Paraphimosis: emergency manual reduction
Paraphimosis is a pulled-back foreskin that has become stuck behind the glans (the rounded head of the penis), squeezing it and blocking the drainage of blood and tissue fluid.
Remember
Swelling is what traps the foreskin, so shrink it first by compressing the glans, then bring the foreskin forward by manual reduction, and treat it as an emergency.
Memory aid
A ring stuck on a swollen finger
Think of the trapped foreskin as the ring: the swelling comes first and makes the grip deeper, and the blood supply fails only later.
In paraphimosis, a foreskin that has been pulled back stays behind the glans (the rounded head of the penis) and cannot be returned. It can follow intercourse, or a urinary catheter being inserted if the foreskin is not put back afterwards. A cancerous mass on the penis can also stop the foreskin being returned.
The trapped foreskin works like a tourniquet (a tight band that squeezes off flow). Blood and lymph (tissue fluid carried away by the lymphatic vessels) cannot drain from the glans, so it swells with oedema (excess fluid in the tissue), and the swelling makes the band tighter still. The swelling comes first and the blood supply is threatened later, but the glans can quickly lose its blood supply. Left untreated, the tissue can die. That is why paraphimosis is an emergency.
Because swelling is what traps the foreskin, the first move is to take the swelling down. The doctor compresses (squeezes firmly) the swollen glans to push the fluid out, then presses the foreskin forward over the glans, using counter pressure from the thumbs and fingers. This is manual reduction.
In more established cases, a penile block (local anaesthetic injected around the base of the penis) and drainage of the swelling may be needed. A dorsal slit, which cuts along the top of the foreskin to release the tight band, is kept for failed reduction or very neglected cases and is usually done under local anaesthetic. Circumcision, the surgical removal of the foreskin, suits severe or recurrent paraphimosis and comes later, usually once the swelling has settled.
Do not confuse it with phimosis, where the foreskin is too tight to pull back. Topical steroids are tried first for phimosis, but a steroid cream does not promptly release a foreskin already trapped behind an acutely swollen glans.
Key facts
- Cause
- intercourse, or a urinary catheter if the foreskin is not put back; a cancerous mass on the penis can also stop the foreskin being reduced.
- Mechanism
- the tight foreskin blocks the drainage of blood and tissue fluid from the glans first, so it swells, and the blood supply is threatened later.
- First step
- compress the swollen glans, then perform manual reduction with counter pressure from the thumbs and fingers.
- Further options
- in more established cases a penile block and drainage of the swelling may be needed, and a dorsal slit (usually under local anaesthetic) is kept for failed reduction or very neglected cases.
- Circumcision
- a later step to prevent paraphimosis returning, usually once the swelling has settled, and not the first step.
- Prevention
- after a urinary catheter, replace the foreskin over the glans.
Exam traps
- Circumcision is not the first step for a foreskin trapped behind the glans. It removes the foreskin permanently and is used for severe paraphimosis or to prevent recurrence, usually once the swelling has settled, and simple manual reduction comes before it.
- Topical steroid cream belongs to phimosis (a foreskin too tight to pull back), not to a foreskin that is already pulled back and trapped: a cream does not promptly release a foreskin trapped behind an acutely swollen glans.
- A red, swollen glans can look infected, as in balanitis (inflammation of the glans), but antibiotics and waiting leave a tight band of foreskin in place and risk necrosis (tissue death) of the glans.
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