Paraphimosis Reduction Procedures

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Paraphimosis is the inability to reduce a swollen and proximally positioned foreskin over the glans penis (see images below). ^{[1, 2, 3]} Paraphimosis is most often iatrogenic, occurring when medical personnel forget to reduce the foreskin after instrumentation or catheterization of the urethra. ^{[1, 4]} The foreskin does not become fully mobile before the age of 3-4 years, predisposing children younger than 3-4 years to paraphimosis when their caregivers retract the foreskin for cleaning. Patients present with a red, painful, and swollen glans penis associated with an edematous, proximally retracted foreskin that forms a circumferential constricting band. The penile shaft proximal to the constricting band typically is soft. ^[5]

The retracted foreskin initially blocks lymphatic drainage from the distal penis, progressively causing further edema of the retracted foreskin. If the foreskin remains retracted and the edema continuous, venous obstruction followed by arterial flow are expected within hours to days. ^[6]

For more information on paraphimosis and the related condition phimosis, see Medscape Reference article Phimosis and Paraphimosis.

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All patients with paraphimosis require emergent reduction.

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Nonsurgical techniques are relatively contraindicated in patients who have the following conditions:

Necrotic or ulcerated foreskin

Necrotic or ulcerated penis

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Reduction of paraphimosis is a painful procedure. The use of parenteral analgesic and sedative agents is recommended. Anesthesia with local infiltration may be used.

Various methods of penile anesthesia exist (see Technique section). For more information, see Nerve Block, Dorsal Penile.

Procedural sedation is recommended in the pediatric patient. For more information, see Procedural Sedation.

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Topical anesthetic cream (eutectic mixture of local anesthetics [EMLA]; lidocaine, adrenaline, tetracaine [LAT]; tetracaine, adrenaline, cocaine [TAC]) (For more information, see Anesthesia, Topical.) ^[7]

4 x 4 gauze

Povidone-iodine solution (eg, Betadine)

Sterile drapes

Sterile gloves

Local anesthetic solution without epinephrine (lidocaine 1%)

Syringe, 10 mL

Needles, 18- and 27-gauge (ga)

Crushed ice

Babcock clamps, 6-8

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Position the patient supine, with his legs separated.

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Obtain informed consent. Explain the procedure in detail to the parent/guardian of a pediatric patient.

Apply a liberal amount of the local anesthetic cream to the glans and foreskin.

Wait for the anesthesia to take effect.

Clean the penis of the local anesthetic cream.

Apply an antiseptic solution to the penis and foreskin (see image below).

Place sterile drapes to create a sterile field around the penis.

If adequate anesthesia has not been achieved, penile anesthesia should be performed. One of two techniques may be used for penile anesthesia. Both techniques are painful and require the administration of parenteral analgesics and/or procedural sedation and analgesia.

Inject 1-2 mL of lidocaine 1% near the right and left dorsal penile nerves (the 10- and 2-o’clock positions close to the base of the penis; see image below).

Circumferentially infiltrate lidocaine 1% around the base of the penis (see image below).

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Apply slow and steady manual compression over the glans penis and edematous foreskin, squeezing distally to proximally in order to mobilize the edema proximally (see image below).

The pressure should be applied for 5-10 minutes and can be delegated to the patient or caregiver.

After manual compression, position the thumbs on both sides of the urethral meatus and the index and middle fingers proximal to the phimotic ring (see image below).

Apply continuous force to move the phimotic ring distally over the glans (see image below).

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Half fill a surgical glove with water and ice chips, express the remaining air, and tie a knot in the wrist of the glove.

Insert the penis into the invaginated thumb of the glove.

Apply circumferential pressure for 5-10 minutes.

Attempt to manually reduce the foreskin again.

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This technique requires administration of local anesthetic.

The Babcock clamp is a noncrushing tissue clamp.

It can be safely used to reduce the paraphimotic foreskin.

