Chapter 148. Paraphimosis Reduction

A paraphimosis is defined as the inability to reduce a proximally positioned foreskin over the glans penis and back to its normal anatomic position. The most common causes for a paraphimosis are iatrogenic. Following examination or instrumentation of the penis, medical personnel may 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 3 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 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. In a paraphimosis, the foreskin is retracted behind the glans and becomes edematous. The base of the foreskin is the location of the constricting or phimotic ring (Figures 148-1 & 148-2).

Arterial supply to the foreskin is derived from superficial branches of the external pudendal artery, which originates 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 dorsal arteries of the penis, which originate from the penile artery. These dorsal penile arteries run deep to Buck's fascia to enter the glans at the coronal sulcus. Arterial supply to the glans penis is thus entirely separate from that of the foreskin.

A retracted foreskin will block lymphatic drainage from the distal penis. As arterial inflow continues, lack of lymphatic drainage will cause a progressive edema of the penis distal to the retracted foreskin. As the foreskin continues to swell the phimotic ring becomes progressively tighter, and if not reduced, will eventually obstruct venous outflow. The distal penis will become painful and hyperemic. The edema will progress to ultimately obstruct arterial inflow resulting in penile ischemia, necrosis, and gangrene. This series of events, from retraction of the foreskin to arterial inflow obstruction, can occur over a few hours to 1 to 2 days. To relieve the obstruction, the phimotic ring must be advanced (reduced) over the glans of the penis.

All paraphimoses require reduction. The earlier a reduction is attempted, the less edematous the tissues will be and the easier it will be to perform the reduction. Nonsurgical techniques should be attempted first. Surgical techniques are indicated if nonsurgical techniques are unsuccessful or the skin is compromised by infection, ulceration, or gangrene.2

There are no absolute contraindications to the reduction of a paraphimosis. While all paraphimoses must be reduced, certain techniques are contraindicated in specific patient subgroups. Nonsurgical techniques are contraindicated in patients with ulcerated or necrotic foreskins as they may cause iatrogenic injury.2 Some authors feel that surgical reductions in children should be reserved for Pediatric Urologists.3,4 A surgical reduction should not be performed until noninvasive and lesser invasive techniques have been attempted. The hyaluronidase technique is contraindicated in penile cancers or infections due to the possibility of spreading infected or malignant cells through the tissue planes.5

• Povidone iodine or chlorhexidine solution
• Lidocaine jelly
• Water-soluble lubricant
• Local anesthetic solution (1% lidocaine or 0.5% bupivacaine) without epinephrine
• 18 gauge needles
• 27 gauge needles
• 10 mL syringe
• 4 × 4 gauze squares
• Crushed ice
• Surgical gloves
• Babcock clamps (6 to 8)
• 2-inch wide roll of elastic bandage (Ace Wrap or Elastoplast)
• Sterile drapes
• Sterile surgical gloves
• Suture scissors
• Two straight hemostats
• #15 surgical blade with handle
• Needle driver
• 3-0 synthetic absorbable suture or chromic catgut suture
• Granulated (table) sugar
• Hyaluronidase, 150 units or 1 cc
• Tuberculin syringe
• Antibiotic ointment, topical
• Petrolatum gauze

Reduction of a paraphimosis can be painful and somewhat distressing to patients. Explain to the patient and/or their representative the risks and benefits of the procedure. Also explain that the progression from nonsurgical to surgical techniques may be required. Obtain an informed consent from the patient. If the patient has an indwelling urinary catheter, it should be left in place during the reduction.

While premedication is rarely necessary, some patients may benefit from mild sedation. Procedural sedation (Chapter 129) and general anesthesia may be required in children.3,4 Analgesia can sometimes be achieved with the topical application of lidocaine jelly or EMLA cream (2.5% prilocaine and 2.5% lidocaine) applied liberally and held in place for 45 to 60 minutes by a biofilm dressing. If this does not provide adequate patient comfort, a ring block or dorsal penile nerve block can be performed with 0.5% bupivacaine and/or 1% lidocaine.6 Refer to Chapter 146 for the complete details regarding penile anesthesia.

