Paraphimosis Emergency Reduction (EAU 2024)

Algorithm Steps

1. ▶

   Start

   Paraphimosis Identified

   Foreskin trapped behind glans, unable to reduce

   1. ●

      Action

      Clinical Assessment

      Evaluate severity and tissue viability

      • Swollen, edematous glans and foreskin
      • Constricting band of phimotic ring behind corona
      • Assess for ischemia (color, sensation)
      • Duration of paraphimosis
      • Prior episodes?
      • Recent catheterization or examination?
      1. ◆

         Decision

         Signs of Ischemia/Necrosis?

         Dark discoloration, pain out of proportion

         1. ⚠

            Warning

            ⚠️ Urgent Urology Consult

            Ischemic tissue requires emergent intervention

            • Immediate urology consultation
            • May require emergent dorsal slit
            • Risk of gangrene if delayed
            • Possible partial amputation for necrotic tissue
            1. ●

               Action

               Dorsal Slit Procedure

               Surgical release of constricting band

               • Identify dorsal midline of constricting band
               • Clamp with hemostat at 12 o'clock for hemostasis
               • Incise crushed tissue with scissors/scalpel
               • Cut through phimotic ring
               • This releases constriction immediately
               • Oversew cut edges with absorbable suture
               • Elective circumcision planned later
               1. ✓

                  Outcome

                  Surgical Release Complete

                  Dorsal slit done, plan definitive management

                  • Wound care instructions
                  • Follow-up in 1-2 days
                  • Elective circumcision in 4-6 weeks
                  • Watch for infection
         2. ●

            Action

            Provide Analgesia

            Dorsal penile nerve block + ring block

            • Dorsal penile block: 2-3mL 1% lidocaine at 10 and 2 o'clock
            • At base of penis, just deep to Buck's fascia
            • Ring block: Circumferential at base
            • NEVER use epinephrine on penis
            • Wait 5-10 minutes for effect
            • Consider procedural sedation if needed
            1. ●

               Action

               Reduce Edema

               Compression techniques before manual reduction

               • Apply ice wrapped in cloth for 5-10 minutes
               • Compression wrap with elastic bandage
               • Granulated sugar application (osmotic reduction)
               • Mannitol-soaked gauze (osmotic)
               • Multiple punctures with 21g needle (advanced)
               • Goal: Reduce glans edema to facilitate reduction
               1. ●

                  Action

                  Manual Reduction Technique

                  Primary treatment - attempt before surgical intervention

                  • Apply steady pressure to glans for 3-5 minutes
                  • Squeeze glans with both hands to reduce edema
                  • Simultaneously pull foreskin distally over glans
                  • Thumbs on glans, index fingers on foreskin
                  • Apply firm, steady traction on foreskin
                  • May take several minutes of sustained effort
                  1. ◆

                     Decision

                     Reduction Successful?

                     Foreskin returns to normal position

                     1. ●

                        Action

                        Post-Reduction Care

                        Observe and arrange follow-up

                        • Observe 30-60 minutes for re-paraphimosis
                        • Keep foreskin in normal position
                        • Ice for residual swelling
                        • Analgesia as needed
                        • Urology follow-up in 1-2 days
                        • Elective circumcision strongly recommended
                        1. ✓

                           Outcome

                           Successfully Reduced

                           Arrange elective circumcision to prevent recurrence

                           • High recurrence risk without circumcision
                           • Urology referral for elective surgery
                           • Patient education on prevention