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A man with penile swelling

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Introduction

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.


History

Presenting complaint

“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:

  • Diabetes mellitus
  • Immunosuppression
  • Penile cancer
  • Previous circumcision

I only have high cholesterol and high blood pressure.”

Medications and allergies

Do you take any regular medications or have allergies?

Specifically, ask:

  • Do you take any blood thinners aside from aspirin?

I am not taking any blood thinners and I have no allergies.”


Clinical examination

It is important to perform a complete examination of the external genitalia

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).

Examination findings

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

Diagnosis

  • Paraphimosis
  • Peno-scrotal oedema

Paraphimosis

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

Management

Analgesia

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).

Additional measures

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.


References

  1. Bragg BN, Kong EL, Leslie SW. Paraphimosis. Published in 2020. Available at: [LINK]
  2. Williams JC, Morrison PM, Richardson JR. Paraphimosis in elderly men. Published in 1995. Available at: [LINK]


Reviewer

Miss Hannah Wells

Consultant Urologist


Editor

Hannah Thomas


 

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