Acute conditions affecting the foreskin that must be recognized in the Emergency Department include a phimosis and a paraphimosis. The Emergency Physician must be able to accurately identify and manage these conditions as well as recognize when an urgent Urology consultation is necessary. A dorsal slit of the prepuce or foreskin can be performed in the Emergency Department. This technique is used to relieve strangulation of the glans by a paraphimosis (Figure 181-1) or to aid in the visualization of the urethral meatus in patients with a phimosis (Figure 181-2).1 The technique is easy to learn and simple to perform.
A paraphimosis. (Courtesy of Eric F. Reichman, PhD, MD.)
ANATOMY AND PATHOPHYSIOLOGY
The anatomy of the penis is simple (Figure 181-3). 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 corpora cavernosa and contains the urethra.2
The blood supply to the foreskin and glans is provided by the 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. 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.4
A dorsal slit is performed to reduce a paraphimosis or phimosis when other less invasive techniques are unsuccessful. A paraphimosis is the inability to replace the retracted foreskin over the glans into its naturally occurring position (Chapter 179). It is considered an emergency since prolonged retraction of the foreskin creates a constricting ring that quickly compromises vascular and lymphatic circulation with eventual engorgement and necrosis of the glans and foreskin. A phimosis is the inability to retract the distal foreskin over the glans penis (Chapter 180).5,6 A phimosis is no longer present once ...