Paraphimosis

Last updated
Paraphimosis
Paraphimosis.jpg
Pronunciation
Specialty Urology
Complications Gangrene of the glans penis
TypesPhysiological, pathological
CausesIatrogenic, handling foreskin improperly
Risk factors Phimosis, uncircumcised
PreventionReturning foreskin to unretracted position after retraction, foreskin stretching, circumcision
TreatmentManual reduction, circumcision
Frequency0.2% (uncircumcised children) [3]

Paraphimosis is an uncommon [4] medical condition in which the foreskin of a penis becomes trapped behind the glans penis, and cannot be reduced (pulled back to its normal flaccid position covering the glans). If this condition persists for several hours or there is any sign of a lack of blood flow, paraphimosis should be treated as a medical emergency, as it can result in gangrene. [4] [5] [6]

Contents

Causes

Paraphimosis is usually caused by medical professionals (iatrogenic) or parents who handle the foreskin improperly. [4] [6] The foreskin may be retracted during penile examination, penile cleaning, urethral catheterization, or cystoscopy; if the foreskin is left retracted for a long period, some of the foreskin tissue may become Oedematous (swollen with fluid), which makes subsequent reduction of the foreskin difficult.[ citation needed ]

Prevention and treatment

Paraphimosis can be avoided by bringing the foreskin back into its normal, forward, non-retracted position after retraction is no longer necessary (for instance, after cleaning the glans penis or placing a Foley catheter). Phimosis (both pathologic and normal childhood physiologic forms) is a risk factor for paraphimosis; [5] physiologic phimosis resolves naturally as a child matures, but it may be advisable to treat pathologic phimosis via long-term stretching or elective surgical techniques (such as preputioplasty to loosen the preputial orifice or circumcision to amputate the foreskin tissue partially or completely).[ citation needed ]

The foreskin responds to the application of tension to cause expansion by creating new skin cells though the process of mitosis. The tissue expansion is permanent. Non-surgical stretching of the foreskin may be used to widen a narrow, non-retractable foreskin. [7] Stretching may be combined with the use of a corticosteroid cream. [8] [9] Beaugé recommends manual stretching for young males in preference to circumcision as a treatment for non-retractile foreskin because of the preservation of sexual sensation. [10]

Paraphimosis can often be effectively treated by manual manipulation of the swollen foreskin tissue. This involves compressing the glans penis and moving the foreskin back to its normal position, perhaps with the aid of a lubricant, cold compression, and local anesthesia as necessary. If this fails, the tight edematous band of tissue can be relieved surgically with a dorsal slit, [4] [6] or a circumcision. [11] [12] [13] [14] [15] An alternative method, the Dundee technique, entails placing multiple punctures in the swollen foreskin with a fine needle, and then expressing the edema fluid by manual pressure. [12] According to Ghory and Sharma, treatment by circumcision may be elected as "a last resort, to be performed by a urologist". [16] Other experts recommend delaying elective circumcision until after paraphimosis has been resolved. [4] A non-invasive method is the application of granulated sugar to induce transfer of the hypotonic fluid out of the edematous tissue towards the wet sugar via osmotic gradient, to reduce swelling and enabling manual reduction. [6]

Related Research Articles

<span class="mw-page-title-main">Glans penis</span> End of the penis

In male human anatomy, the glans penis or penile glans, commonly referred to as the glans, is the bulbous structure at the distal end of the human penis that is the human male's most sensitive erogenous zone and primary anatomical source of sexual pleasure. The glans penis is present in the male reproductive organs of humans and most other mammals where it may appear smooth, spiny, elongated or divided. It is externally lined with mucosal tissue, which creates a smooth texture and glossy appearance. In humans, the glans is located over the distal ends of the corpora cavernosa and is a continuation of the corpus spongiosum of the penis. At the summit appears the urinary meatus and at the base forms the corona glandis. An elastic band of tissue, known as the frenulum, runs on its ventral surface. In men who are not circumcised, it is completely or partially covered by a fold of skin called the foreskin. In adults, the foreskin can generally be retracted over and past the glans manually or sometimes automatically during an erection.

