7.10 Phimosis and Paraphimosis

agk’s Library of Common Simple Emergencies

Presentation

Phimosis is the inability to retract the foreskin over the glans, and is usually due to a contracted preputial opening. Patients with phimosis may seek acute medical care when they develop signs and symptoms of infection, such as pain and swelling of the foreskin and a purulent discharge. Paraphimosis occurs when the foreskin cannot be replaced in its normal position after it is retracted behind the glans. The tight ring of preputial skin which is caught behind the glans creates a venous tourniquet effect and leads to edematous swelling of the glans.

What to do:

• For paraphimosis, squeeze the glans firmly for at least ten minutes to reduce the edematous swelling. Wrap the shaft and swollen glans with a gauze pad followed by a two inch elastic bandage that will produce constant, gentle compression. After ten to fifteen minutes, remove it, then push the glans proximally and slide the prepuce back over the glans. If manual reduction fails, anesthetize the dorsal foreskin and carefully incise the constricting tissue.
• Treating phimosis usually involves the management of acute infection. Frequent hot compresses or soaks are needed along with antibiotics such as cefadroxil (Duricef) for a balinitis.
• In both paraphimosis and phimosis, followup care should be provided. When swelling and inflammation subside, circumcision should be performed.

Discussion

Poor hygene and chronic inflammation are the usual causes of stenosing fibrosis of the preputial opening. In the case of a neglected paraphymosis, arterial occlusion may supervene and gengrene of the glans develop. When phimosis results in acute urinary retention, the tip of a hemostat can be inserted into the scarred end of the foreskin and gently opened, allowing the patient to void satisfactorily until urologic cosultation can be obtained. One common cause of paraphymosis is retracting the foreskin to clean the glans and place a Foley catheter, but forgetting to reduce the foreskin afterwards.

Illustration

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