The techniques described below to reduce a paraphimosis begin with manual compression and progress to incision of the phimotic ring. They should be attempted in a stepwise manner from least invasive to most invasive in the order presented below.

Manual Reduction

This method has been extensively described.3,7–10 Liberally apply an anesthetic jelly or water-soluble lubricant to the glans and foreskin. Do not coat the penile shaft or else it will be too slippery to facilitate an easy reduction.

Apply manual compression directly to the glans and edematous foreskin by grasping them with the palm of a gloved hand (Figure 148-3). Apply slow and steady pressure for 5 to 10 minutes. Many physicians do not have the time or the strength to apply pressure to a patient's penis for 5 to 10 minutes. In children, the parent may be asked to provide the manual compression. Compression may also be provided by circumferentially wrapping a bandage around the penis beginning at the glans and working toward the base of the penis. Apply the bandage so that it places more pressure distally and less proximally. This will mobilize the edematous fluid from distal to proximal. The bandage can be an Ace Wrap or Elastoplast,10 a gauze sponge soaked in lidocaine jelly, or a gauze sponge soaked in cold water.7

Remove the bandage or release manual compression after it has been applied for 5 to 10 minutes. Apply the index and middle fingers of both hands to surround the top of the penile shaft proximal to the phimotic ring and the ring fingers underneath the penile shaft (Figure 148-4). Place both thumbs adjacent to the urethral meatus (Figure 150-3). Push the glans proximally with the thumbs while the fingers simultaneously provide countertraction to pull the phimotic band over the glans. Apply continuous force until the phimotic band moves distal to the glans. This same technique can be applied if the patient has an indwelling urinary catheter (Figure 148-5).

Alternatively, encircle the entire foreskin in one hand and pull distally while simultaneously pushing the glans proximally with the thumb of the opposite hand.8 It is important to be very deliberate in the first attempt as the patient will become more anxious on subsequent attempts. This same technique can be applied if the patient has an indwelling urinary catheter.

Iced Glove Technique

This technique combines cold to induce vasoconstriction and compression to reduce swelling.2,8 It uses a glove to provide a circumferential ice pack to the foreskin to reduce edema. Half-fill a size 8 surgical glove with crushed ice and cold water. Squeeze the air from the glove and tie a knot in the wrist of the glove. Invaginate the thumb into the body of the glove. Liberally lubricate the glans and foreskin. Insert the penis into the invaginated thumb of the glove. Apply manual pressure with a clenched fist or bandage for 5 to 10 minutes. Attempt manual reduction as described previously.2,3,4,8

Babcock Clamp Technique

This technique can be used when manual reduction has been unsuccessful. It has a high rate of success in reducing a paraphimosis.3,8,11 This technique requires penile anesthesia (Chapter 146). Use only Babcock clamps. All other surgical clamps will crush and devitalize tissue.

Apply 6 to 8 Babcock clamps circumferentially around the phimotic ring (Figure 148-6A). Place one edge of each clamp just proximal to the phimotic ring and the other edge just distal to the phimotic ring. It is important to grasp a sufficient amount of the constricting ring to avoid tearing the skin once traction is applied. Space the clamps evenly around the circumference of the penis. Grasp all of the Babcock clamps in one hand. Simultaneously and slowly apply distal traction to the clamps to pull the phimotic ring over the glans (Figure 148-6B). After reduction, remove the Babcock clamps. Examine the foreskin for any signs of traumatic injury from the clamps.

