Urgent message: Most cases of paraphimosis can be managed in the urgent care setting and prompt treatment is necessary to avoid complications.
MOHAMED A. FAYED, MD
Overview
An uncircumcised male’s penis consists of the penile shaft and glans penis covered by foreskin. At birth, the foreskin and glans penis are fused, which is called physiologic phimosis. Approximately half of uncircumcised males have fully retractable foreskins by age 10 years; by age 17, the foreskins of almost all males are fully retractable.
Case presentation
A 29-year-old male presents to the urgent care center complaining of penile swelling and irritation (Figures 1 and 2). He reports increased sexual activity in the last 3 months. During this period, he has also had a new sexual partner. He denies any history of sexually transmitted disease (STDs). He also denies any history of diabetes.
Observation and Findings
Physical examination of the patient reveals the following:
Pulse: 60 bpm BP: 120/76 Temp: 97.7°F RR: 12
Cardiac exam: Normal regular heart and rhythm, no murmur.
Lung exam: Clear to auscultation bilaterally Abdominal exam: Soft and no tenderness
Genital exam: Swollen foreskin, not retractable around the glans penis. The glans penis is pink with no swelling or tenderness.
Diagnosis and Treatment
This patient had paraphimosis (Figures1 and 2). His foreskin was not reducible on trial. Therefore, he was sent to the Emergency Room (ER) for immediate reduction and urology consultation.
Discussion
Paraphimosis occurs when the foreskin in an uncircumcised male is retracted behind the glans penis. If it goes unrecognized, it can cause venous and lymphatic congestion and later, blood flow obstruction of the glans penis with potential for permanent damage and gangrene. It is prudent to recognize and treat this condition to prevent penile complications.
Paraphimosis is common in elderly patients. It may occur after urinary catheterization or medical examination if the foreskin is not returned to its natural location over the glans, which is termed iatrogenic paraphimo- sis. One theory regarding the predisposition of elderly men to paraphimosis is decreased frequency of erections from erectile dysfunction.1 Balanitis at any age is also associated with development of paraphimosis.2 In the medical literature, paraphimosis has been reported after sexual intercourse and after prolonged erections in erotic dancing.3-5
Paraphimosis must be treated promptly to prevent glans ischemia. Patients with this condition can present in different stages and early stage paraphimosis (mini- mal changes of the glans penis) can be managed in the clinic, an urgent care center, or the ER without the need for emergent specialty consultation. Many methods for successful paraphimosis reduction have been reported; however, the most commonly used initial maneuver involves manual compression of the distal glans penis or application of ice packs at the glans penis for a few minutes to decrease edema, followed by reduction of the glans penis back through the proximal constricting band of foreskin.6 In cases of significant edema and pain of the glans penis, adjunctive therapy to reduce the pain is advised, such as penile nerve block, topical analgesic or oral narcotics before penile manipulation.6 For these patients, emergent referral to an expert also is advisable.
After foreskin reduction, referral to a urologist is important. Urologists can offer other treatment options to prevent recurrence, such as circumcision. Cases of chronic paraphimosis have been reported.6 In these patients, a mildly constricting irreducible fibrous band of foreskin is present, but glans edema and necrosis are absent. Symptoms only develop with erection. Patients diagnosed with chronic paraphimosis require modified or formal circumcision for treatment.7
References
- Williams J, Morris P, Richardson Paraphimosis in elderly men. Am J Emerg Med. 1995;13(3):351–354.
- Dubin J,Davis Penile emergency. Emerg Med Clin North Am. 2011Aug;485-499.
- Berk D, Lee Paraphimosis in a middle-aged adult after intercourse. Am Fam Physi- cian. 2004;69(4):807–808.
- Ramdass M, Naraynsingh V, Kuruvilla T, et Paraphimosis due to erotic dancing. Case report: Trop Med Int Health. 2000;5(12):906–907.
- Paynter Paraphimosis. Emerg Nurse. 2006 Jul;14(4):18-19.
- Choe Paraphimosis: current treatment options. Am Fam Physician. 2000;62: 2623–2626.
- Rangarajan M, Jayakar Paraphimosis revisited: Is chronic paraphimosis a predomi- nantly third world condition? Trop Doct. 2008;38:40–42.