Dorsal Slit of the Foreskin

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Dorsal slit of the foreskin is performed to relieve strangulation of the glans by a paraphimosis or to visualize the urethral meatus in patients with phimosis. ^{[1, 2]} Dorsal slit of the foreskin is performed to relieve strangulation of the glans by a paraphimosis or to visualize the urethral meatus in patients with phimosis. ^{[1, 2]} A retrospective study comparing elective circumcision versus dorsal slit for elective management of phimosis found no differences between the groups in terms of stenosis, postoperative pain, need for reoperation, parental appreciation of postoperative pain, or functional and esthetic satisfaction. Bleeding was more frequent in the circumcision group (1.7%; P = .03). ^[3]

Phimosis is the inability of the foreskin to retract and expose the glans. ^[4] Dorsal slit of the foreskin should only be performed on patients who are experiencing urinary retention as a result of the phimosis and in whom a urethral catheter cannot be blindly inserted. ^{[5, 6]} See image below.

Paraphimosis is the inability to replace the retracted foreskin. ^{[7, 8]} Dorsal slit of the foreskin should only be performed on patients whose paraphimosis could not be reduced with manual techniques. ^[9] See image below.

See the list below:

No absolute contraindications exist to the performance of dorsal slit of the foreskin.

Dorsal slit of the foreskin should be performed only after failure of noninvasive techniques. For detailed descriptions of manual reduction techniques for paraphimosis, please see Medscape Reference article Paraphimosis Reduction Procedures.

Pediatric patients, patients who have bleeding disorders or are taking anticoagulants, and patients who are immunocompromised or have an infected foreskin are better treated by (or after consultation with) a urologist. ^{[10, 11]}

Dorsal slit of the foreskin is a painful procedure. Consider the use of parenteral analgesia with or without procedural sedation to reduce the patient’s discomfort. ^[12]

Using a 5-mL syringe with a 27-gauge (ga) needle, raise a skin wheal of local anesthetic solution without epinephrine subcutaneously in the 12-o’clock position of the dorsal midline of the penis. Insert the needle through the skin wheal and advance it distally, injecting subcutaneously as the needle advances to the distal edge of the foreskin (see image below). This method does not provide analgesia to the ventral aspect of the penis and foreskin.

Alternatively, local anesthesia can be achieved by doing a dorsal nerve block with or without a ring block. ^[13] For more information, see Nerve Block, Dorsal Penile.

See the list below:

Povidone-iodine solution (eg, Betadine)

Lidocaine 1-2% without epinephrine

Sterile gloves

Sterile drapes

Syringe, 5 mL

Needles, 18 and 27 ga

Gauze squares, 4 x 4 inches

Straight hemostats or straight Kelly clamps

Iris scissors or No. 15 scalpel

Needle driver

Absorbable sutures, 3-0 or 4-0

Petroleum gauze

Topical antibacterial ointment

See the list below:

The patient should lie supine with his genitalia exposed.

Obtain informed consent from the patient.

Administer parenteral analgesia with or without a sedative, followed by local anesthesia of the foreskin and penis.

Apply povidone-iodine solution to the penis in circular motions from the glans and proximally to include the scrotum and the surrounding skin. Repeat the iodine application at least 2 more times and apply sterile drapes to create a sterile field.

After verifying adequate anesthesia of the foreskin, apply 2 hemostats over the foreskin and phimotic ring at the 11-o’clock and 1-o’clock positions. Make sure that the inferior jaw of the clamp is below the phimotic ring and that the superior jaw is on top of it. Be sure not to clamp the skin of the penile shaft.

Pull the 2 hemostats away from each other and have an assistant hold them. Using Iris scissors or a No. 15 scalpel, incise the foreskin at the 12-o’clock position (in between the 2 clamps). Be sure not to incise the skin of the penile shaft. See image below.

An alternative method is to crush the foreskin at the 12-o’clock position with a straight hemostat for 2-3 minutes before incising the crushed foreskin.

Remove the hemostats, cover with a dry sterile gauze pad, and let the edges ooze for a few minutes. Then, reduce the paraphimotic foreskin using a manual technique.

After verifying adequate anesthesia of the foreskin, insert the bottom jaw of a straight hemostat between the foreskin and the glans penis at the 12-o’clock position. Advance the hemostat until its tip reaches the coronal sulcus.

Gently swipe the hemostat to break any adhesions between the glans and the foreskin.

The tip of the hemostat should be easily palpated and seen tenting the foreskin at the coronal sulcus. If the possibility exists that the jaw of the hemostat is inside the urethra, pull the hemostat out and reinsert it.

After confirming correct placement of the bottom jaw of the hemostat (at the 12-o’clock position between the glans and the foreskin), close the instrument and allow it to crush the foreskin for 2-3 minutes. See image below.

Remove the hemostat and use the straight scissors to carefully cut the crushed foreskin. Cover with a dry sterile gauze pad and let the edges ooze for a few minutes. Then, reduce the phimotic foreskin using a manual technique.

Note that the foreskin opens up in a rectangular fashion. See image below.

Using an absorbable 3-0 or 4-0 suture, approximate the edges of the foreskin to the opposite edge on the same side. A gap remains in the 12-o’clock position. See image below.

An alternative is to use a simple running absorbable suture to ensure hemostasis of the incised edges. See image below.

