Penile Swelling – OSCE Case

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. I’ve never had anything like this before. ”

Have you ever had any problems with your foreskin in the past?

“It has always been tight, and sometimes retraction is a little difficult”

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.”

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

• 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

Analgesia

Adequate analgesia should be administered as soon as possible. This compassionate first measure will make reducing the foreskin more tolerable for the patient.

Urgent manual reduction

Performing manual reduction involves the following:

• Place both of your thumbs on 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 tolerating pressure on the glans, 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

An outpatient urology review would be required to discuss circumcision to prevent a recurrence.