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.