Paraphimosis

What is Paraphimosis?

Paraphimosis is a serious problem related to male genitalia. This happens in males who are not circumcised and occurs when the foreskin gets stuck behind the head of the penis. It results in squeezing of the penis’ head, causing a painful blockage of blood flow. This can lead to a swollen vein, fluid build-up, and in worst cases, death of tissue. On the other hand, phimosis is a condition where the foreskin cannot be pulled back from the head of the penis.

What Causes Paraphimosis?

Paraphimosis often happens by accident, usually when the foreskin gets pulled back for cleaning, inserting a urinary tube, for a medical procedure like a cystoscopy, or a general examination of the penis. If, after pulling back the foreskin, it is not promptly returned to its original position over the tip of the penis, it can lead to paraphimosis. Other, less common causes include harm to the penis during sexual intercourse or self-inflicted injuries.

It’s very important that anyone who regularly changes Foley catheters – which are flexible tubes used to collect urine from the bladder – always makes sure to return the foreskin to its correct position after the procedure. This helps to prevent the occurrence of paraphimosis.

Risk Factors and Frequency for Paraphimosis

In boys who have not undergone circumcision and are between four months to 12 years old, issues related to the foreskin, such as paraphimosis, are relatively uncommon. It’s found in only about 0.2% of these boys. Other conditions affecting the penis are more frequently seen, including balanitis (5.9%), irritation (3.6%), penile adhesions (1.5%), and phimosis (2.6%).

When it comes to adults, paraphimosis is typically seen in teenage boys. Around 1% of all males older than 16 years may experience this condition.

• In uncircumcised boys from four months to 12 years old, paraphimosis is quite rare (0.2%).
• Other penis-related problems such as balanitis (5.9%), irritation (3.6%), penile adhesions (1.5%), and phimosis (2.6%) are more common in this age group.
• Paraphimosis is most commonly found in teenage boys among adults.
• About 1% of all adult males over 16 years of age are likely to experience paraphimosis.

Signs and Symptoms of Paraphimosis

When checking a patient for paraphimosis, it’s important to take a comprehensive background. This includes recent instances of catheterization, instrument use, cleaning, or any other procedures involving the penis. The person’s daily cleaning habits and any regular foreskin retraction need to be considered. It’s also vital to know whether they are circumcised or not. Despite popular belief, it’s still possible to develop paraphimosis after circumcision. This could be because the person wrongly believes they’re circumcised or if there’s excess foreskin left after the procedure.

The common signs of paraphimosis include redness, pain, and swelling of the foreskin and glans, due to the constriction caused by tight foreskin. Some people might describe it as ‘penile swelling’ and it might not always be painful. Doctors are advised to take reports of ‘penile swelling’ seriously as they could indicate a case of paraphimosis that needs quick treatment. In certain cases, a photo sent by the patient can help determine the severity of the condition.

The diagnosis is usually done based on the background, but if that isn’t conclusive, a physical examination is conducted. This involves examining the penis, foreskin, and, if present, a urethral catheter. A pink color on the glans indicates good blood supply while a dark, pale, blue or black color might suggest insufficient blood supply or even dead tissue.

If a patient has a Foley catheter, the reason for its insertion and any complications arising at that time should be assessed beforehand. While removing the Foley catheter can help alleviate the paraphimosis, it may sometimes be difficult to replace it, causing a new problem. However, Foley removal isn’t always necessary to successfully treat paraphimosis.

Testing for Paraphimosis

If a patient is experiencing symptoms like sudden pain and swelling in the tip of the penis, they may have a condition that requires medical attention. The head of the penis and the foreskin (the loose skin that covers the head of an uncircumcised penis) are often noticeably swollen and appear congested. However, the main part of the penis might still appear normal and unaffected. They might also be a tight band of tissue that makes it hard for the foreskin to be pulled back over the head of the penis.

Your doctor will typically be able to diagnose this condition through a physical examination. They’ll be looking for signs like an inability to easily pull your foreskin back over the head of your penis and other visible signs. Essentially, it is the difficulty in returning the retracted foreskin back to its normal position that confirms the diagnosis.

Treatment Options for Paraphimosis

Paraphimosis is a condition where the foreskin cannot be pulled back to its normal position after being retracted. It can often be treated without requiring sedation or painkillers in mild, uncomplicated cases. More challenging cases may need local anesthesia, pain-relieving medication, or sedation. The treatment methods mainly fall into two categories: manual reduction and surgical repair.

Manual reduction involves techniques that can be done with or without compression, using substances that draw out water from swollen tissues or techniques that puncture and drain fluid. Here’s how it typically works:

One straightforward method is by continuously pressing the head of the penis (glans) and the swollen, edematous foreskin for several minutes. This helps shrink the swelling before trying to bring the foreskin back to its normal position. The other technique involves putting both thumbs on the glans with index and middle fingers gripping the stuck foreskin. Gradually and steadily, pressure is exerted to push the narrowed foreskin outwards, back over the glans. It can be more attainable when done with a bit of lubricant. But remember, excessive lubricant might be counterproductive as it might make the skin too slippery to hold.

