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Paraphimosis
Updated: Dec 30, 2017
Author: Nathan A Brooks, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS

Overview

Practice Essentials
Paraphimosis is a urologic emergency in which the retracted foreskin of an uncircumcised male cannot be returned to its normal
anatomic position. It is important for clinicians to recognize this condition promptly, as it can result in gangrene and amputation
of the glans penis. Prompt urologic intervention is indicated.

Background
Paraphimosis occurs when the foreskin of an uncircumcised or partially circumcised male is retracted for an extended period of
time. This in turn causes venous occlusion, edema, and eventual arterial occlusion. The foreskin is unable to be reduced easily
over the glans owing to this progressive edema. The condition represents a urologic emergency, as compromise of the arterial
flow to the glans and constriction can cause gangrene and amputation of the glans penis.

Paraphimosis differs from phimosis, a nonemergent condition in which the foreskin cannot be retracted behind the glans penis.
Paraphimosis occurs only in uncircumcised or partially circumcised males.[1, 2]

Illustration of paraphimosis. The foreskin is swollen and edematous. A constricting collar or band is present behind the glans
penis.

Paraphimosis may occur when the foreskin has been pulled back behind the head of the penis for an extended period and is
often caused by well-meaning health professionals who have retracted the foreskin to perform penile examination or urethral
instrumentation. Because paraphimosiis is almost always iatrogenically or inadvertently induced, simple education and
clarification of proper prepuce care to parents, the individuals themselves, and health care professionals may be all that is
required to prevent it.
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When paraphimosis is suspected, immediately obtain a urology consult for proper evaluation and diagnosis. Prompt attention
and treatment of this emergency should lead to a favorable outcome.

Epidemiology
Frequency

Paraphimosis is a relatively uncommon condition and is less common than phimosis.

Paraphimosis is almost always an iatrogenically or inadvertently induced condition; however, case reports have described coital
paraphimosis leading to penile necrosis,[3] as well as penile piercings leading to paraphimosis.[4] Paraphimosis occurs more
often in hospitals and nursing homes than in the private community, where the affected individual or a parent often retracts the
prepuce and then inadvertently leaves it in its retracted position. In most cases, the foreskin reduces on its own and therefore
precludes paraphimosis; however, if the slightest resistance to retraction of the prepuce is present, leaving it in this state
predisposes it to paraphimosis. As edema accumulates, the condition worsens.

A large minority of males in the United States are uncircumcised, and thus are susceptible to paraphimosis. According to the
National Hospital Discharge Survey (NHDS), circumcision rates in the US declined from an all-time high of 78-80% in the mid-
to-late 1960s to 55%-60% in 2003.The NHDS found that in 2010, 58.3% of newborn boys were circumcised. Actual rates were
presumably somewhat higher, however, as this figure does not include circumcisions performed in the community.[5]

Etiology
Paraphimosis can occur after retraction of the foreskin during detailed penile examination, cleaning of the glans penis, urethral
catheterization, or cystoscopy. For healthcare providers or patients retracting the patient’s foreskin for any intervention or
examiniation it is of vital importance to replace the foreskin to the anatomic position covering the glans.

Development of paraphimosis after catheterization is not uncommon. Before the insertion of a urethral catheter, a health
professional retracts the foreskin to sterilely prepare and drape the glans penis. The retracted foreskin may be left in that
manner for several hours to days. The failure to restore the prepuce to its original position sometimes leads to the development
of paraphimosis.

More unusual causes of paraphimosis include the following:

Self-infliction, such as piercing with a penile ring into the glans [6]
Placement of a preputial bead
Erotic dancing [7]
P lasmodium falciparum infection [8]
Contact dermatitis (eg, from the application of celandine juice to the foreskin [9] )
Haemophilus ducreyi infection (chancroid) [10]

Pathophysiology
When the foreskin becomes trapped behind the corona for a prolonged period, it forms a tight band of tissue around the penis.
This constricting ring initially impairs venous blood and lymphatic flow from the glans penis and prepuce, in turn causing edema
of the glans. As the edema worsens, arterial blood flow becomes compromised. The ensuing tissue ischemia and vascular
engorgement cause painful swelling of the glans and prepuce and may eventually lead to gangrene or autoamputation of the
distal penis.

