Paraphimosis is an acutely developed condition in which the narrowed foreskin infringes on the head of the penis and cannot spontaneously return to its normal position. Disease is characterized by severe pain in the area of infringement, an increase in the volume and cyanosis of the glans penis, swelling of the foreskin, which looks like a dense swollen roller, difficulty urinating. The diagnosis is based on the results of an external examination of the penis and anamnestic data. Treatment may include conservative bimanual reduction of the pinched glans penis and surgical methods – puncture of edematous tissues, longitudinal dissection of the foreskin (incision), circular excision of the foreskin (circumcision).
N47 Excess foreskin, phimosis and paraphimosis
Paraphimosis is a complication of phimosis that develops when the naked glans penis is pinched at its base by a dense narrow ring of preputial tissue. Pathology occurs when the foreskin is completely withdrawn (retracted) behind the coronal furrow. With paraphimosis, spontaneous retraction of the glans penis into the preputial sac becomes impossible.
The main danger of paraphimosis is the likelihood of necrosis and gangrene of the glans penis, therefore, in andrology and urology, this condition is regarded as requiring emergency medical care. Most often, paraphimosis develops in boys and boys, but it can also be diagnosed in adult men.
Paraphimosis is a complication of congenital or acquired phimosis. Normally, the separation of the outer and inner leaves of the foreskin proceeds independently, starting from birth and ending during puberty. In the first years of the boy’s life, there is a “physiological phimosis” caused by epithelial bonding of the glans penis and the inner sheet of the foreskin.
Spontaneous opening of the preputial sac in most cases occurs at the age of 3 to 6-7 years. Intensive premature removal of the foreskin with the removal of the glans penis becomes the cause of most cases of true phimosis. Paraphimosis occurs in the presence of phimosis of the II–III degree, rarely develops at the I degree and does not happen at the IV degree of phimosis, when it is impossible to expose the head of the penis.
In boys, disease most often occurs during hygienic procedures in connection with forced attempts by parents to move the skin behind the coronal furrow. In adult patients, infringement of the glans penis by the extremely narrowed flesh can develop during masturbation or sexual contact. A possible cause of paraphimosis may be an inelastic short frenulum of the foreskin, which makes it difficult to expose the head and return the tissues to their original position.
Iatrogenic paraphimosis may occur due to forced exposure of the glans penis during catheterization of the urethra and bladder, cystoscopy. It is possible to develop paraphimosis with primary syphilis and the presence of a syphilitic ulcer of the prepuce; with the development of allergic reactions from the genitals. The cases of paraphimosis when performing penile piercing are described.
Paraphimosis occurs as a result of forced retraction of the narrowed foreskin behind the base of the glans penis and the inability to return it back. Circular infringement of the glans penis by the foreskin leads to venous and lymphatic stagnation, rapid development of tissue edema and disruption of arterial blood flow.
Paraphimosis has an acute onset and manifests itself with pronounced local symptoms. The foreskin with paraphimosis takes the form of a dense swollen roller under the head of the penis. The infringement contributes to the growth of edema and a significant increase in the volume of the penis head, which is accompanied by an increase in its compression by a ring of preputial tissue. The proximal part of the trunk of the penis is not changed. With paraphimosis, there is a sharp soreness and cyanosis of the glans penis; the pain increases at the slightest touch. A typical pose of a patient with paraphimosis is widely spaced legs and a trunk bent forward. With paraphimosis, urination becomes difficult; children may develop acute urinary retention.
If for a long time it is not possible to return the foreskin to its original position, paraphimosis can be complicated by ischemia and partial necrosis of the glans penis, the development of ischemic gangrene of the foreskin ring. Partial autoamputation of the distal part of the penis is possible.
If paraphimosis occurs, it is necessary to immediately consult a doctor: a pediatric surgeon, urologist or andrologist. The diagnosis of paraphimosis is established on the basis of anamnestic data and visual examination of the penis.
Paraphimosis refers to urgent conditions requiring urgent medical intervention. First aid for paraphimosis consists in applying cold to the place of infringement (an ice bubble, a cold compress); applying a bandage with a hypertonic solution, an elastic compression bandage; applying local anesthetics, injections of hyaluronidase to the area of edema. These measures not only reduce pain, but also reduce swelling of the glans penis.
Treatment of paraphimosis can be conservative and operative. With timely detection of paraphimosis, conservative bimanual reduction of the glans penis into the infringing ring of the foreskin is performed under local (in children – general) anesthesia after lubricating the surface of the penis with vaseline oil or glycerin. Sometimes a puncture of the edematous tissues of the foreskin is performed beforehand to create an outflow of fluid. After successful reduction of paraphimosis, local baths with a solution of potassium permanganate, applications of camphor oil, prednisolone ointment are prescribed.
If 2-3 attempts to correct the glans penis are unsuccessful, a preliminary longitudinal (dorsal) dissection of the infringing ring is performed. Since paraphimosis is accompanied by deformation of the foreskin, in order to avoid repeated cases of infringement, a circular excision of the foreskin (circumcision) is performed 1-1.5 months after the acute process subsides. Currently, circumcision is often performed using a laser or a radiosurgical scalpel. For the prevention of postoperative infectious complications, antibiotics and general restorative therapy are prescribed.
Prognosis and prevention
With timely access to a doctor and surgical treatment of paraphimosis, the prognosis of the disease is favorable. Advanced cases of paraphimosis threaten necrosis and ischemic gangrene of the glans penis, the need for its amputation. Prevention of paraphimosis consists in the early diagnosis and treatment of phimosis, the prohibition of premature forced removal of the foreskin, careful urological manipulation. To detect phimosis, adolescent boys must be examined by a pediatric urologist-andrologist.