<span class="mw-page-title-main">Foreskin restoration</span> Process to expand skin on the penis

Foreskin restoration is the process of expanding the skin on the penis to reconstruct an organ similar to the foreskin, which has been removed by circumcision or injury. Foreskin restoration is primarily accomplished by stretching the residual skin of the penis, but surgical methods also exist. Restoration creates a facsimile of the foreskin, but specialized tissues removed during circumcision cannot be reclaimed. Actual regeneration of the foreskin is experimental at this time. Some forms of restoration involve only partial regeneration in instances of a high-cut wherein the circumcisee feels that the circumciser removed too much skin and that there is not enough skin for erections to be comfortable.

<span class="mw-page-title-main">Genital modification and mutilation</span> Permanent or temporary changes to human sex organs

Genital modifications are forms of body modifications applied to the human sexual organs, such as piercings, circumcision, or labiaplasty. The term genital mutilation is generally used for genital modifications that diminish the recipient's quality of life and result in adverse health outcomes, whether physical or mental.

<span class="mw-page-title-main">Clitoral hood</span> Part of the vulva that covers and protects the glans of the clitoris

In female humans and other mammals, the clitoral hood is a fold of skin that surrounds and protects the glans of the clitoris; it also covers the external clitoral shaft, develops as part of the labia minora and is homologous with the foreskin in the male reproductive system. The clitoral hood is composed of mucocutaneous tissues; these tissues are between the mucous membrane and the skin, and they may have immunological importance because they may be a point of entry of mucosal vaccines.

<span class="mw-page-title-main">Phimosis</span> Medical condition

Phimosis is a condition in which the foreskin of the penis cannot stretch to allow it to be pulled back past the glans. A balloon-like swelling under the foreskin may occur with urination. In teenagers and adults, it may result in pain during an erection, but is otherwise not painful. Those affected are at greater risk of inflammation of the glans, known as balanitis, and other complications.

The preputial mucosa of the penis is the epithelium of the inside of the prepuce, or foreskin. To differentiate it from the cutaneous skin of the outside of the prepuce, it is sometimes referred to as the inner mucosa. It starts at the ridged band of the prepuce and continues to the coronal sulcus, where it meets the epithelium of the glans and penile shaft. The preputial mucosa is devoid of hair, as is the cutaneous surface.

Penile cancer, or penile carcinoma, is a cancer that develops in the skin or tissues of the penis. Symptoms may include abnormal growth, an ulcer or sore on the skin of the penis, and bleeding or foul smelling discharge.

<span class="mw-page-title-main">Hypospadias</span> Medical condition

Hypospadias is a common variation in fetal development of the penis in which the urethra does not open from its usual location on the head of the penis. It is the second-most common birth defect of the male reproductive system, affecting about one of every 250 males at birth, although when including milder cases, is found in up to 4% of newborn males. Roughly 90% of cases are the less serious distal hypospadias, in which the urethral opening is on or near the head of the penis (glans). The remainder have proximal hypospadias, in which the meatus is all the way back on the shaft of the penis, near or within the scrotum. Shiny tissue that typically forms the urethra instead extends from the meatus to the tip of the glans; this tissue is called the urethral plate.

<span class="mw-page-title-main">Balanitis</span> Inflammation of the glans penis

Balanitis is inflammation of the glans penis. When the foreskin is also affected, the proper term is balanoposthitis. Balanitis on boys still in diapers must be distinguished from redness caused by ammoniacal dermatitis. The word balanitis is from the Greek βάλανοςbalanos, literally meaning 'acorn', used because of the similarity in shape to the glans penis.

<span class="mw-page-title-main">Frenulum breve</span> Medical condition

Frenulum breve, or short frenulum, is a condition in which the frenulum of the penis, which is an elastic band of tissue under the glans penis that connects to the foreskin and helps contract it over the glans, is too short and thus restricts the movement of the foreskin. The frenulum should normally be sufficiently long and supple to allow for the full retraction of the foreskin so that it lies smoothly back on the shaft of the erect penis.

Preputioplasty or prepuce plasty, also known as limited dorsal slit with transverse closure, is a plastic surgical operation on the prepuce or foreskin of the penis, to widen a narrow non-retractile foreskin which cannot comfortably be drawn back off the head of the penis in erection because of a constriction (stenosis) which has not expanded after adolescence.

