Treatment of Paraphimosis
Paraphimosis is a urologic emergency requiring immediate manual reduction through compression of the edematous glans followed by repositioning of the foreskin, with surgical intervention reserved only for cases where manual reduction fails. 1, 2
Immediate Management Algorithm
First-Line: Manual Reduction
- Apply firm, sustained compression to the edematous glans for 5-10 minutes to reduce swelling, then manually pull the prepuce forward over the glans while simultaneously pushing the glans backward through the constricting ring. 3, 2
- Ice packs or compressive elastic bandages can be applied prior to manual reduction to decrease edema 4
- This technique is successful in the majority of cases and can be performed in an outpatient or emergency department setting 5
Second-Line: Puncture Technique
- If manual compression alone fails due to severe edema, use an 18-gauge hypodermic needle to puncture the edematous foreskin at multiple sites, followed by gentle manual compression 4
- This rapidly diminishes swelling and permits easier manual reduction of the prepuce 4
- This technique avoids the need for immediate surgical intervention 4
Third-Line: Surgical Intervention
- When manual reduction techniques fail or in cases with significant swelling or prolonged duration, perform a dorsal slit procedure to relieve the constricting ring. 1, 3
- The dorsal slit is typically followed by elective circumcision after inflammation resolves 1, 6
- Irreducible paraphimosis treated surgically prevents potential necrosis of the glans and urinary obstruction 3, 4
Prevention of Recurrence
Immediate Prevention
- Always return the prepuce to cover the glans following any penile manipulation, catheterization, or examination—this is the key preventive measure as paraphimosis is often iatrogenically induced. 2
Long-Term Management
- For patients with recurrent episodes or underlying phimosis, apply betamethasone 0.05% ointment to the tight preputial ring twice daily for 4-6 weeks 1
- Consider elective circumcision for definitive management of recurrent paraphimosis, as this eliminates the anatomical substrate for future episodes. 1, 6
Critical Pitfalls to Avoid
- Never delay treatment—paraphimosis can lead to vascular compromise and necrosis of the glans if the constricting ring is not relieved promptly. 3, 2
- Do not overlook iatrogenic causes: failure to replace the foreskin after catheterization or examination is the most common preventable cause 2
- In elderly men or those with underlying lichen sclerosus, there is a higher likelihood of requiring surgical intervention due to inelastic, scarred tissue 1
- Paraphimosis is classified as a pediatric urologic emergency requiring immediate intervention, not observation 7
Special Populations
Pediatric Patients
- Paraphimosis occurs predominantly in infants and toddlers with partial or full phimosis as the underlying condition 5
- The same reduction techniques apply, though children may require procedural sedation for adequate pain control during manual reduction 4