What is the best course of action for a patient with a retracted penis and inability to retract the foreskin to visualize the meatus for catheter insertion?

Management of Retracted Penis with Inability to Visualize Meatus for Catheterization

For a patient with a retracted penis and inability to retract the foreskin to visualize the meatus for catheter insertion, the clinician should attempt gentle manual retraction of the foreskin first, and if unsuccessful, perform a dorsal slit procedure to gain access to the urethral meatus.

Initial Assessment and Management

• Assess for signs of paraphimosis (inability to replace a retracted foreskin), which can cause penile engorgement and priapism requiring emergency treatment 1
• Evaluate for phimosis (inability to retract the prepuce over the glans), which may be physiologic or pathologic 2
• Determine if there is evidence of balanitis xerotica obliterans (an infiltrative skin condition causing pathological phimosis), which is considered an absolute indication for surgical intervention 2

Step-by-Step Management Approach

First-Line Approach

1. Attempt gentle manual retraction

   • Apply gentle traction to the penis to elongate the shaft and improve visualization 1
   • Use adequate lubrication to reduce friction and facilitate retraction 1
   • For paraphimosis, attempt manual reduction after a penile nerve block 1

2. If manual reduction is unsuccessful:

   • Consider injection of hyaluronidase to allow edematous fluid to dissipate in cases of paraphimosis 1
   • Select an appropriately sized catheter (typically 14-16 Fr for adults) to minimize trauma while maintaining adequate drainage 3

When Initial Attempts Fail

1. Perform a dorsal slit procedure

   • This is indicated when manipulation is not effective for paraphimosis 2
   • The procedure provides immediate access to the urethral meatus for catheterization 2
   • This is usually followed by definitive treatment (often circumcision) at a later date 2

2. Establish prompt urinary drainage

   • If unable to place a urethral catheter, consider suprapubic tube placement 1
   • Avoid repeated attempts at urethral catheterization as this may increase injury extent 1

Special Considerations

• For patients with suspected urethral injury:

  • Perform retrograde urethrography before attempting catheterization if blood is present at the meatus 1
  • Blind catheter passage should be avoided unless exceptional circumstances require emergent drainage 1

• For patients with phimosis:

  • Consider topical corticosteroid therapy as a non-surgical alternative for future management 4, 5
  • Topical corticosteroids applied twice daily for 4-8 weeks achieve complete retractability in approximately 75% of patients 4, 6

Long-Term Management

• After successful catheterization, consider definitive treatment of the underlying condition:
  • For phimosis: Topical corticosteroid therapy has shown success rates of 67-95% in children and may be an effective alternative to circumcision 5, 7
  • For recurrent issues: Consider surgical options including circumcision or preputioplasty 2
  • For patients with buried penis: Note that these patients respond poorly to topical steroid treatment and may require surgical intervention 7

Cautions and Pitfalls

• Avoid forceful retraction which can cause trauma, pain, and worsen the condition 2
• Do not attempt blind catheterization when urethral injury is suspected, as this may worsen the injury 1
• Be aware that patients with severe balanitis xerotica obliterans or buried penis with penoscrotal webbing typically require surgical management rather than conservative approaches 5