Make sure that the foreskin is reduced to a natural position covering the glans to avoid iatrogenic paraphimosis.

Generously apply a topical antibacterial ointment over the suture line and loosely cover with petroleum gauze and sterile gauze.

Use paper tape to secure the dressing to the penile skin. Avoid circumferential dressing or taping around the penis, as this can cause ischemia and necrosis.

Some authors recommend the routine administration of prophylactic antibiotics, though this practice is not evidence-based.

The patient should be observed in the emergency department for at least 30 minutes to ensure adequate hemostasis. An urgent (1-2 d) follow-up with a urologist should be arranged for aftercare and consideration of elective circumcision. ^{[14, 15]}

See the list below:

Dorsal slit of the foreskin should be performed only after failure of noninvasive techniques.

In the setting of phimosis, ensure that the tip of the hemostat is easily palpated after insertion below the foreskin and that tenting at the coronal sulcus is observed. If the possibility exists that the jaw of the hemostat is inside the urethra, pull the hemostat out and reinsert it.

See the list below:

Injury to the urethra or glans: Use of proper technique should prevent inadvertent injury.

Skin laceration: Inadvertent lacerations to the penile shaft skin should be sutured with an absorbable suture.

Bleeding: Crushing of the foreskin with a clamp before incising it and placing stitches appropriately after the foreskin incision should decrease bleeding.

Wound infection: Daily inspection and local wound care by the patient or his caregiver should minimize rates of infection. Some authors recommend the prophylactic use of antibiotics.

Stine RJ, Avila JA, Lemons MF, Sickorez GJ. Diagnostic and therapeutic urologic procedures. Emerg Med Clin North Am. 1988 Aug. 6(3):547-78. [Medline].

Lawless MR. The foreskin. Pediatr Rev. 2006 Dec. 27(12):477-8. [Medline].

Corona C, Cañizo A, Cerda J, Fanjul M, Carrera N, Tardáguila A, et al. [Phimosis: dorsal slit or circumcision?]. Cir Pediatr. 2011 Jan. 24(1):51-4. [Medline].

McGregor TB, Pike JG, Leonard MP. Pathologic and physiologic phimosis: approach to the phimotic foreskin. Can Fam Physician. 2007 Mar. 53(3):445-8. [Medline].

Thiruchelvam N, Nayak P, Mostafid H. Emergency dorsal slit for balanitis with retention. J R Soc Med. 2004 Apr. 97(4):205-6. [Medline].

Barkin J, Rosenberg MT, Miner M. A guide to the management of urologic dilemmas for the primary care physician (PCP). Can J Urol. 2014 Jun. 21 Suppl 2:55-63. [Medline]. [Full Text].

Choe JM. Paraphimosis: current treatment options. Am Fam Physician. 2000 Dec 15. 62(12):2623-6, 2628. [Medline].

Rangarajan M, Jayakar SM. Paraphimosis revisited: is chronic paraphimosis a predominantly third world condition?. Trop Doct. 2008 Jan. 38(1):40-2. [Medline].

Williams JC, Morrison PM, Richardson JR. Paraphimosis in elderly men. Am J Emerg Med. 1995 May. 13(3):351-3. [Medline].

Borsellino A, Spagnoli A, Vallasciani S, Martini L, Ferro F. Surgical approach to concealed penis: technical refinements and outcome. Urology. 2007 Jun. 69(6):1195-8. [Medline].

Chu CC, Chen YH, Diau GY, Loh IW, Chen KC. Preputial flaps to correct buried penis. Pediatr Surg Int. 2007 Nov. 23(11):1119-21. [Medline].

Burstein B, Paquin R. Comparison of outcomes for pediatric paraphimosis reduction using topical anesthetic versus intravenous procedural sedation. Am J Emerg Med. 2017 Oct. 35 (10):1391-1395. [Medline].

Flores S, Herring AA. Ultrasound-guided dorsal penile nerve block for ED paraphimosis reduction. Am J Emerg Med. 2015 Jun. 33 (6):863.e3-5. [Medline].

Holman JR, Stuessi KA. Adult Circumcision. American Family Physician. March 15, 1999. 59(6):1514-8. [Medline]. [Full Text].

Williams JC, Morrison PM, Richardson JR. Paraphimosis in elderly men. Am J Emerg Med. 1995 May. 13(3):351-3. [Medline].

Reichman E, Simon R. Dorsal slit of the foreskin. Emergency Medicine Procedures. New York, NY: McGraw-Hill; 2004.

Roberts JR, Hedges JR. Urologic procedures. Chanmugam AS, Chudnofsky CR, Custalow CB, Dronen SC, eds. Roberts: Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, Pa: WB Saunders; 2004. 1075-6.

Gil Z Shlamovitz, MD, FACEP Associate Professor of Clinical Emergency Medicine, Keck School of Medicine of the University of Southern California; Chief Medical Information Officer, Keck Medicine of USC

Gil Z Shlamovitz, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association

Disclosure: Nothing to disclose.

Eric W Snyder, MD, MS Chief Resident, Deparment of Emergency Medicine, University of California at Los Angeles/Olive View-UCLA Medical Center

Eric W Snyder, MD, MS is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Sexual Medicine Society of North America, Tennessee Medical Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Endo, Avadel.

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center

Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

The authors and editors of Medscape Reference gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.

Dorsal Slit of the Foreskin

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