Paraphimosis

Scope

This guideline covers Paraphimosis in both adults and children.

Paraphimosis occurs when a tight prepuce is retracted and is then unable to be replaced as the glans swells.

Always check there is no encircling foreign body constricting venous return, such as a ring, rubber band or hair.

If simple methods to resolve it fail (see management) then refer urgently to a urologist.

Assessment

Paraphimosis

Risk factors

  • A tight prepuce causes swelling when it is retracted. This may occur after failing to pull the foreskin forward to its natural position after cleaning or catheterisation
  • Scarring of the prepuce after repeated forcible retraction in an attempt to 'cure' a physiological phimosis
  • Vigorous sexual activity
  • Chronic balanoposthitis (typically in patients with diabetes)
  • Penile piercing can lead to paraphimosis but the most common cause is urinary catheterisation when, after inserting the catheter, there is failure to replace the foreskin over the glans after the procedure

Presentation

  • There is oedema around the constricting band that is usually the prepuce
  • There may be pain on erection
  • Infants may present just with irritability
  • A carer may discover the condition incidentally in a debilitated patient
  • In later stages, the glans may develop a blue or black colour due to necrosis

Red Flags

Failure to remove the constricting band of paraphimosis will result in necrosis of the glans.

Management

Paraphimosis
  • Gentle compression with a saline-soaked swab followed by reduction of the prepuce over the glans is usually successful
  • Gradual manual reduction of the prepuce over the glans is done by placing both index fingers on the dorsal border of the penis and thumbs on the glans. The glans is pushed back while the index fingers pull the prepuce back over the glans
  • This technique can be facilitated by trying to achieve reduction of swelling first. Ice may be applied. Manual compression is achieved by asking the patient to squeeze the glans for anything from 5 to 30 minutes. Osmotic reduction involves application of a swab soaked in 50% dextrose to the swollen area for an hour
  • If simple measures fail refer urgently to urology

Referral

Referral Criteria

Paraphimosis
  • Urgent urological referral is recommended for paraphimosis, especially when associated with a permanent urethral catheter
  • Manual reduction of a paraphimosis is usually possible but patients should, subsequently, be referred for consideration of circumcision

Referral Instructions

For adults:

e-Referral Service Selection:

  • Specialty: Urology
  • Clinic Type: Not Otherwise Specified
  • Service: DRSS-Northern-Urology-Devon CCG - 15N
For children:

e-Referral Service Selection

  • Specialty: Children's & Adolescents Services
  • Clinic Type: Urology/Surgery – not otherwise specified
  • Service: DRSS-Northern-Children's & Adolescent Services - 15N

Referral Forms

DRSS referral form

Pathway Group

This guideline has been signed off by the Western Locality on behalf of NHS Devon CCG.

Publication date: June 2020

Last updated: 08-06-2020

 

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