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Paraphimosis

Paraphimoses


Presentation

The most common sign and symptom of paraphimosis is the inability of the foreskin of the penis to come back from its retracted position. Such a situation leads to development of the following symptoms:

  • Inflammation of the glans penis
  • Inflammation of the foreskin of penis
  • Development of constricted band of tissue behind the head of the penis.
  • Pain in the penis region
  • Glans penis turns dark blue in color due to inadequate blood supply.
Aspiration
  • This review outlines the treatment options available for resolving this condition: manual reduction methods, osmotic methods, puncture and aspiration methods and treatments using sharp incision.[ncbi.nlm.nih.gov]
  • Aspiration A tourniquet is applied to the shaft of the penis. A 20-gauge needle is then used to aspirate 3-12 mL of blood from the glans, parallel to the urethra. This reduces the volume of the glans sufficiently to facilitate manual reduction.[emedicine.medscape.com]
  • A blood aspiration is conducted after the application of tourniquet over the penis. This entails the measurement and analysis of the blood that aspires in the blood vessels of the penis.[hxbenefit.com]
  • Inject the lidocaine just deep to Buck's fascia, approximately 3 mm to 5 mm beneath the skin, ensuring negative aspiration of blood before injecting.[ncbi.nlm.nih.gov]
  • Aspirate the Glans Apply tourniquet to shaft of penis ( seems counterintuitive ). Insert 20-gauge needle parallel to the urethra ; aspirate 3-12 mL of blood from glans to reduce its size.[pedemmorsels.com]
Painful Erection
  • Pathologic phimosis may be detected in males who report painful erections, hematuria, recurrent urinary tract infections, preputial pain, or a weakened urinary stream. (See below.) Physiologic phimosis versus pathologic phimosis.[emedicine.medscape.com]
  • Symptoms of may include: Difficulty or pain during urination Painful erection Paraphimosis (A medical emergency where the foreskin can't return to it's normal location once retracted.)[rxlist.com]
  • Phimosis might cause: Relapsing inflammations of the glans and foreskin Pain and discomfort during sexual intercourse Painful erection, which may lead to erectile dysfunction Full obstruction of the glans, which may result in inability to urinate Premature[imop.gr]
  • Abnormal phimosis may cause painful erections, blood in the urine (haematuria), recurrent urinary tract infections, pain and a weak urine stream. There may be swelling, redness and tenderness of the foreskin.[patient.info]
Penile Pain
  • He had experienced referred penile pain from his prostate cancer, and to overcome this, had attempted to 'gate out' his pain by constricting his penis and thus stimulating the pudendal nerve.[ncbi.nlm.nih.gov]
  • Patients often experience penile pain and edema of the penile shaft proximal to the glans and corona, where a tight phimotic ring is present.[aibolita.com]
  • With phimosis, the male child may have any or all of the following signs and symptoms: Difficulty with urination Pain upon urination Blood in the urine Pain in the penis With paraphimosis, males can have these additional symptoms: Penile pain (particularly[emedicinehealth.com]
  • pain Redness (erythema) Swollen glans (the shaft of the penis is not swollen) Tenderness Complications of Paraphimosis Tissue death caused by loss of blood supply (gangrene) and spontaneous detachment of diseased tissue (autoamputation) of the glans[healthcommunities.com]
  • Tags: genital trauma paraphimosis Penile pain Phimosis Sean M. Fox I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same.[pedemmorsels.com]
Penile Pain
  • He had experienced referred penile pain from his prostate cancer, and to overcome this, had attempted to 'gate out' his pain by constricting his penis and thus stimulating the pudendal nerve.[ncbi.nlm.nih.gov]
  • Patients often experience penile pain and edema of the penile shaft proximal to the glans and corona, where a tight phimotic ring is present.[aibolita.com]
  • With phimosis, the male child may have any or all of the following signs and symptoms: Difficulty with urination Pain upon urination Blood in the urine Pain in the penis With paraphimosis, males can have these additional symptoms: Penile pain (particularly[emedicinehealth.com]
  • pain Redness (erythema) Swollen glans (the shaft of the penis is not swollen) Tenderness Complications of Paraphimosis Tissue death caused by loss of blood supply (gangrene) and spontaneous detachment of diseased tissue (autoamputation) of the glans[healthcommunities.com]
  • Tags: genital trauma paraphimosis Penile pain Phimosis Sean M. Fox I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same.[pedemmorsels.com]
Chancroid
  • Many esoteric aetiologies have been implicated in the development of paraphimosis including piercing the foreskin, Plasmodium falciparum infection, application of celadine juice to the foreskin, chancroid, pessaries and the implantation of pearls.[ncbi.nlm.nih.gov]
  • […] iatrogenic, involving failure to return the foreskin to its normal location, classically after catheter placement. 2 Paraphimosis in middle-aged adults is usually linked with unusual causes, including piercings, lichen sclerosis, Plasmodium, contact allergy, chancroid[aafp.org]
Edema of the Penis
  • As arterial inflow continues, lack of lymphatic drainage will cause a progressive edema of the penis distal to the retracted foreskin. As the foreskin continues ...[mhmedical.com]

