Paraphimosis is a urological emergency condition in which the foreskin in an uncircumcised penis stays retracted behind the glans penis for a prolonged period of time instead of reducing to its anatomical position. This can lead to engorged venous and arterial vessels causing reduced blood flow and oxygen to the glans resulting in inflammation of the glans. If prompt treatment is not delivered then this may result in permanent loss of distal glans penis.
Generally, most of the cases are acute in which patients present to the emergency department immediately; however, there are some reported cases of chronic form in which patients present several days after the initiation of the condition.
Paraphimosis is a rare condition affecting males and there are only few cases reported all around the world. Most commonly affected groups are children or elderly males and usually it is an iatrogenically induced condition.
What is The Diagnosis for Paraphimosis?
The diagnosis of paraphimosis is based on the history, clinical examination and signs and symptoms; there are no tests for the diagnosis of paraphimosis. Since, there are no tests for the confirmation of diagnosis; the clinician should pay careful attention to the history of the patient as well as the coinciding signs and symptoms on physical examination.
Generally, pediatric patients present with symptoms of acute urinary obstruction such as weak urinary stream, straining while voiding or sensation of incomplete voiding.
Adult patients mostly complain of penile pain. It is also important to note the initiation of the condition as with increased time duration, the severity of the condition also increases.
The physical examination of the glans penis shows enlarged, erythematous and congested glans with a collar of inflamed foreskin. A constricting band of tissue will be noted behind the glans and the penile shaft will be normal. It is important to observe the early signs of ischemia and necrosis. A soft, pink and supple glans reassures blood flow to the part while a blue black or rigid glans is a concern for early necrosis.
The patients with urinary incontinence usually have catheter in place due to various medical conditions such as prostate enlargement or post pelvic or urinary tract surgery. The removal of the catheter is necessary while considering reduction of the foreskin.
There are various differential diagnoses that can make the diagnosis for paraphimosis difficult. These include allergic reactions (this can be differentiated by the history of changes in detergents/clothing/cleansers and the patch test will be positive and the discontinuation of the allergic factor will subside the signs and symptoms), insect bites (the history will reveal exposure to an insect and it will also present with classic itching along with the visible site of sting and the inflammation will subside by antihistamines), tourniquet syndrome (physical examination will show presence of constricting ring used to enhance erection) and hair coil strangulation (physical examination will reveal the presence of hair coil typically from mother and it will be usually found in infants).
Etiology of Paraphimosis
The most common cause behind paraphimosis is the retraction of foreskin in an uncircumcised penis by a healthcare professional and inadvertently leaving it in the retracted position, instead to reducing it to its anatomical position. Iatrogenically induced paraphimosis can be seen after urological examination, catheterization and cystoscopy.
Paraphimosis can also be caused by varying sexual activities especially in uncircumcised males with narrow opening of the foreskin (known as phimosis) and penile piercings and rings. It can also be caused by partial circumcision, poor personal hygiene, and recurrent bacterial infections such as balanitis, parasitic infestations, lichen sclerosis, diabetes and hemangiomas of the penis.
Paraphimosis is caused by retraction of foreskin behind the glans penis in the presence of phimotic ring, which causes constriction of the glans. This results in vascular engorgement causing secondary edema and the vascular compromise to the distal glans penis leads to ischemia and necrosis of the distal penis.