# Paraphimosis Reduction

## Overview

This module describes how to reduce a paraphimosis, or entrapment of the foreskin in the retracted position.

## Indications

1. Paraphimosis

## Contraindications

1. Weigh up the risks and benefits of the “puncturing method” in patients with local infection, ulceration, or penile cancer

## Patient information & consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“Your foreskin has become stuck behind the swollen head of your penis. If we don’t treat it, the head of your penis will not get enough blood supply, which could endanger it. That is why I need to urgently get the foreskin back into place.”

### What can my patient expect?

“If it is necessary, I can give you an injection for pain, as this procedure can sometimes be painful. I will apply pressure to the head of your penis to reduce the swelling, then I will try to pull the foreskin over the head of the penis. I may try a few other techniques, like putting your penis in a solution which reduces swelling. If all else fails, I will call a senior colleague who can make a small cut in the foreskin to release it.”

### What is my patient’s role?

“Let me know if you have any allergies. Fearing blood or needles is normal, but tell me if you have fainted from it. Tell me if the pain is too severe and we can try the injection. Try to stay calm.”

## Preparation

Prepare a trolley with equipment.

### Documentation

1. Patient notes

### Equipment

1. Alcohol-based hand rub

2. Sharps container
   Sharps container

   If a sharps container is not within arm's length, use a kidney dish or other hard container to temporarily hold used sharps and to carry them to the sharps container for disposal.

3. Sterile gloves

4. Skin disinfectant
   Skin disinfectant

   Commonly used preparations include 0.5-2% chlorhexidine in 70% alcohol (Steriprep), or 10% povidone iodine. There is no consensus on the superiority of one agent above another. Caution: chlorhexidine solutions may be associated with burns and skin breakdown in infants < 2 months old.

5. Sterile pack

6. Sterile swabs

7. Lubricant

8. If

   anaesthesia
   anaesthesia

   This procedure is not well tolerated because of the problem site. Consider anaesthesia sooner rather than later as the patient will be pain-free, more relaxed and cooperative. In small children, weigh up the risks of conscious sedation with the trauma of a local anaesthetic.

   is required, equipment for a Penile Subcutaneous Ring Block

9. Adjuncts:

   1. Non-adhesive bandage
   2. Mannitol or sugar
   3. 22-25 G needle
   4. Hyaluronidase, a tuberculin syringe and 22-25 G needle

## Site & Positioning

Position the patient supine.

## Procedure

Follow medical asepsis with sterile gloves.

1. Perform hand hygiene.

2. Open the sterile pack to create a sterile field and open sterile items onto the field. Squeeze lubricant onto the field. Pour skin disinfectant into the well.

3. Don sterile gloves.

4. Clean and drape the penis.

5. Give local anaesthesia if necessary.

6. Grip the glans firmly (you may need to use gauze) and apply continuous pressure for 3-5 minutes, until the oedema subsides.

7. Apply lubricant. Place both your thumbs on the glans, and your fingers behind the ring of constrictive foreskin. Gradually push the glans through the phimotic ring.

8. If unsuccessful: wrap a bandage tightly around the penis, from distal to proximal, and wait for up to 10 minutes before unwrapping and repeating step 7.

9. If still unsuccessful: immerse the glans and foreskin in granulated sugar or swabs soaked in mannitol or 50% dextrose for up to an hour and repeat step 7.

10. If still unsuccessful: make numerous small punctures in the foreskin to reduce oedema and repeat step 7.

11. If still unsuccessful: consider up to two 1 ml

    hyaluronidase injections
    hyaluronidase injections

    If this is not readily available, call a senior.

    into the foreskin and repeat step 7.

12. Record the completion of the procedure in patient notes.

## Troubleshooting

I cannot reduce the paraphimosis.

If these noninvasive techniques fail, a dorsal slit procedure may need to be performed by a urologist or senior colleague.

I want to prevent paraphimosis from recurring.

Patients with reduced paraphimosis should have an elective dorsal slit procedure or circumcision 6 weeks after reduction.

## Risks

1. Failed reduction

2. Injury to the penile skin or foreskin

3. Phimosis due to injury to the foreskin

## References

1. Chung PH. How To Do Paraphimosis Reduction Without Dorsal Slit. In: MSD Manual. 2020. Available from: https://www.msdmanuals.com/professional/genitourinary-disorders/how-to-do-genitourinary-procedures/how-to-do-paraphimosis-reduction-without-dorsal-slit

2. Choe JM. Paraphimosis: Current Treatment Options. Am Fam Physician. 2000 Dec 15;62(12):2623-2626.

3. Bragg BN, Kong EL, Leslie SW. Paraphimosis. [Updated 2021 Aug 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459233/

4. Hayashi Y, Kojima Y, Mizuna K, Kohri K. Prepuce: Phimosis, Paraphimosis, and Circumcision. The Scientific World Journal. 2011;11:289–301

5. Pohlman GD, Phillips JM, Wilcox DT. Simple method of paraphimosis reduction revisited: Point of technique and review of the literature. Journal of Pediatric Urology. 2013;9:104-107.

6. Ross A, Naidoo C. How To Reduce a Paraphimosis. In: Mash B, Blitz-Lindeque J, eds. South African Family Practice Manual. 2nd ed. Pretoria: Van Schaik Publishers; 2010: 110-111.