“I have never seen a paraphimosis that I haven’t been able to reduce manually. Go back and give it a proper squeeze for 15 minutes.”
In this Pro Tip blog, we look at how to deal with cases of paraphimosis.
Dealing with Paraphimoses
A paraphimosis is when the foreskin is pulled back behind the glans and left there long enough causing swelling. It’s a fairly common occurrence around the hospital, and with a bit of common sense and a few tricks, can be easily remedied. The following tips should help to de-mystify how to reduce a paraphimosis, saving you and your patient a lot of trouble.
As I found when I was a junior SHO, almost all can be reduced with patients and a good squeeze.
1. Prevention is better than a cure
The 2 main causes for paraphimosis are
- Young men not pulling the foreskin back after sexual activity, and
- Elderly men whose foreskins are not pulled back following catheterisation.
There’s not much that can be done to prevent the first one, but remembering to put things back where you found them after catheterisation can reduce the incidence of paraphimosis in hospital inpatients. If you have caused a paraphimosis, make sure you know how to put it right.
2. Don’t bother with……
Ice water, sugar, hypertonic fluids, etc.. It’s a difficult part of the body to dip into ice water or fluids and is bound to cause a mess. I have even heard of one patient receiving the topical application of strawberry ice cream due to a lack of ice on the ward. I’m not sure I’ve ever seen this successful either. It’s probably best to move straight onto the next step.
3. The urologists handshake
The best way to reduce a paraphimosis is to squeeze the tissue fluid out of the swollen foreskin. This takes time. So, pull up a chair, get ready with your best small talk, and prepare to be in for the long haul.
It might take 5 or 10 minutes of gentle, firm, persistent squeezing starting at the tip and pushing the tissue fluid back past the tight band before the skin can be pulled forward. Make sure you are up to date with current affairs, the 5 day forecast and football scores before you start.
Using some gauze gently squeeze the glans until the swelling goes down. Try starting out with your index finger and thumb in an OK sign around the glans and then move to using the tips of all your fingers, like miming a birds beak, when the swelling starts going down. You might need to change your grip again to get all of swelling out of the tissue distal to the phimotic ring.
Then placing the tips of your fingers proximal to the phimotic ring and your thumbs on the glans, simultaneously pull the foreskin forward and thumb the glans in until the ring pops forwards.
4. Sounds painful
This procedure can clearly be painful. In some patients with minimal swelling, anaesthetia may not be required and gentle squeezing of the tissue fluid may be all that’s required for everything to pop back to where it should be.
For young children a quick gas anaesthetic s probably the kindest and least traumatic way to go about it and for adults a penile block may be required.
Have a chat with a urologist and get them to show you how to carry out a penile block, its simple and can be very effective.
Remember! Use 1% lidocaine without adrenaline. Do not use anesthetic with adrenaline on the penis. If in doubt remember to never use adrenaline on fingers, nose, penis, toes.
5. What if squeezing doesn’t work
If a good block and a proper squeeze doesn’t work then the patient may need surgical intervention and this would require an anaesthetic and a urologist and some instruments. The Dundee method involved pocking multiple puncture holes around the swelling with a needle as a way of maximizing fluid release when squeezing.
Dorsal slits and circumcisions may also be an option, but circumcisions are often left until the residual swelling resolves after reducing a paraphimosis.
Hopefully these tips will give you a good change of avoiding a paraphimosis and reducing any you encounter. If you see a paraphimosis, do the common sense things above, and if you struggle and need to call a urologist, hang around and ask them to show you what they did. It’s the best way to learn.
Words by Dr. Paul Sturch.