Management of Paraphimosis
Paraphimosis requires immediate manual reduction after penile nerve block anesthesia, using compression techniques to reduce edema and reposition the foreskin over the glans; if manual reduction fails after adequate attempts, perform a dorsal slit procedure followed by circumcision. 1, 2, 3
Initial Assessment and Diagnosis
Paraphimosis occurs when the retracted foreskin becomes trapped proximal to the glans, creating a constricting ring that causes venous occlusion and progressive edema—functioning like a tourniquet on the distal penis. 1 The condition presents with:
- Painful swelling of the glans and distal penile shaft 1
- Visible constricting band of foreskin proximal to the glans 3
- Risk of glans necrosis if untreated 1, 4
- Potential urinary obstruction in severe cases 4
This is a urologic emergency requiring prompt intervention to prevent tissue necrosis. 1, 4
Step-by-Step Management Algorithm
First-Line: Manual Reduction with Compression
Perform penile nerve block anesthesia before attempting reduction to ensure adequate pain control and patient cooperation. 2 The standard manual reduction technique involves:
- Apply firm, sustained compression to the edematous glans for 5-10 minutes to express edema fluid proximally through the constricting ring 1, 2
- Simultaneously apply pressure to push the glans distally while pulling the foreskin proximally over the glans 1
- Success rate with simple manual compression is high when performed early 2
Second-Line: Osmotic and Puncture Methods
If initial manual reduction fails, escalate to adjunctive techniques:
- Puncture technique: Use an 18-gauge needle to puncture the edematous foreskin at multiple sites, followed by gentle manual compression to express fluid and facilitate reduction 4
- This technique allows rapid diminution of swelling and permits easier manual reduction 4
- Osmotic methods: Apply granulated sugar or hypertonic solutions to reduce edema, though evidence is limited 2
- Compressive elastic bandages: Wrap the glans to mechanically reduce edema before attempting reduction 4, 5
Third-Line: Surgical Intervention
When manual reduction techniques fail despite adequate attempts, perform a dorsal slit procedure. 3 This involves:
- Making a longitudinal incision through the constricting band on the dorsal surface of the foreskin 3
- This immediately relieves the constriction and allows repositioning 3
- Circumcision should follow the dorsal slit, either immediately or in a delayed fashion 1, 3
Critical Pitfalls to Avoid
- Never delay treatment waiting for spontaneous resolution—the constricting ring will not resolve on its own and tissue necrosis risk increases with time 1, 4
- Never attempt reduction without adequate anesthesia—pain prevents patient cooperation and adequate compression force 2
- Never confuse paraphimosis with priapism—these are distinct conditions requiring completely different management approaches 6
- In uncircumcised men with genital piercings, paraphimosis can occur as a complication and requires the same reduction approach, though jewelry may need removal first 6
Post-Reduction Management
After successful reduction:
- Educate patients and caregivers to always return the foreskin to its normal position after retraction for cleaning or catheterization 3
- Consider elective circumcision consultation to prevent recurrence, particularly in elderly or institutionalized patients at risk for repeated episodes 1
- If dorsal slit was required, definitive circumcision prevents future episodes 3