An elderly gentleman is brought to the surgical assessment due to complaints of a painful penis. His carers have noticed some penile swelling. Work through the case to reach a diagnosis and effectively manage the patient.
“The tip of my penis is very sore and more swollen than usual”
History of presenting complaint
When did this start?
“It has only been since my catheter was changed two days ago by the district nurses”
Have you ever experienced this before?
“No, this is the first time”
Have you ever had any problems with your foreskin in the past?
“It has always been tight and sometimes retraction is a little difficult”
Other components of the history
Past medical history
Do you have any other medical conditions?
Specifically, ask about:
“I only have high cholesterol and high blood pressure.”
Medications and allergies
Do you take any regular medications or have allergies?
Do you take any blood thinners aside from aspirin?
“I am not taking any blood thinners and I have no allergies.”
In addition, assess the patient’s catheter to ensure it is correctly positioned (i.e. appropriate length of the catheter outside of the penis).
Finally, assess for peripheral oedema (may help differentiate paraphimosis from penoscrotal oedema).
On examination, you note the following features:
Prepuce retracted and glans exposed with no overt lesions
Swelling behind coronal sulcus: oedematous and acutely painful
Palpable circumferential ‘band’ of tissue causing distal congestion
The catheter (16Ch) is correctly positioned
Paraphimosis involves a retracted foreskin (prepuce) behind the glans which cannot be replaced again.
This is commonly caused by a constricting band of tissue which prevents venous/lymphatic return causing worsening swelling of the distal penile tissues. The worsening swelling makes it increasingly difficult to replace the foreskin to its original position.
Paraphimosis is a urological emergency and will continue to worsen until effectively treated. If paraphimosis is left untreated for a prolonged period, the blood supply to the distal penis may be compromised resulting in tissue necrosis.
Possible causes of paraphimosis include:
Iatrogenic retraction after examination or catheterisation
Post-coital foreskin retraction
Retracted by the patient intentionally or inadvertently
Analgesia should be administered as soon as possible. This is a compassionate first measure that will make reduction of the foreskin more tolerable for the patient.
Urgent manual reduction
Performing manual reduction involves the following:
Place both of your thumbs either side of the urethral meatus
Place your index and middle fingers behind the tight band
Apply gentle pressure with thumbs to reduce oedema with concurrent counter pressure with fingers to pull the band back over the glans
If there are difficulties with toleration of pressure on glans then consider topical local anaesthetic creams or standard penile block (without adrenaline).
Further measures which may be considered if the foreskin is unable to be reduced include:
Senior assistance from urology
Dundee technique: multiple needle puncture of the prepuce to expel oedema
Emergency dorsal slit: full-thickness prepuce incision at 12 o’clock*
Formal circumcision as an outpatient to prevent a recurrence
*Consider dorsal slit contraindications such as anticoagulation or deranged coagulation
Outpatient urology review would be required to discuss circumcision to prevent a recurrence.
Bragg BN, Kong EL, Leslie SW. Paraphimosis. Published in 2020. Available at: [LINK]
Williams JC, Morrison PM, Richardson JR. Paraphimosis in elderly men. Published in 1995. Available at: [LINK]