Medicine:Paraphimosis

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Paraphimosis
Paraphimosis.jpg
Pronunciation
SpecialtyUrology
ComplicationsGangrene of the glans penis
TypesPhysiological, pathological
CausesIatrogenic, handling foreskin improperly
Risk factorsPhimosis, uncircumcised
PreventionReturning foreskin to unretracted position after retraction, foreskin stretching, circumcision
TreatmentManual reduction, circumcision
Frequency0.2% (uncircumcised children)[3]

Paraphimosis is an uncommon[4] medical condition in which the foreskin of a penis becomes trapped behind the glans penis, and cannot be reduced (pulled back to its normal flaccid position covering the glans). If this condition persists for several hours or there is any sign of a lack of blood flow, paraphimosis should be treated as a medical emergency, as it can result in gangrene.[4][5][6]

Causes

Paraphimosis is usually caused by medical professionals (iatrogenic) or parents who handle the foreskin improperly.[4][6] The foreskin may be retracted during penile examination, penile cleaning, urethral catheterization, or cystoscopy; if the foreskin is left retracted for a long period, some of the foreskin tissue may become Oedematous (swollen with fluid), which makes subsequent reduction of the foreskin difficult.[citation needed]

Prevention and treatment

Paraphimosis can be avoided by bringing the foreskin back into its normal, forward, non-retracted position after retraction is no longer necessary (for instance, after cleaning the glans penis or placing a Foley catheter). Phimosis (both pathologic and normal childhood physiologic forms) is a risk factor for paraphimosis;[5] physiologic phimosis resolves naturally as a child matures, but it may be advisable to treat pathologic phimosis via long-term stretching or elective surgical techniques (such as preputioplasty to loosen the preputial orifice or circumcision to amputate the foreskin tissue partially or completely).[citation needed]

The foreskin responds to the application of tension to cause expansion by creating new skin cells though the process of mitosis. The tissue expansion is permanent. Non-surgical stretching of the foreskin may be used to widen a narrow, non-retractable foreskin.[7] Stretching may be combined with the use of a corticosteroid cream.[8][9] Beaugé recommends manual stretching for young males in preference to circumcision as a treatment for non-retractile foreskin because of the preservation of sexual sensation.[10]

Paraphimosis can often be effectively treated by manual manipulation of the swollen foreskin tissue. This involves compressing the glans penis and moving the foreskin back to its normal position, perhaps with the aid of a lubricant, cold compression, and local anesthesia as necessary. If this fails, the tight edematous band of tissue can be relieved surgically with a dorsal slit,[4][6] or a circumcision.[11][12][13][14][15] An alternative method, the Dundee technique, entails placing multiple punctures in the swollen foreskin with a fine needle, and then expressing the edema fluid by manual pressure.[12] According to Ghory and Sharma, treatment by circumcision may be elected as "a last resort, to be performed by a urologist".[16] Other experts recommend delaying elective circumcision until after paraphimosis has been resolved.[4] A non-invasive method is the application of granulated sugar to induce transfer of the hypotonic fluid out of the edematous tissue towards the wet sugar via osmotic gradient, to reduce swelling and enabling manual reduction. [6]

References

  1. ↑ OED 2nd edition, 1989 as /ˌpærəfaɪˈməʊsɪs/.
  2. ↑ Entry "paraphimosis" in Merriam-Webster Online Dictionary.
  3. ↑ Paraphimosis. 2020-07-01. PMID 29083645. https://www.ncbi.nlm.nih.gov/books/NBK459233/. Retrieved 2020-07-16. 
  4. ↑ 4.0 4.1 4.2 4.3 4.4 "Paraphimosis". eMedicine. October 7, 2009. http://emedicine.medscape.com/article/442883-overview. "Patients with severe paraphimosis that proves refractory to conservative therapy will require a bedside emergency dorsal slit procedure to save the penis. A formal circumcision can be performed in the operating room at a later date... At a later date, a formal circumcision can be performed as an outpatient procedure." 
  5. ↑ 5.0 5.1 "Phimosis and Paraphimosis". eMedicine. April 28, 2010. http://emedicine.medscape.com/article/777539-overview. "Patients with phimosis, both physiologic and pathologic, are at risk for developing paraphimosis when the foreskin is forcibly retracted past the glans and/or the patient or caretaker forgets to replace the foreskin after retraction." 
  6. ↑ 6.0 6.1 6.2 6.3 "Paraphimosis: current treatment options". American Family Physician 62 (12): 2623–6, 2628. December 2000. PMID 11142469. http://www.aafp.org/afp/20001215/2623.html. "If a severely constricting band of tissue precludes all forms of conservative or minimally invasive therapy, an emergency dorsal slit should be performed. This procedure should be performed with the use of a local anesthetic by a physician experienced with the technique... Circumcision, a definitive therapy, should be performed at a later date to prevent recurrent episodes, regardless of the method of reduction used... Granulated sugar has shown to be effective in the treatment of paraphimosis, based on the principle of fluid transfer occurring through osmotic gradient. Granulated sugar is generously spread on the surface of the edematous prepuce and glans. The hypotonic fluid from the edematous prepuce travels down the osmotic gradient into the sugar, reducing the swelling and allowing for manual reduction.". 
  7. ↑ "Non-surgical management of phimosis". The Australian and New Zealand Journal of Surgery 59 (12): 963. December 1989. doi:10.1111/j.1445-2197.1989.tb07640.x. PMID 2597103. 
  8. ↑ "Phimosis: stretching methods with or without application of topical steroids?". The Journal of Pediatrics 147 (5): 705–6. November 2005. doi:10.1016/j.jpeds.2005.07.017. PMID 16291369. 
  9. ↑ "Long-term efficiency of skin stretching and a topical corticoid cream application for unretractable foreskin and phimosis in prepubertal boys". Urologia Internationalis 82 (1): 81–8. 2009. doi:10.1159/000176031. PMID 19172103. 
  10. ↑ "The causes of adolescent phimosis". Br J Sex Med (September–October): 26. 1997. 
  11. ↑ "Phimosis, Adult Circumcision, and Buried Penis". eMedicine. April 15, 2009. http://emedicine.medscape.com/article/442617-overview. "Reduction of the foreskin under sedation is almost always possible. However, in some situations, a dorsal slit or circumcision is required" 
  12. ↑ 12.0 12.1 to be 5 "Reduction of paraphimosis the simple way - the Dundee technique". BJU International 83 (7): 859–60. May 1999. doi:10.1046/j.1464-410x.1999.00119.x. PMID 10368214. http://www3.interscience.wiley.com/journal/119091336/abstract. 
  13. ↑ Surgical care at the district hospital. World Health Organization. 2003. pp. 9–10. ISBN 92-4-154575-5. 
  14. ↑ First Aid for the Emergency Medicine Clerkship. 2006. pp. 231. ISBN 0-07-144873-X. 
  15. ↑ Pediatric Urology for the Primary Care Provider. 2008. pp. 80. ISBN 978-1-55642-785-5. 
  16. ↑ "Phimosis and Paraphimosis". eMedicine. April 28, 2010. http://emedicine.medscape.com/article/777539-treatment. 

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