Another compression technique incorporates wrapping the swollen part of the penis with an elastic bandage from the glans towards the base. The bandage should be left on for about 10 to 20 minutes to reduce swelling, and then go on to attempt one of the manual reduction methods described above. Remember to first place a gauze pad around the swollen foreskin before the bandage.

Applying ice packs or similar cold items to the swollen areas can be helpful, but it also may do more harm than good in certain situations as it could reduce blood supply to that part of the penis. Therefore, many experts advise against this method.

Doctors also sometimes use a beneficial technique that entails filling a “sleeve” made from the thumb of a surgical glove with a cream that contains local anesthetics, which can help numb and soften the skin on the affected area. However, this could also make the skin slippier and harder to manipulate.

The swelling can also be managed by directly injecting an enzyme called hyaluronidase into the swollen foreskin. This enzyme makes it easier for the trapped fluid to leave the tissue layers of the displaced foreskin, therefore reducing the swelling and edema.

A method called “osmotic technique” involves applying substances that have a high solute concentration on the swollen areas to draw out water and therefore reduce the swelling. Elements like granulated sugar or gauze soaked in a 20% mannitol solution can be used for this purpose.

If the penis is very painful, had paraphimosis for a long time, or is severe, a particular kind of anesthesia called a dorsal penile block can be used. It involves injecting some local anesthetic around the base of the penis, which is often guided by ultrasound.

If non-surgical techniques prove inadequate, surgical treatment might be required. The penile area will be prepared for surgery with an antiseptic solution, followed by numbing via a penile block. A surgery would typically involve making a small incision on the swelling that would allow the relief of the constriction and passage over the glans. This method can prevent the foreskin from getting tightly stuck again.

In severe cases, if the blood supply to the penis is severely compromised, herm tissue death and gangrene can occur. Management of such a severe event includes partial amputation of the penis, removal of the glans and/or excision of the dead tissue from the penis. A case was recently discussed where without resorting to amputation, good results were achieved using a specific kind of tube to drain and careful surgical cleaning of dead tissues.

After treating a patient with significant paraphimosis, it is highly recommended to perform an elective circumcision or a dorsal slit procedure because of the high risk of it recurring.

What else can Paraphimosis be?

The following are various medical conditions that a doctor might consider when diagnosing a patient:

• Acute angioedema (severe skin swelling)
• Allergic contact dermatitis (skin rash caused by contact with allergens)
• Anasarca (swelling of the skin caused by fluid collection)
• Balanitis (inflammation of the head of the penis)
• Balanitis xerotica obliterans (a progressive skin condition affecting the penis)
• Cellulitis (skin infection)
• Foreign body tourniquet (a constriction of a body part by a tight object)
• Insect bites
• Penile carcinoma (penis cancer)
• Penile fracture (tearing of the tissue of the penis)
• Penile hematoma (a collection of blood in the tissue of the penis)

What to expect with Paraphimosis

Paraphimosis, a condition affecting the foreskin of men, typically responds very well to treatment if it’s diagnosed and dealt with swiftly. During the treatment process, there might be a bit of bleeding as skin is pulled back, but negative long-term impacts are uncommon.

It’s important to note, however, that paraphimosis can often come back. For those who want to prevent it from recurring, one option could be circumcision, but this can only be done once any swelling has reduced and if the patient is a suitable candidate for the surgery.

An alternative option, particularly for older patients or those with serious health conditions, could be a procedure known as a dorsal slit, which involves making a small cut in the foreskin. Both circumcision and the dorsal slit procedure can be effective in preventing paraphimosis from coming back.

Possible Complications When Diagnosed with Paraphimosis

Paraphimosis can lead to several uncomfortable and potentially dangerous complications such as pain, infection, and inflammation of the tip of the penis. If you don’t get treatment soon enough, the end part of the penis could get poor blood supply which can lead to tissue death. Surgical procedures to correct paraphimosis can also have complications like bleeding, infection, injury to the tube that carries urine out of the body (urethra), and loss of some of the penile skin.

Common Side Effects:

• Pain
• Infection
• Inflammation of the tip of the penis (glans penis)
• Poor blood supply to the penis (ischemia)
• Tissue death in penis (necrosis)
• Complications from surgery
• Bleeding during or after surgery
• Injury to the urine carrying tube (urethra)
• Shorter penile skin

Preventing Paraphimosis

After treatment or surgery, patients should be reassured that their outlook for recovery is generally quite positive. They should be advised on the importance of cleanliness, ensuring that the foreskin is returned to its normal position if it has been pulled back. If penile jewelry has contributed to their condition, it’s recommended to avoid using it in the future. If the condition keeps coming back, the patient might want to think about opting for circumcision to prevent future episodes.