Paraphimosis (foreskin trapped proximal to coronal sulcus) is a urologic emergency, and reduction is always indicated when the condition is present
CONTRAINDICATIONS
None
RISKS/CONSENT ISSUES
Pain (local anesthesia will be given)
Local bleeding
Infection (sterile technique will be used)
Scarring at site of incision/dilation (though definitive treatment will likely include circumcision, removing the scarred tissue)
Damage to glans penis and urethral meatus
General Basic Steps
If manual reduction fails to restore normal anatomy, proceed to assisted manual reduction; if that fails as well, proceed to phimotic ring incision. A urologist should be contacted if manual reduction fails, and will need to be actively involved if emergency circumcision is required because of reduction failure.
Patient preparation
Anesthesia
Manual reduction
Assisted manual reduction (FIGURE 37.1)
Phimotic ring incision
TECHNIQUE
Patient Preparation
Position: Supine with legs slightly abducted
Consider light procedural sedation as well
Anesthesia
A topical anesthetic may be all that is necessary
Apply viscous lidocaine or eutectic mixture of local anesthetics (EMLA) to the inner layer of the foreskin
Also serves as a lubricant
If further anesthesia is necessary, progress from local, to dorsal nerve block, and, finally, to penile ring block
See chapter 36 for details and pictures of penile anesthesia
When providing local anesthesia with lidocaine (without epinephrine), be sure to infiltrate into the constricting ring as well
Manual Reduction
Using your hands or an elastic bandage, manually compress the glans and foreskin for 3 to 5 minutes to remove as much edema as possible
Place both thumbs on the glans penis and apply slow, steady pressure while using your other fingers just proximal to the phimotic ring to pull the foreskin over the glans penis (FIGURE 37.2)
Successful reduction occurs when the phimotic foreskin is reduced back to normal position over the glans
If unsuccessful, proceed to assisted manual reduction methods