Paraphimosis Reduction

Paraphimosis (foreskin trapped proximal to coronal sulcus) is a urologic emergency, and reduction is always indicated when the condition is present

CONTRAINDICATIONS

None

RISKS/CONSENT ISSUES

Pain (local anesthesia will be given)

Local bleeding

Infection (sterile technique will be used)

Scarring at site of incision/dilation (though definitive treatment will likely include circumcision, removing the scarred tissue)

Damage to glans penis and urethral meatus

General Basic Steps

If manual reduction fails to restore normal anatomy, proceed to assisted manual reduction; if that fails as well, proceed to phimotic ring incision. A urologist should be contacted if manual reduction fails, and will need to be actively involved if emergency circumcision is required because of reduction failure.

Patient preparation

Anesthesia

Manual reduction

Assisted manual reduction (FIGURE 37.1)

Phimotic ring incision

TECHNIQUE

Patient Preparation

Position: Supine with legs slightly abducted

Consider light procedural sedation as well

Anesthesia

A topical anesthetic may be all that is necessary

Apply viscous lidocaine or eutectic mixture of local anesthetics (EMLA) to the inner layer of the foreskin

Also serves as a lubricant

If further anesthesia is necessary, progress from local, to dorsal nerve block, and, finally, to penile ring block

See chapter 36 for details and pictures of penile anesthesia

When providing local anesthesia with lidocaine (without epinephrine), be sure to infiltrate into the constricting ring as well

Manual Reduction

Using your hands or an elastic bandage, manually compress the glans and foreskin for 3 to 5 minutes to remove as much edema as possible

Place both thumbs on the glans penis and apply slow, steady pressure while using your other fingers just proximal to the phimotic ring to pull the foreskin over the glans penis (FIGURE 37.2)

Successful reduction occurs when the phimotic foreskin is reduced back to normal position over the glans

If unsuccessful, proceed to assisted manual reduction methods

FIGURE 37.1 Technique for compression of glans to reduce edema and allow for manual reduction of paraphimosis. (From Green M, Strange GR. Paraphimosis reduction. In: Henretig FM, King C, eds. Textbook of Pediatric Emergency Procedures. Philadelphia, PA: Williams & Wilkins; 1997:1008, with permission.)

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