Paraphimosis

Paraphimosis?

Don't Panic!

When the foreskin is trapped behind the glans and can not go forward, that is called paraphimosis.

It may mean no more than being the owner of a broad glans and/or a short foreskin, but it can be a medical emergency.

If the retracted foreskin becomes swollen with fluid (oedematous), its appearance can be very alarming. This may happen if you fall asleep with your foreskin retracted, for example. If its colour is bright red, there is no need for concern - yet.

If you have a retracted foreskin and

pain
inability to urinate (piss)
a tight band around the back of the glans, and/or
a firm or hard glans (with no erection)

it is very important to bring the foreskin forward to its normal position. If this is not done, the tissues may die from want of fresh (oxygenated) blood and the glans may even fall off! The dead (necrotic) tissue is black.

This is one of the very few things that can go seriously wrong with an intact penis and not a circumcised one. (So it's a wonder it hasn't been heavily promoted as a reason to circumcise babies.)

How to bring it back
You can probably bring your foreskin back yourself. The procedure is very like getting a tight ring off your finger. The essence of getting the glans back through the foreskin is not stretching the foreskin, but compressing the glans. Gently squeezing it and pushing it with your thumbs will press the blood back down the penis and make it smaller. It can then be pushed back through the narrowest part of your foreskin. A drop or two of something slippery like cooking oil or sexual lubricant on the glans may help.

If the patient is a child, the person reducing the paraphimosis by this method needs to know that the process will hurt, but only momentarily.

One good way to reduce the swelling is by covering the penis in ordinary (granulated) sugar. This draws the fluid out of the penis by osmosis (the old high school water-through-a-membrane trick).

If this fails, it is important to see a doctor. S/he can draw off the fluid with a hypodermic needle or, as a last resort, cut through the tight band.

Recently another method has been recommended, the "Dundee technique". This involves pricking the swollen prepuce about 20 times (under anaesthetic) and letting the fluid escape.

The doctor may then recommend circumcision or try to order it, maybe telling you tales of necrosis, gangrene and autoamputation ("You penis will fall off!") to scare you into it. Circumcision will remove any chance of this happening again. But if the doctor has put a slit in your foreskin, that is probably enough and it won't happen again. Otherwise, it's up to you whether you think you can trust yourself to act in time next time - as you did this time. You're hardly likely not to notice that your foreskin is retracted. It also depends how much you value your foreskin.

The commonest cause of paraphimosis is iatrogenic (doctor-caused), when a catheter (drainage tube) is put in your penis and your foreskin is not brought forward again - probably because the doctor or nurse is unfamiliar with the normal foreskin. (Picture of a iatrogenic paraphimosis. Note the catheter.) The catheter pushing out from inside and the foreskin constricting from outside combine to produce the paraphimosis. The catheter needs to be removed before the paraphimosis is reduced. No catheter, no paraphimosis, and no need for circumcision. The catheter can be put back, the foreskin pulled forwards and paraphimosis will not occur again.

Veteran Intactivist Marilyn Milos RN writes:

For paraphimosis, gently squeeze the glans to get the extra fluid out of the glans (which is like a sponge) and, if that is not sufficient, warm a little water with lots of sugar in it, soak a piece of gauze or fabric in the sugar solution and wrap it around the glans, leave it for 10-15 minutes. The sugar will draw out extra fluid and the foreskin should be able to be returned to its forward position. If it's still tight, put
the penis, where the foreskin begins, between the first two fingers (like you would hold a syringe, or a cigarette), then push the glans into the foreskin until you feel it "pop" in. Sometime, with a child, this hurts a little, but just for a moment and then suddenly the anxiety and pain are both gone and everything is back to normal.

I am easily able to talk parents through this over the telephone and have spared a lot of boys the trouble and trauma of being taken to an emergency room.

For information about the opposite case, a foreskin that will not go back behind the glans, see phimosis.

Based on an article and a pamphlet in the American Family Physician, but written in a more foreskin-friendly way. This page may not offer medical advice, but a doctor has checked and approved it.

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The Dundee Technique

The Dundee technique is reported in BJU International 83 (7), 859-860: "Reduction of paraphimosis the simple way - the Dundee technique" by J.M. Reynard and J.M. Barua.

"In most cases, ring-block local anaesthesia using 10 - 20 Ml of 0.5% marcain was used; in three cases general anaesthesia was used... The oedematous [fluid-swollen] prepuce was cleaned with an antiseptic cream. A 26 G needle (outer diameter 0.45 mm) was used to make approximately 20 puncture holes in the oedematous prepuce. Using gentle but firm pressure, the oedema fluid was expressed from the foreskin until it had been completely decompressed, allowing easy reduction of the prepuce."

Out of 17 patients treated by this method, 12 were not later circumcised, nor did they suffer from paraphimosis again.