What is the management and treatment of paraphimosis?

Management and Treatment of Paraphimosis

Paraphimosis is a urologic emergency requiring immediate manual reduction, and if this fails, surgical intervention with a dorsal slit procedure is necessary to prevent glans necrosis. 1, 2, 3

Initial Assessment and Immediate Management

Recognition of Emergency Status

• Paraphimosis occurs when the retracted foreskin becomes trapped behind the corona, forming a constricting band that acts like a tourniquet, causing vascular occlusion and potential glans necrosis if not promptly treated 3, 4
• This is classified as an emergency surgical condition in pediatric urology that should not be postponed, even during pandemic conditions 1

Pain Control

• Administer penile block local anesthesia before attempting reduction to facilitate the procedure and improve patient comfort 5

Treatment Algorithm

Step 1: Manual Reduction (First-Line)

• Compress the edematous glans manually to force fluid proximally, then attempt to pull the constricting band of foreskin forward over the glans 3, 4
• Apply sustained manual compression for several minutes to reduce edema before attempting repositioning 4, 5

Step 2: Osmotic and Puncture Methods (If Manual Reduction Fails)

• Apply ice packs or compressive elastic bandages to reduce distal edema 6
• Use an 18-gauge hypodermic needle to puncture the edematous foreskin at multiple sites, followed by gentle manual compression to express fluid 6
• This puncture technique results in rapid diminution of swelling, permitting easier manual reduction 6

Step 3: Surgical Intervention (If Conservative Measures Fail)

• Perform a dorsal slit procedure to relieve the constricting ring when manual reduction techniques fail or in cases with significant swelling or prolonged duration 2, 3
• The dorsal slit should be followed by elective circumcision after resolution of inflammation 2, 3

Prevention of Recurrence

Immediate Post-Reduction Care

• Always return the prepuce to cover the glans following any penile manipulation (catheterization, examination, cleaning) to prevent iatrogenic paraphimosis 4
• This is the most critical preventive measure, as paraphimosis is often iatrogenically induced 4

Long-Term Management

• For patients with recurrent episodes or underlying phimosis, apply betamethasone 0.05% ointment twice daily for 4-6 weeks to the tight preputial ring 2, 7
• Consider elective circumcision for definitive management of recurrent paraphimosis 2

Special Populations and Considerations

Patients with Lichen Sclerosus

• Patients with underlying lichen sclerosus have a higher likelihood of requiring surgical intervention and may be less responsive to conservative measures 2, 7
• If circumcision is performed, continue topical corticosteroids postoperatively to prevent Koebnerization and further scarring around the coronal sulcus 1

Young Adults

• Consider penile piercing as a possible precipitating cause of paraphimosis in this age group 2

Elderly Men

• Be particularly vigilant about complications, as delayed treatment can lead to glans necrosis requiring more extensive intervention 3

Common Pitfalls to Avoid

• Never leave the foreskin retracted after catheterization, examination, or cleaning procedures 4
• Do not delay intervention—paraphimosis requires prompt treatment to prevent ischemic injury 3, 4
• If performing dorsal slit, plan for subsequent circumcision rather than leaving the patient with a partially incised foreskin 3, 6
• Always send excised foreskin tissue for histopathological examination to exclude lichen sclerosus or penile intraepithelial neoplasia 7, 8