A variation of this technique uses two operators and two Adson forceps in place of Babcock clamps.12,13 This method is briefly described for completeness but is not recommended even though it is described in the medical literature. Adson forceps are toothed forceps. Traction with an Adson forceps can result in the teeth pulling through the phimotic ring and tearing the foreskin. One operator applies an Adson forceps to the phimotic ring at the 3 o'clock position and a second at the 9 o'clock position. The first operator pulls the foreskin distally via the forceps, while a second operator compresses the glans and pushes it proximally.

Needle Decompression Technique

This technique mechanically expresses fluid from the edematous foreskin via a series of puncture holes in the foreskin.3,9,14–17 Penile anesthesia is required with this technique. Clean the penis of any dirt or debris. Drape and isolate a sterile field around the penis. Apply povidone iodine or chlorhexidine solution to the penis and allow it to dry. Perform a penile block (Chapter 146).

Insert a sterile, hollow-bore 18 gauge needle 3 to 5 mm deep into the edematous foreskin. The use of needles as large as 18 gauge to as small as 26 gauge have been described. An 18 gauge is preferred as it makes a hole large enough to allow blood and fluid to escape from the tissues and not close or clot closed. Continue to puncture holes circumferentially around the edematous foreskin (Figure 148-7). An average of 8 to 12 holes are required. Different recommendations to use as few as 1 to as many as 20 punctures have been made.15,16 Wrap a gauze square around the foreskin and glans. Grasp the glans and foreskin in the palm of a gloved hand and apply manual compression. Edema fluid and blood will be expressed from the puncture holes allowing the foreskin to decompress. The gauze square will allow the Emergency Physician to maintain a grasp as the penis becomes slippery with blood and edema fluid. After the foreskin is decompressed, reduce it manually or with Babcock clamps.

Dorsal Slit of the Foreskin

The Emergency Physician must always be prepared to perform surgical techniques if nonsurgical reduction is unsuccessful. This technique involves the incision of the phimotic ring under strict aseptic technique.2,6,8 Place the patient supine and anesthetize the penis (Chapter 146), if it has not been done previously. Apply povidone iodine or chlorhexidine solution to the penis and let it dry. Apply sterile drapes to isolate a surgical field. Consider the administration of parenteral sedation prior to performing this procedure to alleviate the patient's anxiety.

Clamp a straight-blade hemostat over the foreskin and phimotic ring at the 11 o'clock and 1 o'clock positions. Place one jaw of each hemostat beneath the phimotic ring and the other jaw on top of it. Be careful not to clamp the skin on the shaft of the penis. Pull the foreskin taut between the hemostats. Grasp the hemostats with the nondominant hand or have an assistant hold them. Incise the foreskin and phimotic ring at the 12 o'clock position with a scissors or a #15 scalpel blade (Figure 148-8A). Be careful not to cut the skin on the shaft of the penis. Remove the hemostats. The incision will open into a pentagonal shape (Figure 148-8B). Reduce the foreskin over the glans. Cover the penis with sterile gauze and allow the edges of the incision to ooze for 10 to 15 minutes.

This technique can be technically difficult for the non-Surgeon. As an alternative to the two-hemostat technique, a one-hemostat technique may be performed. Place one hemostat over the foreskin and phimotic ring at the 12 o'clock position (Figure 148-8A). Remove the clamp after 1 to 2 minutes. Cut the crushed tissue with scissors through the phimotic ring. Be careful not to cut the skin on the shaft of the penis. The foreskin will then open up as described above (Figure 148-8B).

After the foreskin has been incised and reduced over the glans, approximate the cut edges with 3-0 chromic suture using a simple interrupted stitch (Figure 148-8C). Sew edge 1 and edge 2, on the illustration, together. Sew edge 3 and edge 4, on the illustration, together. A gap will remain at the 12 o'clock position that corresponds to the area of the initial incision. Alternatively, sew the cut edges with a simple running stitch (Figure 148-8D). Loosely apply petrolatum gauze and gauze squares over the wound. Apply a piece of tape to hold the dressing on the penis. Do not apply the tape circumferentially as this can result in penile ischemia.

