A paraphimosis is defined as the inability to reduce a proximally positioned foreskin over the glans penis and back to its normal anatomic position.1 The most common cause for a paraphimosis is iatrogenic. Medical personnel may forget to reduce the foreskin over the glans following examination or instrumentation of the penis. This is particularly true in patients who are sedated, confused, demented, or delirious.
Elderly patients are particularly at risk as their predisposition to erectile dysfunction and decreased libido result in fewer erections to naturally dilate the foreskin. The elderly, demented, and cognitively delayed are at increased risk for poor genital hygiene and a paraphimosis.2 Other patients may fail to reduce their foreskin after intercourse or urination.3 Infants and toddlers have a normal physiologic phimosis that resolves by the age of 3 in over 90% of cases. This predisposes them to a paraphimosis when well-meaning caregivers forcibly retract the foreskin during cleaning. A paraphimosis may also occur when a narrowed or phimotic foreskin is retracted and unable to be reduced. Paraphimosis has been reported secondary to genital piercing, erotic dancing, and various cutaneous lesions (e.g., hemangioma and cutaneous lymphoproliferative disorders).4-6
A patient with a paraphimosis usually presents with severe penile pain. The process may have a more indolent presentation in persons with impaired pain sensation (e.g., the elderly or diabetics). Patients with altered mental status may simply present with agitation and are at risk for complications of a paraphimosis as they are often unable to complain of pain. This includes penile ulceration, infection, Fournier’s gangrene, and partial penile autoamputation.7,8 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.
ANATOMY AND PATHOPHYSIOLOGY
The foreskin is composed of a double layer of epidermis overlying subcutaneous tissue. It is attached to the skin at the base of the glans penis. The foreskin covers the glans to a variable degree and can usually be completely pulled over the glans. The foreskin is retracted behind the glans and becomes edematous in a paraphimosis. The base of the foreskin is the location of the constricting or phimotic ring (Figures 179-1 and 179-2).
The anatomy of a paraphimosis.
A paraphimosis. A. Superior view. B. Inferior view.
Arterial supply to the foreskin is derived from superficial branches of the external pudendal artery which originate from the femoral artery. These superficial arteries do not communicate with the deep arteries of the penis. Arterial supply to the glans penis is derived from the paired ...