Paraphimosis

Bradley N. Bragg; Erwin L. Kong; Stephen W. Leslie.

Author Information
Last Update: August 12, 2021.

Continuing Education Activity

Paraphimosis is a common urologic emergency that occurs in uncircumcised males when
the foreskin becomes trapped behind the corona of the glans penis. This can lead to
strangulation of the glans and painful vascular compromise, distal venous engorgement,
edema, and even necrosis. This activity describes the etiology, pathophysiology, evaluation,
and management of paraphimosis and highlights interprofessional teams' role in improving
outcomes for such patients.

Objectives:
 Describe the pathophysiology of patients with paraphimosis.
 Outline the evaluation in patients with paraphimosis.
 Review the conservative and surgical treatment options available for patients with
paraphimosis.
 Summarize interprofessional team strategies for enhancing care coordination to facilitate
rapid diagnosis and management of patients with paraphimosis.
Access free multiple choice questions on this topic.

Introduction
Paraphimosis is a true urologic emergency that occurs in uncircumcised males when the
foreskin becomes trapped behind the corona of the glans penis, leading to strangulation of
the glans as well as painful vascular compromise, distal venous engorgement, edema, and
even necrosis. By comparison, phimosis is the condition when the foreskin is unable to be
retracted behind the glans of the penis.[1]

Etiology
Paraphimosis commonly occurs iatrogenically, when the foreskin is retracted for cleaning,
placement of a urinary catheter, a procedure such as a cystoscopy, or for penile
examination.[1] Failure to return the retracted foreskin over the glans promptly after the
initial retraction can lead to paraphimosis. Other, less common causes include penile coital
trauma and self-inflicted injuries.
It is essential that all caregivers who regularly change Foley catheters routinely
replace the foreskin at the end of the procedure to prevent the development of a
paraphimosis. 

Epidemiology
In uncircumcised children, four months to 12 years old, with foreskin problems,
paraphimosis (0.2%) is less common than other penile disorders such as balanitis (5.9%),
irritation (3.6%), penile adhesions (1.5%), or phimosis (2.6%).[2]

In adults, paraphimosis is most commonly found in adolescents. It will occur in about 1% of

all adult males over 16 years of age.

Pathophysiology
If a constricting band of the foreskin is allowed to remain retracted behind the glans penis
for a prolonged period, it can lead to impairment of distal venous and lymphatic drainage as
well as decreased arterial blood flow to the glans. Arterial blood flow can become affected
over the course of hours to days. This change can ultimately lead to marked ischemia and
potential necrosis of the glans.[3]

Histopathology
At birth, there is normal physiologic phimosis due to natural adhesions between the glans
and the foreskin. During the first 3 to 4 years of life, debris, such as shed skin
cells, accumulates under the foreskin, gradually separating it from the glans. Intermittent
penile erectile activity, such as nocturnal erections, also contributes to the
increased mobility of the foreskin, ultimately allowing it to become completely retractible.

History and Physical

When evaluating a patient with paraphimosis, a pertinent history is important. This history
should include any recent penile catheterizations, instrumentation, cleaning, or other
procedures.[1] The patient should be asked about his routine cleaning of the penis and if he
or a caregiver routinely retracts the foreskin for any reason. It is also important to ask if the
patient is circumcised or uncircumcised. It is still possible to develop paraphimosis in a
patient who has previously been circumcised. This can be due to the patient believing he
was circumcised when he was not or excessive remaining foreskin despite the circumcision.

Typical paraphimosis symptoms include erythema, pain, and swelling of foreskin and glans
due to the constricting ring of the phimotic foreskin. It may sometimes be described by
patients as "penile swelling" and may be relatively painless. Clinicians are cautioned to be
suspicious of any telephone description of "penile swelling" as potentially being a
paraphimosis that requires immediate treatment and not to dismiss such descriptions as
harmless without actually visualizing the lesion. Sometimes a photo sent from the patient's
smartphone may be enough to settle the issue. 

The history usually makes the diagnosis, but if not, it will be obvious on direct physical
examination. The physical exam should focus on the penis, foreskin, and urethral catheter
(if present). A pink color to the glans indicates reasonably good blood supply, whereas a
dark, dusky, pale, bluish or black color implies possible ischemia or even necrosis.

If a Foley catheter is in place, it's recommended to review the reason why the catheter was
needed and whether any difficulties were encountered in placing it, prior to its removal.
While removing the Foley will almost certainly aid in reducing the paraphimosis, in some
circumstances it may prove to be impossible to replace the catheter and now the caregiver
is faced with a new problem. Most of the time, removal of the Foley is not necessary to
successfully reduce the paraphimosis.[1]

Evaluation
The patient typically presents with acute, distal, penile pain and swelling, but the pain is not
always present. The glans and foreskin typically are markedly enlarged and congested, but
the proximal penile shaft is flaccid and unremarkable. A tight band of constrictive tissue is
present, often preventing the easy manual reduction of the foreskin over the glans.
Diagnosis is made clinically by direct visualization, as well as the inability to easily reduce
the retracted foreskin manually.