<span class="mw-page-title-main">Restoration device</span>

A restoration device is a device used for applying tension to skin during the process of non-surgical foreskin restoration. Those who use such a device employ the use of tissue expansion, which causes new skin to grow.

<span class="mw-page-title-main">Penile frenulum</span> Band of tissue under the glans penis connecting the foreskin to the ventral mucosa

The frenulum of the penis, often known simply as the frenulum or frenum, is a thin elastic strip of tissue on the underside of the glans and the neck of the human penis. In men who are not circumcised, it also connects the foreskin to the glans and the ventral mucosa. In adults, the frenulum is typically supple enough to allow manual movement of the foreskin over the glans and help retract the foreskin during erection. In flaccid state, it tightens to narrow the foreskin opening.

<span class="mw-page-title-main">Circumcision</span> Removal of the human foreskin

Circumcision is a procedure that removes the foreskin from the human penis. In the most common form of the operation, the foreskin is extended with forceps, then a circumcision device may be placed, after which the foreskin is excised. Topical or locally injected anesthesia is generally used to reduce pain and physiologic stress. Circumcision is generally electively performed, most commonly done as a form of preventive healthcare, as a religious obligation, or as a cultural practice. It is also an option for cases of phimosis, other pathologies that do not resolve with other treatments, and chronic urinary tract infections (UTIs). The procedure is contraindicated in cases of certain genital structure abnormalities or poor general health.

<span class="mw-page-title-main">Human penis</span> Human male external reproductive organ

In human anatomy, the penis is an external male sex organ that additionally serves as the urinary duct. The main parts are the root, body, the epithelium of the penis including the shaft skin, and the foreskin covering the glans. The body of the penis is made up of three columns of tissue: two corpora cavernosa on the dorsal side and corpus spongiosum between them on the ventral side. The urethra passes through the prostate gland, where it is joined by the ejaculatory duct, and then through the penis. The urethra goes across the corpus spongiosum and ends at the tip of the glans as the opening, the urinary meatus. It is a passage both for excretion of urine and the ejaculation of semen.

<span class="mw-page-title-main">Clitoral hood reduction</span> Cosmetic surgical procedure

Clitoral hood reduction, also termed clitoral hoodectomy, clitoral unhooding, clitoridotomy, or (partial) hoodectomy, is a plastic surgery procedure for reducing the size and the area of the clitoral hood in order to further expose the glans of the clitoris.

<span class="mw-page-title-main">Dorsal slit</span> Incision on penis foreskin expoing the glans

A dorsal slit is a single incision along the upper length of the foreskin from the tip to the corona, exposing the glans without removing any tissue. An ancient practice, it has been a traditional custom among a number of peoples, particularly Filipinos and Pacific Islanders, probably for thousands of years.

<span class="mw-page-title-main">Foreskin</span> Retractable fold of skin which covers and protects the glans of the penis

In male human anatomy, the foreskin, also known as the prepuce, is the double-layered fold of skin, mucosal and muscular tissue at the distal end of the human penis that covers the glans and the urinary meatus. The foreskin is attached to the glans by an elastic band of tissue, known as the frenulum. The outer skin of the foreskin meets with the inner preputial mucosa at the area of the mucocutaneous junction. The foreskin is mobile, fairly stretchable and sustains the glans in a moist environment. Except for humans, a similar structure known as a penile sheath appears in the male sexual organs of all primates and the vast majority of mammals.

<span class="mw-page-title-main">Buried penis</span> Male congenital condition

Buried penis, also called hidden penis or retractile penis, is a congenital or acquired condition in which the penis is partially or completely hidden below the surface of the skin. A buried penis can lead to urinary difficulties, poor hygiene, infection, and inhibition of normal sexual function.

<span class="mw-page-title-main">Circumcision surgical procedure</span>

Circumcision surgical procedure in males involves either a conventional "cut and stitch" surgical procedure or use of a circumcision instrument or device. In the newborn period, almost all circumcisions are done by generalist practitioners using one of three surgical instruments. In the US, the Gomco clamp is the most utilized instrument, followed by the Mogen clamp and the Plastibell. They are also used worldwide.

