Phallopexy for Treatment of

Paraphimosis in the Dog

Three dogs with recurrent paraphimosis were surgically treated by creation of a phallopexy
between the dorsal surface of the penis and the corresponding surface of the prepuce. Follow-up
evaluation was performed 4 to 31 months postoperatively. Treatment was successful in each
case, and no dog had any adverse sequelae. J Am Anim Hosp Assoc 2001;37:397400.

Mary E. Somerville, DVM Introduction

Paraphimosis is the inability to retract the penis into the preputial
Scott M. Anderson, DVM, sheath.1 It is most commonly seen in young, intact male dogs and may
Diplomate ACVS,
occur due to trauma,1,2 masturbation,1,2 sexual activity or the presence
Diplomate ACVECC,
Diplomate ABVP of a female in estrus,3 constriction of preputial hair around the penis,2
pseudohermaphroditism,4 neurological deficits in dogs with posterior
paresis,1 or as an idiopathic event.3 The persistently exteriorized portion
of the penis becomes edematous, inflamed, and traumatized, thus exac-
erbating the paraphimosis.
C Several surgical techniques have been described for treatment of
paraphimosis. In cases where nonsurgical management has failed, cas-
tration,1 enlargement of the preputial orifice, narrowing of the preputial
orifice,1 preputial lengthening (preputioplasty),5 and preputial muscle
myorrhaphy6 have been reported to alleviate the paraphimosis. However,
none of these techniques entirely eliminate the risk of erection, balanitis,
ongoing self-trauma, and recurrence of paraphimosis. Penile amputation
and concurrent scrotal urethrostomy obviously prevents recurrence,2,5,7
but this procedure requires greater surgical time and tissue trauma, and
clients may be unenthusiastic about this alternative.
Phallopexy, creating a permanent adhesion between the dorsal sur-
face of the penile shaft and the adjacent surface of the preputial mucosa,
offers a rapid and effective surgical means to alleviate paraphimosis. By
preventing complete exteriorization of the glans, this procedure elimi-
nates the risk of recurrent paraphimosis and subsequent penile trauma.
In this paper, the authors describe the results of a prospective study of
clinical cases, conducted with the objective of determining the effective-
ness of phallopexy as a treatment for paraphimosis in the dog.

Materials and Methods

From the Department of Surgery,
California Animal Hospital,
1736-A South Sepulveda Boulevard,
Los Angeles, California 90025.
JOURNAL of the American Animal Hospital Association
Between January 1995 and December l997, three dogs [see Table] were
referred for surgical correction of paraphimosis. No dog had a history of
any behavior which could incite paraphimosis. Physical examination,
including a complete neurological evaluation, was performed on each
dog. Physical examination confirmed the presence of paraphimosis in
each case; no other urogenital abnormalities or phimosis were noted.
Each dog had failed to respond to conservative management, consisting
of topical application of lubricants and anti-inflammatory medications
397
398 JOURNAL of the American Animal Hospital Association July/August 2001, Vol. 37

Table

Signalment, Etiology, and Duration of Paraphimosis in Three Dogs

Case Age Duration

No. (yrs) Breed Etiology (wks)

1 6 Labrador retriever Pelvic trauma 8

2 Unknown Mixed terrier Idiopathic >12

3 1 Chihuahua Idiopathic 3

and manual reduction of the penis into the preputial sheath. exteriorized. If it could, then the suture was removed, the
Surgery was performed on each dog. preputial epithelial excision site was extended caudally, and
A 2- to 3-cm skin incision was made at the junction of a new suture was placed at that level. Retraction of the pre-
the right side of the prepuce and the body wall, beginning puce was repeated, as described above, to confirm that the
2.5 cm caudal to the preputial orifice and extending cau- penile shaft was restrained sufficiently caudally to prevent
dally. The underlying subcutaneous tissues and parietal complete exteriorization of the glans. Six to eight sutures of
layer of the prepuce were incised, creating a full-thickness 3-0 polydioxanone were placed in a simple interrupted pat-
incision into the preputial lumen [Figure 1]. tern to appose the corresponding edges of the incisions on
The penile shaft was retracted laterally. In each case, an the penile shaft and preputial mucosa [Figure 4].
area of preputial epithelium 5 mm wide and 1.5 cm long
was excised along the dorsal midline of the preputial
lumen, starting approximately 3 cm caudal to the preputial
orifice [Figure 2].
The penile shaft was exteriorized through the preputial
orifice and flexed ventrocaudally to expose its dorsal sur-
face. An area of epithelium 5 mm wide and 1.5 cm in length
was excised from the dorsal midline of the midportion of
the glans [Figure 3], beginning 2 cm caudal to the penile
tip, with care taken to avoid any deeper incision into the
underlying pars longa glandis. The penis was then replaced
within the prepuce.
A simple interrupted 3-0 polydioxanone suturea was
placed to appose the cranial end of the preputial and penile
incisions. The preputial sheath and orifice were then
retracted caudally to determine if the entire glans could be Figure 2Phallopexy surgical technique: site of preputial
epithelial excision.