Treatment / Management
Mild, uncomplicated paraphimosis may be reduced manually, usually without the need for
sedation or analgesia. More difficult or complicated cases may require local anesthesia with
a dorsal penile block, systemic analgesia, or procedural sedation.
Several methods of reduction are available and can be classified into manual reduction or
surgical repair. 

Manual, non-surgical reduction of the paraphimosis is possible with or

without compression methods, using osmotic agents and puncture-aspiration techniques.

Manual reduction of paraphimosis can often be facilitated by simple compression of the

glans and the swollen, edematous foreskin for several minutes before attempting the
reduction. This allows the edematous swelling of the retracted foreskin to diminish before
attempting repositioning of the foreskin to its usual position. One simple method involves
manually compressing the edematous foreskin while pulling slowly upward on the phallus.

Manual reduction can also be attempted by placing both thumbs over the glans with both
index and long fingers surrounding the trapped foreskin. Then slow, steady pressure is
applied to advance the phimotic portion of the foreskin outwards slowly, back over the
glans. This can be facilitated with a little lubricant. Excessive lubricant should be avoided as
it may make the skin too slippery for reliable grasping.[4]
Another compression technique involves tightly wrapping the swollen portion of the penis
from the glans towards the base with a 1-inch or 2-inch elastic bandage. A gauze pad
should be applied first around the edematous foreskin. The compression bandage can
remain for 10 to 20 minutes to minimize the edema. Then apply one of the manual reduction
methods described above.[5]

Ice packs or surgical gloves filled with ice and applied to edematous areas have been
described as possibly useful in conjunction with other methods to reduce the paraphimotic
swelling.  However, since the main issue in paraphimosis is distal penile vascular
compromise from a constricting fibrous band of the phimotic foreskin, many experts
recommend against using ice in these situations as it may further compromise arterial inflow
to the possibly ischemic portion of the penis.

Another possible compressive treatment method involves cutting the thumb from a surgical

glove to make a "sleeve" and emptying a tube of EMLA cream (2.5% lidocaine and 2.5%
prilocaine; AstraZeneca, London, UK) or similar into the sleeve. This is then placed over the
penis and left for approximately 30 minutes. This allows for local anesthesia and softening
of affected skin to aid in foreskin reduction.  However, while it does provide some analgesic
relief, it may make the skin a little more slippery and harder to manipulate.[6]
Reducing the penile edema from paraphimosis can also be achieved by directly injecting
hyaluronidase into the edematous foreskin.  This has been effective, particularly in children
and infants, in resolving the edema, allowing for an easier manual reduction of the
paraphimosis. The hyaluronidase increases the diffusion of trapped fluid within the tissue
planes of the malpositioned foreskin, which reduces the swelling and edema.[7]
Osmotic methods involve applying substances with a high solute concentration on
the external skin surfaces of the edematous tissue. This would tend to draw water along an
osmotic gradient and thereby reduce the edema. For example, a generous topical
application of granulated sugar to the affected glans and foreskin has been shown to
be effective in helping reduce edema from paraphimosis.[8]
Gauze soaked in 20% mannitol solution has also been used as an osmotic agent to reduce
the edema from paraphimosis. The gauze is left in place for 30 to 45 minutes. It has been
reported to completely eradicate the troublesome edema allowing for easy resolution of the
paraphimosis with manual techniques, as described above. This technique is relatively
painless and is well suited for children.[9]
In many cases, no additional local anesthetic or analgesia is needed, but if the
paraphimosis is long-standing, extremely painful, or severe, then a formal penile anesthetic
block can be used. A dorsal penile block is performed using a 25-gauge or 27-gauge
needle, infiltrating approximately 2.5 mL of 1% lidocaine without epinephrine into the base
of the penis at the junction of the penis and suprapubic skin at the 10 o'clock position, off
the midline to avoid the superficial dorsal vein. Another 2.5 mL is injected at the 2 o'clock
position. Inject the lidocaine just deep to Buck's fascia, approximately 3 mm to 5 mm
beneath the skin, ensuring negative blood aspiration before injecting. Ultrasound guidance
has been shown to be effective in helping to identify landmarks for this procedure.[10]

Puncture and aspiration methods are more invasive and should be reserved for cases
refractory to other less-invasive techniques. The puncture technique involves puncturing the
edematous foreskin several times with a hypodermic needle followed by manual expression
of edematous fluid through the puncture holes. Experienced emergency practitioners can
consider penile corporal aspiration of blood.