All other clamps will crush the foreskin tissue.

Apply 6-8 Babcock clamps evenly spaced around the foreskin by placing one edge just proximal to the phimotic ring with the other edge just distal to the phimotic ring (see image below).

Grasp all clamps in one hand, and simultaneously apply distal traction to pull the phimotic ring over the glans.

After reduction, remove the clamps and inspect the foreskin for injuries.

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This technique requires administration of local anesthetic.

Clean the penis, apply antiseptic solution, and place drapes to create a sterile field.

Use an 18-gauge needle to create 8-12 circumferential holes, 3-5 mm deep, in the foreskin (see image below).

Wrap a piece of 4 x 4 gauze around the glans and foreskin, and apply manual compression for 5-10 minutes, allowing the foreskin to decompress by draining edematous fluid and blood.

Attempt to manually reduce the foreskin again.

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The successfully reduced foreskin should look like a normal uncircumcised penis (see image below).

The patient should feel relief of pressure and pain.

Residual swelling is expected to resolve in a few days.

Observe the patient to ensure the following:

Recovery from anesthesia

Adequate hemostasis

Ability to urinate

All patients should be referred to a urologist in 1-2 days.

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Apply slow and steady manual compression over the glans penis and edematous foreskin, squeezing distally to proximally in order to mobilize the edema proximally. This pressure should be applied for 5-10 minutes and can be delegated to the patient or caregiver.

Circumcision is the recommended definitive therapy for most patients who experience non-iatrogenic paraphimosis. ^{[8, 9]} For more information on circumcision in children and adults, see Medscape Reference Pediatrics article Circumcision and Urology article Phimosis, Adult Circumcision, and Buried Penis.

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A significant degree of pain after the procedure is uncommon. If it occurs, it can be treated with a topical anesthetic.

Swelling usually takes a few days to resolve.

A dorsal slit of the foreskin is indicated if less invasive techniques fail to achieve reduction. ^{[2, 10]}

Penile or foreskin lacerations or tears that result from the manual reduction should be sutured with an absorbable material.

Some bleeding is common following needle decompression and dorsal slit techniques. A compressive dressing may aid with hemostasis.

Prescribing antibiotics to patients with evidence of skin infection or ulcers or after any invasive procedure that involves the foreskin is recommended.

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

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

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

Paynter M. Paraphimosis. Emerg Nurse. 2006 Jul. 14(4):18-9. [Medline].

Dubin J, Davis JE. Penile emergencies. Emerg Med Clin North Am. 2011 Aug. 29(3):485-99. [Medline].

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

Dawson C, Whitfield H. ABC of Urology. Urological emergencies in general practice. BMJ. 1996 Mar 30. 312(7034):838-40. [Medline].

Cathcart P, Nuttall M, van der Meulen J, Emberton M, Kenny SE. Trends in paediatric circumcision and its complications in England between 1997 and 2003. Br J Surg. 2006 Jul. 93(7):885-90. [Medline].

Little B, White M. Treatment options for paraphimosis. Int J Clin Pract. 2005 May. 59(5):591-3. [Medline].

Mackway-Jones K, Teece S. Best evidence topic reports. Ice, pins, or sugar to reduce paraphimosis. Emerg Med J. 2004 Jan. 21(1):77-8. [Medline].

Vunda A, Lacroix LE, Schneider F, Manzano S, Gervaix A. Videos in clinical medicine. Reduction of paraphimosis in boys. N Engl J Med. 2013 Mar 28. 368(13):e16. [Medline].

Reichman EF, Simon RR. Emergency Medicine Procedures. Columbus, Ohio: McGraw Hill Medical Publishing; 2004.

Khan A, Riaz A, Rogawski KM. Reduction of paraphimosis in children: the EMLA® glove technique. Ann R Coll Surg Engl. 2014 Mar. 96 (2):168. [Medline].

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.

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.

Paraphimosis Reduction Procedures

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