Modified Dorsal Slit of the Foreskin

A modified dorsal slit technique has been described where only the phimotic ring is cut rather than the entire foreskin.4,8 Clean, prep, anesthetize, and drape the penis as above. A penile block is the preferred method of anesthesia as injection onto the distal penis is extremely painful (Chapter 146). As an alternative to a penile block, infiltrate immediately under the phimotic ring at the 12 o'clock position with local anesthetic solution without epinephrine using a 27 gauge needle. Be sure to raise a wheal both proximally and distally to the phimotic ring (along the dotted line in Figure 148-9A).

Incise the phimotic ring with a #15 scalpel blade. Incise only the phimotic ring. Do not extend the cut more than 3 mm proximally or distally to the phimotic ring. Once incised, the foreskin will spring open into a diamond-shaped defect (Figure 148-9B). Reduce the foreskin. Cover the penis with gauze and allow the cut edges to ooze for 10 to 15 minutes to decompress the foreskin. Approximate the edges of the wound with 3-0 chromic suture in a running pattern (Figure 148-9C). Apply a bandage of petrolatum gauze and gauze squares over the wound. Apply a piece of tape to hold the dressing on the penis. The tape should not be applied circumferentially as this can cause ischemia to the penis.

A variety of alternative techniques have been described in the literature.5,9,14,18,19,21 These techniques are variations on the basic principles previously discussed. We will briefly review the osmotic (sugar), hyaluronidase, and glans aspiration techniques.

Osmotic (Sugar) Technique

An alternative to surgical techniques is the osmotic technique.9,18,19,21 It is an innovative, painless, but time-consuming method. The glans and foreskin are immersed in sugar. An osmotic gradient is formed between the edematous foreskin and the sugar. The hypertonicity of the sugar draws the edema fluid out of the foreskin. The deflated foreskin can then be manually reduced over the glans. This technique should not be performed if the foreskin or the glans is infected, gangrenous, or ulcerated.

Place ordinary table sugar into the invaginated thumb of a large surgical glove. Insert the penis into the thumb of the glove, like in the iced glove method described above.17 The penis may also be wrapped distally to proximally in a gauze square saturated with a 50% dextrose solution.9,19 In all reports, the sugar was left on the penis for 1 to 2 hours before manual reduction was successful. The maximum time reported before successful reduction was 4 hours.18

Hyaluronidase Method

Hyaluronidase (Amphadase, Amphastar Pharmaceuticals Inc., Rancho Cucamonga, CA; Hydase, PrimaPharm Inc., San Diego, CA; Hylenex, Halozyme Therapeutics, San Diego, CA; Vitrase, Ista Pharmaceuticals Inc., Irvine, CA) is a commercially available mammalian enzyme that degrades the intercellular ground substance of connective tissue. It is widely used in ophthalmologic and plastic surgery as a spreading agent. When injected into an edematous foreskin, hyaluronidase disperses the extracellular edema fluid, facilitating reduction of the paraphimosis.5,14

Clean, prep, drape, and anesthetize the penis. Inject hyaluronidase subcutaneously using a tuberculin syringe at various points around the circumference of the edematous foreskin. A total of 150 units, or 1 cc, of hyaluronidase should be used. An alternative is to inject the hyaluronidase into the puncture holes previously made from the needle decompression technique.9,14 The edema should resolve almost immediately. Manual compression may be applied to the foreskin for 1 to 2 minutes to help mobilize the fluid. After the edema has decreased, manually reduce the foreskin.

The advantage of this technique is the rapidity with which the edema resolves. However, hyaluronidase is contraindicated in patients with penile infections or cancer as it may spread bacteria or malignant cells through the tissue planes. It is also contraindicated if the foreskin or glans is gangrenous or ulcerated.

Glans Aspiration Technique

This method is based on techniques used to treat priapism.20 The author reports using this technique on four patients with paraphimoses with a 100% success rate and no complications. He recommended it for use when the foreskin is very friable and not amenable to vigorous manipulation. This technique is described for the sake of completeness but is not recommended.

