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 foreskin can be performed primarily in the Emergency Department. This technique is used to relieve strangulation of the glans by a paraphimosis or to aid in the visualization of the urethral meatus in patients with a phimosis.1 The techniques are easy to learn and simple to perform.
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 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. 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. 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.5,6 Once the foreskin can be retracted so that the glans penis partially appears, a phimosis is no longer present. A more detailed description of the anatomy and pathophysiology of the penis, a paraphimosis, and a phimosis can be found in Chapters 148 and 149.
A dorsal slit of the foreskin should be performed to release a paraphimosis or a phimosis if noninvasive and lesser invasive techniques are unsuccessful. 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 should be released if it causes urinary retention. The phimotic foreskin should not be forcibly retracted as this can result ...