Surgical treatment of the paraphimosis will be required if the previously described

manual reduction methods are unsuccessful. Prepare the penis and prepuce with a
povidone-iodine or similar antiseptic solution. This can be achieved after the previously-
described penile block. One method involves applying two straight hemostats to grab the
dorsum of the constricting foreskin at the 12 o'clock position. This is followed by making a 1
cm to 2 cm longitudinal incision of the constricting band of edematous foreskin between the
hemostats, which allows for passage over the glans. The incised foreskin is not
reapproximated after reduction, but the edges are oversown with a 3-0 or 4-0 absorbable
suture. This will leave the phimotic portion of the foreskin widely separate and open to
prevent recurrences.
 Ischemia leading to necrosis and gangrene of the glans and distal urethra can occur. 
Management of such a severe complication of paraphimosis is typically partial penectomy,
resection of the glans and/or excision of the necrotic penile tissue. Recently, conservative
management of a case of necrosis of the glans from paraphimosis in a 25 year old was
described with suprapubic tube drainage and careful surgical debridement which provided a
reasonably good result without penile amputation.[11]
An elective circumcision or dorsal slit procedure is strongly recommended in all
patients who have had a significant paraphimosis due to the very great risk of a
recurrence.

Differential Diagnosis
 Acute angioedema 
 Allergic contact dermatitis 
 Anasarca
 Balanitis
 Balanitis xerotica obliterans
 Cellulitis
 Foreign body tourniquet
 Insect bites
 Penile carcinoma 
 Penile fracture 
 Penile hematoma 

Prognosis
The prognosis with paraphimosis is excellent if diagnosed and treated promptly. There may
be some bleeding during skin retraction, but long-term negative outcomes are rare. The
condition can commonly recur; circumcision can preclude recurrence once the inflammation
has subsided and the patient is a viable candidate for the procedure.[12] An alternative to a
circumcision, especially in an older or sicker patient, would be a dorsal slit.  Either is
satisfactory in preventing a recurrence of the paraphimosis.
Complications
Complications that can occur with paraphimosis include pain, infection, and inflammation of
the glans penis. If the condition is not relieved in a sufficiently prompt timeframe, the distal
penis can become ischemic or necrotic. Operative complications include bleeding, infection,
injury to the urethra, and shortened penile skin.

Deterrence and Patient Education

After reduction or surgery, patients should be counseled that their prognosis is quite good.
They should receive instruction on hygiene, be sure and return their foreskin to its normal
position if it has been retracted, and avoid using any penile jewelry if that has contributed to
the condition. The patient may wish to consider circumcision to preclude future episodes,
particularly if recurring cases.

Pearls and Other Issues

After a successful manual reduction, the foreskin should carefully be cleaned. Any
superficial abrasions or tears to the foreskin should be treated with a topical antibiotic
ointment such as bacitracin. Patients should be instructed to avoid retracting the foreskin for
one week and avoid any offending activities contributing to the paraphimosis.

Reducing the paraphimosis successfully is insufficient long-term therapy. All such patients
should be evaluated for further treatment involving a dorsal slit or circumcision procedure to
definitively deal with the tightened foreskin and permanently prevent any recurrences of the
paraphimosis.

Enhancing Healthcare Team Outcomes

Paraphimosis is a urological emergency best managed by an interprofessional team that
includes a pediatrician, emergency department physician, urologist, nurse specialist, and a
surgeon. Mild cases may be reduced manually, but more complex cases usually require
some type of anesthesia.

After a successful manual reduction, the foreskin should carefully be cleaned. Any
superficial abrasions or tears to the foreskin should be treated with a topical antibiotic
ointment such as bacitracin. Patients should be instructed to avoid retracting the foreskin for
one week and avoid any offending activities contributing to the paraphimosis.
 Reducing the paraphimosis successfully is insufficient long-term therapy. All such patients
should be evaluated for further treatment involving a dorsal slit or circumcision procedure to
definitively deal with the tightened foreskin and permanently prevent any recurrences of the
paraphimosis.

Review Questions
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References
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2.
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3.
Palmisano F, Gadda F, Spinelli MG, Montanari E. Glans penis necrosis following
paraphimosis: A rare case with brief literature review. Urol Case Rep. 2018
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4.
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6.
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8.
Cahill D, Rane A. Reduction of paraphimosis with granulated sugar. BJU Int. 1999
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Anand A, Kapoor S. Mannitol for paraphimosis reduction. Urol Int. 2013;90(1):106-
8. [Abstract]
10.
Flores S, Herring AA. Ultrasound-guided dorsal penile nerve block for ED
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