Workup

A thorough physical examination of the penis is enough to confirm the disease. Detailed examination of the penis, glans and scrotum would provide good evidence about the degree of severity of condition. If the glans appears to turn black it indicates that there is lack of blood supply to that area implying the need of immediate treatment. In addition, if the area appears to be firm with inelastic feel then onset of necrosis should be confirmed.

In many cases, it has been studied that patients suffering from paraphimosis have an indwelling catheter. Before the diagnosis, the catheter should be removed for proper examination.

While diagnosing paraphimosis, it is necessary to carefully examine the color and texture of the scrotum. The degree of elasticity of the scrotum should also be noted.

Plasmodium Falciparum
  • Many esoteric aetiologies have been implicated in the development of paraphimosis including piercing the foreskin, Plasmodium falciparum infection, application of celadine juice to the foreskin, chancroid, pessaries and the implantation of pearls.[ncbi.nlm.nih.gov]

Treatment

The primary goal in the treatment of paraphimosis is to restore the retracted foreskin to its original position. This is mostly done manually by exerting pressure to the glans penis and simultaneously pulling the foreskin down. Since this may result in subsequent pain, the method is done by giving anesthesia prior to the procedure [5]. In many cases, nerve block or oral narcotics may also be administered to ease discomfort during the treatment process.

Application of ice to the swollen area is advised [6]. In some cases, a mannitol soaked gauze may be applied to relieve the swelling of paraphimosis by osmosis [7]. However, in severe cases patients may need to be given hyaluronidase injection to reduce the inflammation [8]. In some other cases, a small incision or skin puncture may have to be made in order to release the tension in the affected area [9].

If paraphimosis is treated when the first signs and symptoms appear, the recovery is encouraging. This means that one can expect a full recovery if the condition is promptly treated. However, delay in treatment can require surgical procedures to remove the foreskin. In paraphimosis due to retained foreskin or uncircumcised penis, a corrective surgical may be performed after the foreskin is retracted in place and where blood flow to the organ is fully restored [10].

Prognosis

Prognosis of paraphimosis is extremely favorable if the condition is diagnosed on time and immediate treatment initiated. Failure to identify the problem and treat the condition can lead to development of serious complications.

Complications

When paraphimosis is left untreated for several hours, the blood flow is restricted giving rise to the following complications:

  • Gangrene
  • Auto amputation of distal penis
  • Damage to the glans penis

Etiology

The following are the causative factors that are known to give rise to paraphimosis:

Paraphimosis can also occur during a detailed physical examination of the penile by medical professionals. Such a condition can also result from cytoscopy or urethral catheterization.

Epidemiology

Paraphimosis is an uncommon condition and its exact prevalence rate is not known. As such this situation occurs more in hospitals and nursing homes; accurate documentation of the cases may not be practiced.

