Up to 85% of pathologic phimoses that are mild to moderate will respond to the application of topical steroids to the preputial orifice. It is reasonable for the Emergency Physician to prescribe 0.1% to 0.05% betamethasone dipropionate applied twice daily for 4 to 6 weeks with appropriate Urologic follow-up if there is no urinary obstruction or a urinary catheter can be placed.11 The application of topical corticosteroids is the most cost-effective treatment if the circumstances permit.19
Attempt to pass a size 16 or 18 French Foley or coudé catheter into the bladder. If this is too large, attempt to pass the largest possible catheter. Please refer to Table 145-1 for an age-based list of proper catheter sizes. Care should be taken to avoid forceful placement of the catheter between the foreskin and the glans. Correct catheter placement will be confirmed by an outflow of urine. Refer to Chapter 142 for a complete discussion of urethral catheterization.
Most simply, the opening of the prepuce can be stretched. The patient's penis should be thoroughly anesthetized prior to performing this procedure (Chapter 146). Consideration should also be given to administering intravenous analgesics, intravenous sedation, or procedural sedation (Chapter 129).
Insert the jaws of a closed hemostat just inside the foreskin. Slowly open the arms of the hemostat 2 to 3 mm. Palpate the foreskin to feel both jaws of the hemostat. If the jaws are not palpable, immediately remove the instrument as one of the jaws may be in the urethra. If both jaws of the hemostat are palpable, open the arms to dilate the opening of the foreskin. Remove the hemostat. Clean the glans and undersurface of the foreskin with povidone iodine or chlorhexidine solution. Insert, using strict aseptic technique, a urinary catheter if required (Chapter 142).
This approach is not the ideal technique as it carries significant risk of injury to the patient. Inadvertent placement of the hemostat jaw in the urethra can lacerate the urethra and glans of the penis. Dilating the foreskin can cause irregular tears. Injury may require operative intervention and circumcision to correct any iatrogenic trauma.
Dorsal Slit of the Foreskin
The preferred method to correct an obstructing phimosis in the Emergency Department is the dorsal slit procedure. The patient's penis should be thoroughly anesthetized prior to performing this procedure (Chapter 146). Consideration should also be given to administering intravenous analgesics, intravenous sedation, or procedural sedation (Chapter 129).
Insert the bottom jaw of a straight hemostat between the foreskin and glans at the 12 o'clock position (Figure 149-1A). For those individual patients or cultural situations where dorsal incision of the foreskin, much less excision, is cosmetically unacceptable, a ventral approach may be substituted which will yield an apparently uncircumcised penis without obstructive symptoms.9 Advance the hemostat until the tip of the jaw is at the coronal sulcus (Figure 149-1A). The coronal sulcus is where the foreskin attaches to the penis. Depending on the etiology of the phimosis, adhesions may be encountered. These should be gently broken as the hemostat is advanced. The skin of the foreskin is relatively thin and the jaw of the hemostat should be easily palpated. The tip of the jaw should be seen to tent the skin at the coronal sulcus when properly placed (Figure 149-1B). It cannot be overemphasized that the Emergency Physician must be confident that the instrument has not been inadvertently placed in the urethra. If the jaw of the hemostat cannot be felt and cannot be seen tenting the skin of the foreskin, remove the hemostat and reinsert it.
Dorsal slit of the foreskin. A. A hemostat is inserted under the foreskin and advanced to the coronal sulcus. B. The hemostat is elevated to tent the skin and confirm it is properly placed. C. The dorsal slit has been made. D. The foreskin is retracted. E. Interrupted sutures are placed in the cut edge of the foreskin.
Once properly placed, close the hemostat to crush the foreskin at the 12 o'clock position. Allow the hemostat to remain closed for 2 to 3 minutes to thoroughly crush the foreskin. Remove the hemostat. Insert a scissors and advance it with the same attention to position the tip at the coronal sulcus. Incise the crushed tissue to the level of the coronal sulcus (Figure 149-1C). If straight scissors are not available, a #15 blade may be used to cut the crushed skin after another instrument is placed underneath the foreskin to protect the glans from injury. This method of using a scalpel blade is dangerous and not recommended because control is reduced and the potential for error is unnecessarily increased.
Retract the cut foreskin. This will leave an open wound edge on both sides of the midline (Figure 149-1D). Suture the open wound edges using 3-0 or 4-0 chromic gut suture in an interrupted or running pattern. Begin suturing from the midline to the distal end of the incision (Figure 149-1E).5 Return the foreskin to its “resting” position to guard against a newly acquired iatrogenic paraphimosis. Generously apply a topical antibacterial ointment over the suture line and loosely cover it with a bandage of petrolatum gauze and gauze squares. 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.
Should it be desired, a complete circumcision can be performed after the dorsal slit incision. Using two hemostats, make a series of crushing bites along the foreskin at the level of the coronal sulcus. Use caution not to crush the skin on the shaft of the penis. Using scissors, cut the foreskin along the crushed tissue. Approximate the wound edges using 3-0 or 4-0 chromic gut in an interrupted pattern. Carcinoma should always be considered as an etiology of a phimosis and all excised tissue sent to pathology for histologic evaluation.18