Clean, prep, drape, and anesthetize the penis. Apply a sterile tourniquet to the penile shaft proximal to the phimotic ring. Use either umbilical tape or a Penrose drain. Insert a 20 gauge needle on a 10 mL syringe into the midline of the glans, halfway between the meatus and the corona. Keep the needle and syringe parallel to the urethra. Advance the needle while aspirating with the syringe. Once blood is encountered, stop advancing the needle. Continue to aspirate blood until the glans collapses completely. It is estimated that approximately 3 to 12 mL of blood will need to be aspirated, depending on the size of the glans. Remove the needle. Grasp and firmly squeeze the glans with the nondominant hand. While maintaining this pressure, release the tourniquet and manually reduce the foreskin over the collapsed glans with the dominant hand.

The successfully reduced paraphimosis should have the general appearance of a normal uncircumcised penis. The patient usually notes immediate pain relief. It is normal for residual edema to be present. Reassure the patient that the edema will spontaneously resolve over hours to days.3,8 If invasive techniques were utilized, observe the patient in the Emergency Department for 45 to 60 minutes to confirm hemostasis. Observe the patient for full recovery from any sedation or procedural sedation techniques as per hospital policy.

Wound care following a surgical reduction is the same as that for any sutured laceration. Many physicians do not dress the site at all. But if desired, the site may be covered with antibiotic ointment or petrolatum gauze followed by a dry sterile gauze.6 The patient should be counseled on proper wound care. The patient should inspect the glans and foreskin three to four times a day if Babcock clamps, needle decompression, or surgical techniques were used to reduce the paraphimosis. They should return immediately to the Emergency Department if any signs of infection develop. Advise them to avoid intercourse or masturbation for 4 to 6 weeks.6

Antibiotics should be prescribed if the foreskin is abraded, infected, ulcerated, or torn by the Babcock clamp technique. They should also be prescribed if the foreskin was reduced by an invasive technique (e.g., needle decompression, dorsal slit, modified dorsal slit, hyaluronidase, or glans aspiration). Oral antibiotics whose spectrum covers skin flora should be prescribed. Cephalexin, 500 mg orally four times a day, is usually adequate.

All patients must follow up with a Urologist in 1 to 2 days. The definitive treatment is circumcision. This is typically delayed 7 to 10 days until any edema, inflammation, or ulceration has resolved.7,8

Incomplete reduction and pain are possible complications of manual reduction. With that in mind, it is important to allow enough time for adequate dispersion of edema. Manual reduction may also be associated with glans contusion and even glans ischemia if manual pressure is too great.4 The iced glove method may produce cold injury if not properly monitored during use.3 Compromised penile skin may be torn during manual or Babcock clamp reduction. The treatment is to suture any tears that occur.8

If surgical techniques are performed, bleeding is a common complication in this very vascular tissue. Venous bleeding can be profuse. It is important to have good control of the tissue edges so that adequate hemostatic stitches can be placed. A compressive dressing may aid in hemostasis. If the penile shaft is lacerated during a surgical reduction, it too should be sutured. And as with all invasive procedures, infection may be a complication of the needle decompression, dorsal slit, modified dorsal slit, hyaluronidase, and glans aspiration techniques.

The glans aspiration method runs the risk of transecting the urethra if the needle is not advanced parallel to the urethra. Complications of the hyaluronidase method may range from minor ecchymoses at the injection site to anaphylaxis and shock if the hyaluronidase is inadvertently injected intravascularly.5,14

A paraphimosis is a problem that is best prevented. Replacement of the foreskin after urethral catheterization or glans cleaning is important. Early intervention is necessary and can prevent disastrous tissue loss. The reduction techniques should be attempted in a stepwise manner beginning with noninvasive techniques and progressing to increasingly invasive techniques.