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Presentation
Adult patients with symptomatic paraphimosis most often report penile pain. In the pediatric population, paraphimosis may
manifest as acute urinary tract obstruction and may be reported as obstructive voiding symptoms.

On examination, the glans penis is enlarged and congested with a collar of edematous foreskin. A constricting band of tissue is
noted directly behind the head of the penis. The remainder of the penile shaft is unremarkable. An indwelling urethral catheter is
often present. Simply removing the catheter may help treat paraphimosis caused by an indwelling urethral catheter. The image
below depicts mild-to-moderate paraphimosis.

Mild-to-moderate form of paraphimosis. The treatment involves manual reduction, puncture technique, or medical therapy.

If paraphimosis is left untreated for too long, necrosis of the glans penis can occur. Partial amputation of the distal penis has
been reported. The image below depicts severe paraphimosis.

Severe form of paraphimosis. The distal penis has begun the process of autoamputation.

Relevant Anatomy
The penis is divided into the following three parts:

The root of the penis lies under the pubic bone and provides stability when the penis is erect.

The body of the penis constitutes the major portion of the penis and is composed of 2 cavernosal bodies (ie, corpora
cavernosa) and a corpus spongiosum (ie, head of the penis). The male urethra traverses through the corpus spongiosum
and exits from the meatus. The cavernosal bodies produce an erection when filled with blood.

The glans is the distal expansion of the corpus spongiosum usually covered by the loose skin of the prepuce in
uncircumcised individuals. A collar of tissue immediately behind the glans penis is known as the coronal sulcus.
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The penis is innervated by the left and right dorsal nerves (main sensory nerve supply), which are branches of the pudendal
nerve.

The penis is a highly vascular organ supplied by the internal pudendal artery, which arises from the internal iliac artery and then
branches into the deep penile artery, the bulbar artery, and the urethral artery.

The deep penile artery becomes the cavernosal arteries, which supply the entire corpus cavernosum. The urethral artery
supplies the glans penis and the corpus spongiosum. The bulbar artery nourishes the bulbar urethra and the bulbospongiosus
muscle.

Management
When diagnosed early, paraphimosis can be remedied easily with simple manual reduction in combination with other
conservative measures. Patients with severe paraphimosis that proves refractory to conservative therapy will require a bedside
emergency dorsal slit procedure to save the penis. Formal circumcision can be performed in the operating room at a later date.

Pain control

Paraphimosis is a a painful condition and care should be taken to ensure patient comfort by providing adequate analgesia and
local anesthesia using a dorsal penile nerve block and circumferential penile ring block with lidocaine, bupivicaine, or a
combination of the two. Epinephrine should never be injected. In additional, topical application of lidocaine or prilocaine creams
and direct injection of anesthetic into the foreskin can be used.

Reduction

Once pain control is adequate, manual reduction by attempting to circumferentially compress the foreskin and holding for 2-10
minutes to “squeeze” the edematous fluid along the penile shaft may be attempted. After this fluid has passed proximally, the
foreskin is reduced by placing both thumbs on the glans and using the remaining fingers to pull the foreskin back over the glans
into the anatomic location. There are many variations of this technique, all using the same principle of traction on the foreskin
and countertraction on the glans.

In addition, reduction can include the use of forceps and clamps to pull the foreskin. Those instruments must be used cautiously,
however, as they can crush the skin and cause necrosis of this tissue due to devascularization. The use of a 25-gauge needle to
make several small stab incisions as an outlet for edema fluid has also been described[11] .

Adjuncts to reduction

Ice, osmotic agents such as sugar, and compression wrapping with Coban® have been used as adjuncts to manual reduction
and can be considered. Ice and osmotic agents may require 1-2 hours to take effect, however, so they should not be used when
arterial compromise is suspected.

Dorsal slit

After adequate local anesthesia (with or without sedation) or general anesthesia, the plane between the dorsal foreskin and the
corona is identified. Normally, when performing a dorsal slit, the operator then uses a hemostat to crush the foreskin at the 12
o’clock position, which is also the midline of the dorsal foreskin. This is left in place for 30-60 seconds, to provide hemostasis.
The crushed area is then sharply incised with scissors. The edges are often oversewn with an interrupted or running stitch,
using a dissolvable suture such as chromic.

