Overview
Paraphimosis
Topic Overview
Summary
Paraphimosis is a urological emergency where the retracted foreskin becomes trapped behind the glans, causing a constricting band that impedes venous and lymphatic return. This leads to progressive oedema and, if untreated, arterial compromise and ischaemia of the glans. It commonly occurs after catheterisation or examination when the foreskin is not replaced. Treatment is manual reduction (after analgesia/sedation). Dorsal slit or circumcision is required if manual reduction fails.
Key Facts
- Definition: Retracted foreskin trapped behind glans, unable to be replaced
- Cause: Failure to replace foreskin after retraction (catheter, examination)
- Pathophysiology: Venous congestion → oedema → arterial compromise → ischaemia
- Treatment: Manual reduction (pressure, ice, osmotic agents); dorsal slit if fails
- Prevention: ALWAYS replace the foreskin after retraction
Clinical Pearls
Prevention is key — ALWAYS replace the foreskin after catheterisation or examination
Paraphimosis is a clinical diagnosis — no imaging needed
"Oscar squeeze" — firm compression of glans for 5-10 minutes reduces oedema and allows reduction
Why This Matters Clinically
Paraphimosis is an avoidable emergency. Delay leads to glans necrosis. All healthcare professionals inserting catheters must be trained to replace the foreskin.
Visual Summary
Visual assets to be added:
- Paraphimosis appearance diagram
- Manual reduction technique
- Oscar squeeze demonstration
- Dorsal slit procedure schematic
Epidemiology
Incidence
- Common in uncircumcised males
- Often iatrogenic (catheterisation)
- Peak in children and elderly
Demographics
- Uncircumcised males
- Children (physiological phimosis)
- Elderly (catheterisation, hygiene)
Causes/Triggers
| Cause | Notes |
|---|---|
| Catheterisation | Foreskin retracted, not replaced |
| Medical examination | Foreskin not replaced after inspection |
| Sexual activity | Foreskin remains retracted |
| Poor hygiene | Chronic inflammation → scarring |
| Phimosis | Tight foreskin predisposes |
Pathophysiology
Mechanism
- Foreskin retracted behind glans
- Tight preputial ring creates constricting band
- Venous and lymphatic return obstructed
- Glans and foreskin become oedematous
- Oedema worsens constriction (vicious cycle)
- If untreated: Arterial compromise → ischaemia → necrosis
Time Course
- Early: Oedema, discomfort
- Delayed: Severe oedema, pain, dusky glans
- Late: Ischaemia, necrosis (hours to days)
Clinical Presentation
Symptoms
Signs
Red Flags
| Finding | Significance |
|---|---|
| Dusky/black glans | Ischaemia — urgent reduction |
| Unable to reduce manually | May need dorsal slit |
| Prolonged duration | Higher risk of necrosis |
Pain
Common presentation.
Swelling of glans
Common presentation.
Unable to pull foreskin forward
Common presentation.
Clinical Examination
Penile Examination
- Glans swollen and tender
- Foreskin retracted, tight band behind corona
- Assess colour of glans (pink = viable; dusky/black = ischaemic)
General
- Signs of distress
- Associated UTI or catheter issues
Investigations
Clinical Diagnosis
- No investigations necessary
- Diagnosis is clinical
Consider
- Urinalysis if UTI suspected
- Blood glucose if recurrent/poor healing
Classification & Staging
By Severity
| Stage | Features |
|---|---|
| Mild | Oedema, easily reducible |
| Moderate | Significant oedema, requires analgesia/effort to reduce |
| Severe | Ischaemic changes, unable to reduce manually |
Management
Analgesia
- Topical local anaesthetic (EMLA cream, lidocaine gel)
- Penile block (dorsal nerve block) if needed
- Sedation in children (if necessary)
Manual Reduction — First-Line
Technique:
- Apply ice wrapped in cloth (reduces oedema)
- Apply osmotic agent (granulated sugar, hypertonic saline gauze) — draws out fluid
- Oscar squeeze: Firm circumferential compression of glans for 5-10 minutes
- Once oedema reduced, apply steady pressure to push glans back through preputial ring
- Use both thumbs on glans, fingers behind foreskin
Tips:
- Patience is key
- May take several attempts
- Apply lubricant
If Manual Reduction Fails
| Procedure | Details |
|---|---|
| Puncture technique | Multiple punctures in oedematous foreskin with 21G needle → express oedema |
| Dundee technique | Hyaluronidase injection (disperses oedema) |
| Dorsal slit | Surgical incision of constricting band (under local) |
| Circumcision | Definitive; if recurrent or severe |
Post-Reduction
- Clean and dry
- Counsel on hygiene and foreskin care
- Consider elective circumcision if recurrent
- Document foreskin replacement after catheterisation
Prevention
- ALWAYS replace the foreskin after retraction
- Educate healthcare staff
Complications
Of Paraphimosis
- Glans necrosis
- Gangrene
- Ulceration
- Urinary retention
Of Reduction
- Pain
- Recurrence
- Scarring (if dorsal slit)
Prognosis & Outcomes
Prognosis
- Excellent if reduced promptly
- Rare complications if managed early
Recurrence
- May recur if phimosis not addressed
- Consider elective circumcision
Evidence & Guidelines
Key Guidelines
- No specific national guideline
- Management based on consensus and case series
Key Evidence
- Manual reduction is effective in most cases
- Osmotic agents (sugar) are safe and effective
Patient & Family Information
What is Paraphimosis?
Paraphimosis is when the foreskin gets stuck behind the head of the penis and cannot be pulled back. It is an emergency and needs treatment quickly.
Why Does it Happen?
- After cleaning, examination, or putting in a catheter, the foreskin is not pulled back over the head of the penis
Treatment
- The doctor will apply pressure to reduce the swelling and push the foreskin back
- Sometimes a small cut is needed
- Circumcision may be recommended to prevent it happening again
Prevention
- Always make sure the foreskin is pulled back over the head of the penis after cleaning or medical procedures
Resources
References
Key Studies
- Choe JM. Paraphimosis: current treatment options. Am Fam Physician. 2000;62(12):2623-2626. PMID: 11142469
- Hayashi Y, et al. Prepuce: phimosis, paraphimosis, and circumcision. ScientificWorldJournal. 2011;11:289-301. PMID: 21298220
Reviews
- McGregor TB, Pike JG, Leonard MP. Pathologic and physiologic phimosis: approach to the phimotic foreskin. Can Fam Physician. 2007;53(3):445-448. PMID: 17872680