Paraphimosis · What Is It, Causes, Symptoms, and More

Paraphimosis results from retraction of the foreskin that is not subsequently returned to its pre-retracted position, leading to entrapment of the foreskin behind the glans penis and formation of a constricting band at the coronal sulcus. This may lead to impaired venous and lymphatic drainage, progressive edema, and, if untreated, arterial compromise of the glans.  

In infants and young children, paraphimosis most commonly occurs due to inappropriate or forced foreskin retraction during hygiene by a caregiver or through self-manipulation. In adolescents and adults, it is frequently iatrogenic, occurring after urological procedures such as bladder catheterization or cystoscopy when the foreskin is not replaced. It may also develop following inadequate foreskin reduction after urination, sexual activity, or genital trauma (e.g. genital body piercing), or in the setting of local infection or inflammation that causes foreskin edema and prevents spontaneous reduction. 

Paraphimosis is treated with prompt manual reduction of the foreskin back over the glans penis, a procedure that commonly takes place in the emergency room.  

Before attempting reduction, adequate pain control is essential and is typically achieved using topical analgesics (e.g., lidocaine gel), local anesthetic injections (e.g., lidocaine without epinephrine, bupivacaine), or a dorsal penile nerve block. If local measures do not provide sufficient analgesia, systemic analgesia (e.g., with opioids) and procedural sedation may be required.  

Measures to reduce edema prior to reduction can improve success rates and include the application of ice compresses or compressive wrapping for several minutes. A water-soluble lubricant may also be applied to facilitate reduction. During manual reduction, the healthcare provider applies steady pressure to the glans penis while simultaneously advancing the foreskin distally over the glans.  

If manual reduction is unsuccessful, urologic consultation is required. Alternatively, minimally invasive techniques may be attempted, including osmotic reduction using granulated sugar or hypertonic glucose, the multiple puncture technique with a fine needle to evacuate edema, or injection of hyaluronidase to disperse swelling. When conservative and minimally invasive measures fail, surgical intervention, such as a dorsal slit procedure to relieve the constricting band or emergent circumcision may be necessary.