However, when performing a dorsal slit for paraphimosis, one should identify the dorsal midline of the rolled preputial skin. Make
a vertical incision at the junction of the rolled foreskin (identified as the point between the mucosal, smooth skin and the
preputial thicker, dull skin). This should release the contricting tissue. Mobilize the foreskin so that it can slide over the glans and
back and then oversew the cut edges.[12]

Regardless of the method used, urologic evaluation acutely in the emergency department and then following the acute
interaction for consideration of circumcision are crucial.

Contraindications
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Do not consider circumcision in a neonate with hypospadias, a dorsal hood deformity, or a small penis. Refer the neonate to a
urologist.

Treatment

Medical Therapy
Medical therapy for paraphimosis involves reassuring the patient, reducing the preputial edema, and restoring the prepuce to its
original position and condition. Several methods of reducing the penile swelling have been described. Ice packs, penile wraps,
and manual compression mechanically disperse the penile and preputial edema, while osmotic agents, such as granulated
sugar or mannitol[13] have been reported as effective agents to reduce swelling. Hyaluronidase has been effectively used in the
pediatric population as a method of increasing fluid diffusion, thus decreasing local edema.[14] If a Foley catheter is present,
remove it temporarily until the paraphimosis has resolved.

Reduction

Prior to reduction, consider the use of local anesthesia

Dorsal penile block: Insert a short 25-gauge needle anterior to the pubic arch at the 10-o'clock position until the Buck
fascia is encountered. Insert the needle through the Buck fascia, but remain outside of the corporal bodies. Aspirate to
make sure the needle is not in a corporal body. Inject 10 mL of 1% lidocaine solution. Repeat the process at the 2-o'clock
position.

Ring block: Insert a short 25-gauge needle at the base of the penis until the Buck fascia is encountered. Remain outside
of the corporal bodies. Inject the anesthetic into the Buck fascia circumferentially around the base of the penis.

A combination of dorsal penile and ring blocks should provide adequate local anesthesia. If not, inject additional
anesthetic directly into the incision line.

Once pain control is adequate, manual reduction by attempting to circumferentially compress the foreskin and holding for 2-10
minutes to “squeeze” the edematous fluid along the penile shaft should be attempted. After this fluid has passed proximally, the
foreskin is reduced by placing both thumbs on the glans and using the remaining fingers to pull the foreskin back over the glans
into the anatomic location. There are many variations of this technique with the same principal of traction on the foreskin and
counter traction on the glans. In addition, reduction can include the use of the forceps and clamps to pull the foreskin. Caution
should be used as the use of an instrument which crushes the skin will result in necrosis of this tissue due to revascularization.
The use of a 25 gauge needle to make several small stab incisions as an outlet for edema has also been described After two or
three solid attempts, the authors resort to a dorsal slit procedure as described in Surgical therapy.

Several other methods to effectively reduce the glanular and prepucial edema prior to reduction of the foreskin have been
described in the literature. Some of these methods are described are as follows:

Wrap the penis in plastic and apply ice packs.

Use compressive elastic dressings.

Apply direct circumferential manual compression. (Application of a topical anesthetic such as 2% lidocaine gel or eutectic
mixture of local anesthetics cream [2.5% prilocaine, 2.5% lidocaine; see lidocaine/prilocaine] to the penile skin a few
minutes to an hour before penile manipulation reduces pain and helps patients, particularly children, tolerate the
procedure.[15] )

Apply granulated sugar or mannitol-soaked gauze to the surface of the edematous prepuce and cover it with a condom
or a finger of a rubber glove. The hypotonic fluid from the swollen foreskin moves down the osmotic gradient into the
hypertonic agent, which results in a reduction of the preputial edema. This treatment is based on the principle that fluid
transfer occurs via an osmotic gradient.

Using a tuberculin syringe, inject 1 mL of hyaluronidase (150 U/mL Wydase) directly into several sites of the edematous
prepuce. Hyaluronidase breaks down hyaluronic acid in connective tissue and enhances fluid diffusion between tissue
planes, decreasing preputial swelling and resulting in almost immediate resolution of the edema. (The use of
hyaluronidase in the pediatric population has been well documented.)