References

  1. OED 2nd edition, 1989 as /ˌpærəfaɪˈməʊsɪs/.
  2. Entry "paraphimosis" in Merriam-Webster Online Dictionary .
  3. Bragg BN, Leslie SW (2020-07-01). "Paraphimosis". NCBI Bookshelf. PMID   29083645 . Retrieved 2020-07-16.
  4. 1 2 3 4 5 Donohoe JM, Burnette JO, Brown JA (October 7, 2009). "Paraphimosis". eMedicine. Patients with severe paraphimosis that proves refractory to conservative therapy will require a bedside emergency dorsal slit procedure to save the penis. A formal circumcision can be performed in the operating room at a later date... At a later date, a formal circumcision can be performed as an outpatient procedure.
  5. 1 2 Ghory HZ, Sharma R (April 28, 2010). "Phimosis and Paraphimosis". eMedicine. Patients with phimosis, both physiologic and pathologic, are at risk for developing paraphimosis when the foreskin is forcibly retracted past the glans and/or the patient or caretaker forgets to replace the foreskin after retraction.
  6. 1 2 3 4 Choe JM (December 2000). "Paraphimosis: current treatment options". American Family Physician. 62 (12): 2623–6, 2628. PMID   11142469. If a severely constricting band of tissue precludes all forms of conservative or minimally invasive therapy, an emergency dorsal slit should be performed. This procedure should be performed with the use of a local anesthetic by a physician experienced with the technique... Circumcision, a definitive therapy, should be performed at a later date to prevent recurrent episodes, regardless of the method of reduction used... Granulated sugar has shown to be effective in the treatment of paraphimosis, based on the principle of fluid transfer occurring through osmotic gradient. Granulated sugar is generously spread on the surface of the edematous prepuce and glans. The hypotonic fluid from the edematous prepuce travels down the osmotic gradient into the sugar, reducing the swelling and allowing for manual reduction.
  7. Dunn HP (December 1989). "Non-surgical management of phimosis". The Australian and New Zealand Journal of Surgery. 59 (12): 963. doi:10.1111/j.1445-2197.1989.tb07640.x. PMID   2597103.
  8. Zampieri N, Corroppolo M, Camoglio FS, Giacomello L, Ottolenghi A (November 2005). "Phimosis: stretching methods with or without application of topical steroids?". The Journal of Pediatrics. 147 (5): 705–6. doi:10.1016/j.jpeds.2005.07.017. PMID   16291369. S2CID   29301071.
  9. Ghysel C, Vander Eeckt K, Bogaert GA (2009). "Long-term efficiency of skin stretching and a topical corticoid cream application for unretractable foreskin and phimosis in prepubertal boys". Urologia Internationalis. 82 (1): 81–8. doi:10.1159/000176031. PMID   19172103. S2CID   5287988.
  10. Beaugé M (1997). "The causes of adolescent phimosis". Br J Sex Med (September–October): 26.
  11. Santucci RA, Terlecki RP (April 15, 2009). "Phimosis, Adult Circumcision, and Buried Penis". eMedicine. Reduction of the foreskin under sedation is almost always possible. However, in some situations, a dorsal slit or circumcision is required
  12. 1 2 to be 5 Reynard JM, Barua JM (May 1999). "Reduction of paraphimosis the simple way - the Dundee technique". BJU International. 83 (7): 859–60. doi:10.1046/j.1464-410x.1999.00119.x. PMID   10368214. S2CID   5133709. Archived from the original on 2013-01-05.
  13. Surgical care at the district hospital. World Health Organization. 2003. pp. 9–10. ISBN   92-4-154575-5.
  14. Stead LG, Stead SW, Kaufman MS (2006). First Aid for the Emergency Medicine Clerkship. p. 231. ISBN   0-07-144873-X.
  15. Zderic S, Platcher N, Kirk J (2008). Pediatric Urology for the Primary Care Provider. p. 80. ISBN   978-1-55642-785-5.
  16. Ghory HZ, Sharma R (April 28, 2010). "Phimosis and Paraphimosis". eMedicine.