be found in Chapters 127 and 128.

A dorsal slit of the foreskin should be performed to release a paraphimosis or a phimosis. A paraphimosis is the inability to replace the retracted foreskin over the glans. A paraphimosis is considered an emergency since prolonged retraction of the foreskin leads to swelling of the prepuce resulting in strangulation injury to the glans.1 A phimosis is the inability of the foreskin to retract and expose the glans. A phimosis should be released if it causes urinary retention. A phimosis can be due to true circumferential scar formation. Forceable retraction of a phimotic foreskin will result in tearing of the foreskin. A phimosis may be due to other disease processes such as edema (secondary to congestive heart failure, anasarca), inflammation with or without balanitis, or a malignancy. Refer to Chapters 127 and 128 for further details regarding a paraphimosis or a phimosis.

There are no absolute contraindications to the reduction of a paraphimosis. Surgical reductions in children should be performed by a Pediatric Urologist, a Urologist, or after consultation with a Urologist. A surgical reduction of a paraphimosis should be performed only after noninvasive and lesser invasive techniques have ...

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