Sex distribution
Age distribution

Pathophysiology

Paraphimosis is an emergency situation wherein the foreskin gets trapped and is unable to come back to its original position. When such a condition exists for longer hours, the affected area can swell due to fluid accumulation. This then gradually impairs the blood flow giving rise to serious and life threatening conditions. Patients complain of painful swelling in the affected area.

Prevention

Paraphimosis can be prevented by moving the foreskin back to its normal position. In addition, practicing good personal hygiene can also prevent development of this condition. Paraphimosis is a problem in uncircumcised males; therefore if the process of circumcision is done then such a condition can be prevented.

Summary

Paraphimosis is an uncommon condition affecting uncircumcised males, wherein the foreskin cannot be brought to the original position once it is pulled back [1]. Such a situation causes the foreskin to get stuck and swell which in turn can prevent the blood flow.

Paraphimosis if not treated promptly can be life threatening. Such a condition is also referred to as capistration which is a urologic emergency requiring prompt medical attention. This condition mainly affects children and the geriatric population.

Patient Information

Definition

Paraphimosis is a condition wherein the foreskin of the penis when retracted fails to come back to its normal position. Such a type of condition is a cause of urological emergency demanding immediate medical attention. Paraphimosis strikes uncircumcised males and those in whom the process of circumcision has not been appropriately carried out. With appropriate treatment, the prognosis of the condition is favorable enough and can be completely treated. However, failure to initiate prompt treatment can call for development of serious complications.

Cause

Trauma or injury to the penis and infections due to poor personal hygiene are some of the factors that can cause paraphimosis. In addition to these, failure to bring back the foreskin to its normal position after examination, washing or urination can also lead to development of paraphimosis.

Symptoms

Symptoms of paraphimosis include inflammation of the affected area, pain in the region of penis and tip of the penis turns blue or black in color due to inadequate blood supply.

Diagnosis

A careful physical examination of the penis and scrotum is required for diagnosis of paraphimosis. If the penis appears to get black in color it indicates that the blood supply to the affected area is poor, which means it requires immediate medical intervention.

Treatment

Treatment of paraphimosis includes manually pulling the foreskin back to its normal position by using lubricants. The patient may experience certain pain during the procedure and therefore anesthesia may be required. Ice is applied to the affected area to reduce the inflammation and ease the discomfort. If such a practice does not bring down the swelling then a small incision would be made to release the tension. In severe cases, surgical intervention would be necessary if other treatment modes fail to bring about positive outcome.

References

Article

  1. Dubin J, Davis JE. Penile emergencies. Emerg Med Clin North Am. Aug 2011; 29(3):485-99.
  2. Raman SR, Kate V, Ananthakrishnan N. Coital paraphimosis causing penile necrosis. Emerg Med J. Jul 2008; 25(7):454. 
  3. Koenig LM, Carnes M. Body piercing medical concerns with cutting-edge fashion. J Gen Intern Med. Jun 1999; 14(6):379-85.
  4. Yiğiter M, Arda IS, Hiçsönmez A. An unusual cause of paraphimosis: hemangioma of the glans penis. J Pediatr Surg. 2008; 43(2):e31-3 (ISSN: 1531-5037)
  5. Little B, White M. Treatment options for paraphimosis. Int J Clin Pract. May 2005; 59(5):591-3.
  6. Cahill D, Rane A. Reduction of paraphimosis with granulated sugar. BJU Int. Feb 1999; 83(3):362.
  7. Anand A, Kapoor S. Mannitol for paraphimosis reduction. Urol Int. 2013; 90(1):106-8 
  8. Litzky GM. Reduction of paraphimosis with hyaluronidase. Urology. Jul 1997; 50(1):160.
  9. Hamdy FC, Hastie KJ. Treatment for paraphimosis: the 'puncture' technique. Br J Surg. Oct 1990; 77(10):1186.
  10. Hayashi Y, Kojima Y, Mizuno K, Kohri K. Prepuce: phimosis, paraphimosis, and circumcision.ScientificWorldJournal. Feb 3 2011; 11:289-301.

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Last updated: 2019-07-11 22:17