What is the most likely diagnosis for an uncircumcised male with penile pain, swelling, and redness, and a constrictive band of tissue behind the glans?

Paraphimosis

The most likely diagnosis is paraphimosis—a urologic emergency where the retracted foreskin becomes trapped behind the glans penis, forming a constricting band that causes venous and lymphatic congestion, leading to progressive swelling, pain, and risk of tissue necrosis if not promptly reduced. 1, 2

Clinical Presentation

The key diagnostic features in this patient include:

• Constrictive band of tissue behind the glans - This is the pathognomonic finding of paraphimosis, where the retracted foreskin creates a tight ring that cannot be reduced to its normal position 3, 2
• Marked swelling of the glans and prepuce - The constricting ring causes pressure greater than lymphatic pressure, resulting in progressive edema distal to the incarcerated foreskin 3
• Pain - Results from tissue swelling and progressive vascular compromise 3
• Recent sexual activity - Often iatrogenically induced when the foreskin is retracted and not returned to cover the glans following penile manipulation 2

Why This is an Emergency

• Paraphimosis is classified as a urologic emergency requiring immediate intervention to prevent glans necrosis 1, 4
• The tight constricting ring acts like a tourniquet, causing vascular occlusion that can lead to tissue necrosis if not dealt with quickly 4
• This is considered an emergency surgical condition that should not be postponed 1

Immediate Management Algorithm

Step 1: Attempt manual reduction immediately 1, 2

• Compress the edematous fluid out of the glans by applying firm, steady pressure for several minutes
• Once edema is reduced, attempt to reposition the foreskin over the glans 4, 2

Step 2: If manual reduction fails, proceed to surgical intervention 1

• Perform a dorsal slit procedure to relieve the constriction 1, 4
• This is followed by elective circumcision after resolution of inflammation 1

Distinguishing from Phimosis

This is not phimosis, which is the inability to retract the foreskin over the glans 5, 6. In contrast, paraphimosis occurs when the foreskin has been retracted and cannot be returned to its normal position 6, 2. The presence of a constrictive band behind the glans with the foreskin trapped in a retracted position is diagnostic of paraphimosis, not phimosis.

Critical Pitfall to Avoid

• The foreskin must always be returned to cover the glans following any penile manipulation (catheterization, examination, sexual activity) to prevent paraphimosis 2
• Early intervention is essential—the longer paraphimosis persists, the more difficult reduction becomes due to progressive swelling 3, 2