Figure 1Phallopexy surgical technique: incision into Figure 3Phallopexy surgical technique: site of penile
preputial lumen. epithelial excision.
July/August 2001, Vol. 37
Figure 4Phallopexy surgical technique: appearance of
the completed phallopexy.
The preputial, subcutaneous, and skin layers were closed
in standard fashion. Intact dogs were castrated at the time
of phallopexy. Follow-up examination was performed 2
weeks postoperatively, at the time of suture removal. Long-
term follow-up (31, 4, and 10 months postoperatively in
case nos. 1, 2, and 3, respectively) was obtained by physical
examination in two cases and by telephone interview of the
client in the remaining case.
Results
For each dog, surgery was performed as described above. In
each case, the surgical time was <20 minutes. Two dogs
were castrated at the time of the initial surgery; the third
had been previously castrated for reasons unrelated to para-
phimosis. All dogs were discharged 1 day after surgery. No
complications were observed during healing in any case.
Although the penile shaft could not be exteriorized for fol-
low-up physical examination, the visible portions of the
penis and preputial epithelium had no visible evidence of
balanoposthitis or trauma [Figure 5].
The owners of each dog reported that, after the initial 2-
week healing period, no dog showed persistent excessive lick-
ing, attempts at self-trauma, or signs of discomfort. No owner
Figure 5Appearance of phallopexy site, 31 months post-
operatively.
Phallopexy 399
reported any abnormal degree of preputial discharge, odor,
licking or self-trauma, or any other adverse clinical signs. All
owners were satisfied with the results of the procedure.
Discussion
Paraphimosis is a condition frequently seen in small animal
practice. Most dogs respond to conservative management
(e.g., topical lubricants, topical anti-inflammatory medica-
tions, manual replacement of the penis within the preputial
sheath, and placement of a purse-string suture at the preputial
orifice).2,3,7 In young, intact male dogs, neutering is recom-
mended to minimize sexual excitement and recurrence of
paraphimosis. Despite this, some cases fail to respond to con-
servative management, and surgery is necessary.
Several techniques have been previously described in the
veterinary literature for surgical relief of paraphimosis.
Preputial orifice enlargement (i.e., preputiotomy) can alle-
viate the constriction and strangulation of the penis, and
this procedure is indicated if a true phimosis exists.1
Preputioplasty (i.e., preputial lengthening or preputial
reconstruction)5 or shortening of the preputial muscles (i.e.,
protractor preputii myorrhaphy)6 can also be effective.
However, none of these techniques absolutely preclude the
possibility of recurrent erection, self-trauma, and balanitis
due to desiccation of the exposed penis.2 Therefore, recur-
rent paraphimosis is still possible with these techniques. In
addition, postoperative fibrosis may occur after preputial
orifice enlargement, resulting in an insufficient orifice.2
Narrowing of the preputial orifice has been recom-
mended in cases where the preputial length is adequate but
the orifice is too large.1 This procedure creates a preputial
stenosis to avert paraphimosis; urine retention and bal-
anoposthitis are possible sequelae if the orifice is too
small,2 while recurrent paraphimosis may occur if the ori-
fice is left too large. Lastly, amputation of the penis (i.e.,
phallectomy) is effective,2,5,7 but in the authors experience,
most clients prefer a less drastic option.
Phallopexy avoids many of the potential complications
of the previously described procedures. Since the phal-
lopexy physically prevents protrusion of the penis during
erection, the penis cannot protrude far enough through the
preputial orifice to permit recurrence of paraphimosis.
Since the preputial orifice itself is not altered by this proce-
dure, the complications relating to excessive width or nar-
rowing of the orifice (i.e., recurrent paraphimosis or
stenosis resulting in urine retention and secondary bal-
anoposthitis) do not occur. Client acceptance of this proce-
dure was excellent, with all clients expressing satisfaction
at the outcome.
