What is the most appropriate next physical exam finding for a 68-year-old male with a history of neurogenic bladder, managed by straight catheterization (straight cath), presenting with decreased urine output, edematous and tender prepuce, and swelling of the glans?

Manipulation of the Foreskin is the Most Appropriate Next Physical Exam Finding

For a 68-year-old male with neurogenic bladder managed by straight catheterization who presents with decreased urine output, edematous and tender prepuce, and swelling of the glans, manipulation of the foreskin is the most appropriate next physical exam finding to evaluate for paraphimosis.

Rationale for Foreskin Manipulation

The clinical presentation strongly suggests paraphimosis, which is a urologic emergency occurring in uncircumcised males when the foreskin becomes trapped behind the corona, forming a constricting band of tissue 1. This condition:

• Often occurs iatrogenically after penile manipulation (such as straight catheterization)
• Presents with edema and swelling of the prepuce and glans
• Can lead to decreased urine output due to urethral compression
• Requires immediate assessment and intervention

Diagnostic Algorithm

1. Inspect the penis - Already completed, showing edematous prepuce and swollen glans
2. Manipulate the foreskin - Next critical step to:
   • Confirm diagnosis of paraphimosis
   • Assess reducibility of the foreskin
   • Evaluate the degree of constriction
   • Determine if immediate intervention is needed

Why Other Options Are Less Appropriate

• Elevation of the scrotum: Not immediately relevant as the primary issue appears to be at the penile level rather than scrotal pathology

• Testicular illumination: Used to diagnose hydrocele or testicular masses, which are not suggested by the current presentation

• Palpation of the CVA (costovertebral angle): While kidney pathology can cause decreased urine output, the penile findings strongly suggest a local cause

• Palpation of the prostate: While relevant in neurogenic bladder patients, the acute presentation with penile edema suggests a more urgent penile pathology requiring immediate attention

Management Considerations in Neurogenic Bladder Patients

Patients with neurogenic bladder managed by straight catheterization are at increased risk for urethral complications 2, 3. The American Urological Association guidelines note that urethral stricture can cause difficulty with intermittent self-catheterization in neurogenic bladder patients 2.

In this case:

• The decreased urine output likely results from urethral obstruction due to paraphimosis
• Manipulation of the foreskin is essential to determine if urgent reduction is needed
• If paraphimosis is confirmed, treatment options include reduction of edema followed by mechanical compression, pharmacologic therapy, puncture technique, or dorsal slit 1

Important Caveats

• Attempting urinary catheterization before assessing and potentially treating the paraphimosis could worsen the condition
• Patients with neurogenic bladder have high rates of urinary tract complications and hospitalizations 4
• Prevention of paraphimosis in patients requiring intermittent catheterization includes proper education on returning the prepuce to cover the glans following penile manipulation 1

Manipulation of the foreskin is therefore the most appropriate next step in the physical examination to diagnose paraphimosis and guide immediate management decisions in this patient with neurogenic bladder presenting with decreased urine output and penile edema.