Definition

Paraphimosis is a condition affecting uncircumcised males, where the foreskin, once retracted behind the glans of the penis, becomes trapped and cannot be returned to its original position. This can cause swelling and severe pain. It's deemed a medical emergency because it can restrict blood flow to the tip of the penis. Paraphimosis differs from phimosis, which is when the foreskin is too tight to be pulled back over the glans. Phimosis is more common in children and is generally not considered a serious condition.

Causes

The causes of paraphimosis include the foreskin becoming trapped and unable to be pulled back over the tip or base of the penis. This condition can occur due to several reasons such as

• Pulling back the foreskin during penile hygiene but not immediately returning it to its original position or pulling back the foreskin too forcefully.
• Medical procedures, such as catheterization, where the foreskin needs to be retracted for ease of insertion. Healthcare providers may forget to return the foreskin to its original position, covering the tip of the penis. This condition can also occur during other medical procedures or examinations.
• Having a tight foreskin that is difficult to retract.
• Poor personal hygiene, which can lead to infections.
• History of injury to the genital area.
• Swelling in the penis and foreskin area due to insect bites.
• Piercing of the penis.
• Using a penis ring during sexual intercourse to maintain an erection.
• Diabetes, which can cause chronic inflammation in the penis and foreskin, leading to paraphimosis.

Risk factor

The primary risk factor for paraphimosis is being an uncircumcised male. However, several factors can increase the risk of developing paraphimosis, including:

• Age: While paraphimosis can occur at any age, it is more common during adolescence.
• Poor hygiene habits when cleaning the penis.
• Excessively tight foreskin.
• Previous medical procedures on the penis.
• Occurrence in older males, particularly those with diabetes, catheterization, or previous bacterial infections.

Symptoms

The symptoms of paraphimosis include:

• Inability to retract the foreskin back to its original position covering the tip of the penis.
• Severe pain in the penis.
• Swelling of the foreskin.
• Changes in the color of the tip of the penis to dark red, bluish, or purplish.
• Difficulty urinating.

Diagnosis

The diagnosis of paraphimosis is typically made by the doctor through a combination of symptom inquiry and direct physical examination of the penis. Swelling and severe pain in the affected area are common complaints. During the physical examination, the doctor will observe the swollen and discolored appearance of the penis, which aids in confirming the diagnosis.

In most cases, diagnostic tests are not necessary to establish the diagnosis of paraphimosis. However, if an infection is suspected as the cause, the doctor may recommend further testing.

It's important to note that if the individual has previously undergone circumcision, paraphimosis can be ruled out. Given the urgency of paraphimosis as a medical emergency, prompt action is necessary, and the doctor may advise immediate treatment or referral to the emergency room.

Management

Paraphimosis requires prompt treatment as it is considered a medical emergency due to its potential danger. Treatment options typically administered by a doctor include:

• Pain relief medication administered orally, through anesthetic gel application, or via injections around the penis.
• Attempting reduction, which involves trying to pull the foreskin back to its original position over the tip of the penis. This procedure often requires the use of special fluids or gels to reduce swelling.
• Making a small incision in the trapped skin to facilitate pulling it back over the tip of the penis. This incision is usually made in the upper foreskin, and the doctor provides anesthesia and pain relief medication.
• Circumcision surgery, which involves the removal of some or all of the penile covering skin. This procedure is also conducted under anesthesia and accompanied by pain relief medication.
• Ice application to the penis may help reduce swelling, but there is a risk of further restricting blood flow. Ice is only recommended in cases where severe blood flow obstruction is not evident.

Since paraphimosis can recur, the doctor may recommend circumcision as a preventive measure. Antibiotics may be prescribed if there are signs of infection. While circumcision carries risks such as bleeding and infection, these are inherent to any medical procedure. Following treatment, a follow-up examination should be scheduled 2-3 weeks later, especially if there are signs of infection or if wounds have not healed.

Complications

Obstruction can typically be treated, but if left unattended for too long, it can lead to several complications, such as:

• Kidney failure
• Infection
• Increased likelihood of stone formation

Prevention

The only definitive way to prevent paraphimosis is through circumcision. Other preventive measures are only temporary because the risk of paraphimosis persists as long as the penile foreskin is present. Some additional preventive measures, if circumcision is not performed, include:

• Maintain hygiene by regularly cleaning the tip of the penis.
• Ensure that the foreskin is pulled back to its normal position covering the penis after cleaning, sexual intercourse, or urination.
• Ensure that the foreskin is returned to its normal position after urinary catheterization or other procedures.
• Avoid leaving the foreskin retracted for too long after pulling it back.

When to see a doctor?    

If you experience the above symptoms or if the foreskin cannot be moved back to its original position, seek medical attention immediately. This condition is an emergency and must be addressed promptly. Seek medical attention immediately if the swelling worsens, the pain increases, or if you develop a fever.

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