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Using ice and osmotic agents might take 1-2 hours to have an effect and should not be used when arterial compromise is
suspected.

Regardless of the method chosen, when the preputial swelling and edema have subsided, correct the paraphimosis by gentle
manual reduction (see image below).

This demonstrates the technique of manually reducing the paraphimotic foreskin.

To reposition the prepuce, place both thumbs on the glans penis and wrap the fingers behind the prepuce. Apply gentle steady
pressure to the prepuce with counterpressure to the glans penis as the prepuce is pulled down.

When performed properly, the constricting band of tissue should come down to completely cover the glans with the prepuce. If
the prepuce comes down but the constricting band remains behind, the paraphimosis has not been reduced properly or
sufficiently.

For more information, see Paraphimosis Reduction Procedures.

In patients who are determined to retain the appearance of an uncircumcised phallus, the authors have the patient apply
triamcinolone cream 0.1% to the affected area to possibly reduce the fibrosis of the ring. This has been described in the
treatment of phimosis and has proven efficacious in temporarily preventing recurrent phimosis, decreasing the need for
circumcision. After 6 weeks of triamcinolone application, if the prepuce can easily be retracted and reduced, the patient may
proceed as such, but the risk for recurrent phimosis and paraphimosis remains. More often than not, the authors ultimately
perform circumcision.

Surgical Therapy
The puncture technique,[16, 17] a minimally invasive procedure, and blood aspiration are common therapies used to
decompress the edematous prepuce.

To perform the puncture technique, commonly referred to as the Perth-Dundee method, an 18- or 21-gauge hypodermic needle
is used to puncture the edematous prepuce at multiple sites and to release the trapped fluid (see image below). External
drainage results in rapid resolution of edema, which is followed by manual reduction of the foreskin.

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The puncture method to relieve preputial edema resulting from paraphimosis. Using a needle, several punctures are made in
the foreskin to relieve the trapped fluid.

Alternatively, blood aspiration of the penis may be attempted after a tourniquet has been applied.

If a severely constricting band of tissue precludes all forms of conservative or minimally invasive therapy, an emergency bedside
dorsal slit procedure may be performed, followed by a delayed circumcision.

Dorsal Slit

After adequate local anesthesia with or without sedation or general anesthesia, the plane between the dorsal foreskin and the
corona is identified. Normally when performing a dorsal slit, a hemostat is then used to crush the foreskin at the 12 o’clock
position which is also the midline of the dorsal foreskin. This is left in place for hemostasis for 30-60 seconds. The crushed area
is then sharply incised with scissors. The edges are often over sewn with an interrupted or running dissolvable suture such as
chromic.

However, when performing a dorsal slit for paraphimosis, one should identify the dorsal midline of the rolled preputial skin. Make
a vertical incision at the junction of the rolled foreskin (identified as the point between the mucosal, smooth skin and the
preputial thicker, dull skin. This should release the contricting tissue. Mobilize the foreskin so that it can slide over the glans and
back and then oversew the cut edges[12] .

Regardless of the method used, urologic evaluation acutely in the emergency room setting and then following the acute
interaction for consideration of circumcision are crucial.

Preoperative Details
Obtaining properly informed consent before performing circumcision is critical. Inform patients, parents, and/or caregivers of the
potential risks of bleeding, infection, suture disruption, urethral injury, and too much or too little skin being removed. Also inform
patients that circumcision does not affect the length or girth of the penis.

Instruct patients to abstain from genital stimulation for up to 6 weeks after surgery. Inadvertent erections can strain suture lines
and cause incisions to break down.

Patients undergoing circumcision for recurrent balanitis should be free of infection before the procedure.