In horses, conservative management of paraphimosis
with a purse-string suture,8 circumcision,8,9 prepu-
tiotomy,8,10,11 phallectomy,8,9,11 and the Bolz technique of
penis retraction (i.e., phallopexy) has been reported.9,11
With phallopexy, if the penis is sutured too far caudally
within the prepuce, urine retention in the prepuce and urine
scald can occur in the equine;11 these complications were
not observed in the dogs of this study.
400 JOURNAL of the American Animal Hospital Association
Since the preputial tissues are loose and somewhat
mobile, the exact location of the incision in the preputial
mucosa requires some judgment by the surgeon. Creating
the phallopexy too far cranially within the prepuce could
allow exteriorization of the entire glans. However, the
authors were concerned that if the phallopexy was created
excessively caudally, this could lead to urine pooling and
balanoposthitis. Although there are no defined criteria for
positioning of the penis within the prepuce, retaining the
penile tip 5 to 10 mm inside the preputial orifice (with the
prepuce and penis in a neutral, nonerect state) has been pro-
posed.12 This guideline appears to be satisfactory for the
phallopexy procedure, since postoperatively only a minimal
length of the glans (i.e., an insufficient length to permit
recurrence of paraphimosis) could be exteriorized, even
with maximal retraction of the prepuce.
Although none of the patients in this study had any
behavioral component contributing to the development of
paraphimosis, the procedure should still be successful in
such patients. As described above, the glans could not be
exteriorized sufficiently to permit paraphimosis postopera-
tively, so recurrence should not be possible regardless of
patient behavior. In patients exhibiting behavior-induced
paraphimosis, behavioral modification should be attempted
prior to surgery.
The phallopexy could also have been created on the ven-
tral, rather than the dorsal, surface of the penile shaft. How-
ever, the preputial tissues ventral to the penis are looser and
more mobile than those dorsal to the penis. The authors
were therefore concerned that a ventral phallopexy might
not reliably retain the penis entirely within the prepuce. In
addition, a ventral phallopexy would create a risk of iatro-
genic urethral trauma.
Conclusion
Phallopexy was a successful surgical treatment for paraphi-
mosis in three dogs. The technique was rapid (<20 minutes
surgical time) and effective in each case. In the dogs of this
study, no recurrence, complications, or adverse sequelae
were observed. In cases where conservative management
has failed, phallopexy should be considered as one of the
surgical options.
July/August 2001, Vol. 37
a PDS II; Ethicon, Inc., Somerville, NJ
References
11. Fossum TW, Hedlund CS, Hulse DA, et al., eds. Surgery of the repro-
ductive and genital systems. In: Small animal surgery. St. Louis:
Mosby, 1997:569-572.
12. Soderbergh SF. Diseases of the penis and prepuce. In: Birchard SJ,
Sherding RG, eds. Saunders manual of small animal practice.
Philadelphia: WB Saunders, 1994:886-891.
13. Elkins AD. Canine paraphimosis of unknown etiology: a case report.
Vet Med 1984;79:638-639.
14. Lee J. Paraphimosis in a psuedohermaphrodite dog. Vet Med
1976;71:1076-1077.
15. Hobson HP. Surgical procedures of the penis. In: Bojrab MJ, ed. Cur-
rent techniques in small animal surgery. Philadelphia: Lea and
Febinger, 1990:423-430.
16. Chaffee VW, Knecht CD. Canine paraphimosis: sequel to inefficient
preputial muscles. Vet Med 1975;70:1418-1420.
17. Ndiritu CG. Lesions of the canine penis and prepuce. Mod Vet Pract
1979;60:712-715.
18. Boero MJ. A simple technique for conservative therapy of acute trau-
matic paraphimosis in the horse. Proceed, 36th Ann Conv Am Assoc
Equine Pract 1991:625-628.
19. Suann CJ, Horney FD. Surgical treatment of paraphimosis in a pony.
Can Vet J 1983;11:341-342.
10. Clem MF, DeBowes RM. Paraphimosis in horsespart II. Comp
Cont Ed Pract Vet 1989;11:184-187.
11. Schumacher J. The penis and prepuce. In: Auer JA, Stick JA, eds.
Equine surgery. Philadelphia: WB Saunders, 1999:546-547.
12. Proescholdt TA, DeYoung DW, Evans LE. Preputial reconstruction for
phimosis and infantile penis. J Am Anim Hosp Assoc 1977;13:725-727.