Anesthesia

Adequate anesthesia for emergency department management of paraphimosis is technically challenging using a landmark-
based technique of a dorsal penile block (DPB). The landmark-based DPB is not standardized and options include “10 o'clock
and 2 o'clock” infrapubic injections with or without ventral infiltration or a ring block. Given the inherent technical imprecision,
large dosage of a local anesthetic (up to 50 mL) can be required to achieve an adequate block. Successful use of an ultrasound-
guided approach has been reported wherevy the dorsal penile nerves were precisely targeted in the fascial compartment just
deep to Buck fascia, reducing the need for large local anesthetic.[18]
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Postoperative Details
After the dorsal slit, petroleum jelly and sterile gauze or petrolatum gauze dressings may be applied over the sutures, followed
by a sterile white gauze dressing. Prescribe oral narcotics and discharge the patient. Some surgeons also prescribe oral
antibiotics. the patient should apply bacitracin or vasoline to the suture 2-3 times daily for the next 1-2 weeks or per the
preference of the performing physician

Remove the dressing 24-48 hours after surgery. Advise patients to wear loose-fitting clothes, to gently wash the wound daily for
the next 5-7 days, and to refrain from any sexual activity for the next 6 weeks to prevent breakdown of the sutures and incision
line. Some surgeons additionally recommend keeping the wound completely dry to avoid inadvertent infection of the suture line.

Follow-up
Patients generally undergo follow-up examination in 2-3 weeks to check the wound. Assess the wound for signs of infection and
inspect the suture line.

For excellent patient education resources, visit eMedicineHealth's Men's Health Center. Also, see eMedicineHealth's patient
education articles Foreskin Problems and Circumcision.

Complications
Complications of paraphimosis include pain, infection, and swelling of the glans penis. The distal portion of the penis can
become ischemic and even necrotic.

Potential complications involved with any dorsal slit include bleeding, infection, shortening of penile skin, and urethral injury.

Postoperative bleeding is the most common complication. Meticulous hemostasis during the initial surgery is the rule. Bleeding
may occur if a scab is pulled off during removal of the dressing. This bleeding can often be controlled with direct pressure. In
rare cases, electrocautery or ligature is required.

Urethral injury is extremely rare.

Outcome and Prognosis

Paraphimosis does not recur after a proper circumcision.

Outcome after a dorsal slit procedure or a circumcision is excellent. Sometimes, patients with a favorable outcome from dorsal
slit procedures decline circumcision.

Contributor Information and Disclosures

Author

Nathan A Brooks, MD Resident Physician, Department of Urology, University of Iowa Hospitals and Clinics

Nathan A Brooks, MD is a member of the following medical societies: American Urological Association
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Disclosure: Nothing to disclose.

Coauthor(s)

James A Brown, MD, FACS Professor of Urology, Residency Program Director, Medical Director, Department of Urology,
Professor of Biomedical Engineering, Andersen-Hebbeln Professor of Prostate Cancer Research, University of Iowa, Roy J and
Lucille A Carver College of Medicine

James A Brown, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological
Association, Society for Basic Urologic Research, Society of Laparoendoscopic Surgeons, Society of University Urologists,
Society of Urologic Oncology, American Association of Clinical Urologists, Society of Government Service Urologists

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy;
Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Shlomo Raz, MD Professor, Department of Surgery, Division of Urology, University of California, Los Angeles, David Geffen
School of Medicine

Shlomo Raz, MD is a member of the following medical societies: American College of Surgeons, American Medical Association,
American Urological Association, California Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of
Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American
Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of
Laparoendoscopic Surgeons, Society of University Urologists

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: AUA Journal of
Urology<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cook Medical; Olympus, .

Additional Contributors

Allen Donald Seftel, MD Professor of Urology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson
Medical School; Head, Division of Urology, Director, Urology Residency Training Program, Cooper University Hospital

Allen Donald Seftel, MD is a member of the following medical societies: American Urological Association

Disclosure: Received consulting fee from lilly for consulting; Received consulting fee from abbott for consulting; Received
consulting fee from auxilium for consulting; Received consulting fee from actient for consulting; Received honoraria from journal
of urology for board membership; Received consulting fee from endo for consulting.

Jeffrey M Donohoe, MD, FAAP Assistant Professor of Pediatric Urology, Department of Surgery, Division of Urology, Children’s
Medical Center, Medical College of Georgia

Jeffrey M Donohoe, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American
Urological Association

Disclosure: Nothing to disclose.

Jason O Burnette, MD Resident Physician, Department of Surgery, Section of Urology, Medical College of Georgia

Jason O Burnette, MD is a member of the following medical societies: American Society for Clinical Pharmacology and
Therapeutics, American Urological Association

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Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Jong M. Choe,
MD, FACS, and previous coauthor Hye Kim, RPh, to the development and writing of this article.

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