Paraphimosis describes the condition when the foreskin of an uncircumcised male is retracted behind the glans penis, with resultant edema. As swelling of the glans increases, the prepuce can no longer return to its anatomic position. This condition is considered a urologic emergency, as prompt reduction is necessary to alleviate further swelling and tissue compromise (1).

Historically, paraphimosis reduction involved either manual reduction or surgical intervention via the dorsal slit technique. While these two modalities continue to be mainstays of definitive treatment, other methods of reduction have gained acceptance. Regardless of the method chosen, prompt recognition and treatment is crucial in preventing further swelling and long-term sequelae.

Paraphimosis occurs exclusively in the partially circumcised or the uncircumcised male. The uncircumcised penis is composed of the penile shaft, the coronal sulcus, the glans penis, and the foreskin. In a prepubertal population, the foreskin becomes increasingly mobile. In the mature penis, the foreskin can normally be retracted to expose the glans. Paraphimosis occurs when the foreskin is retracted proximal to the glans penis behind the coronal sulcus (2). This often occurs in a health care setting with preparation of the penis for catheterization. It can also occur with daily cleaning. Less often, paraphimosis has been reported with body piercing or sexual activity (1,2).

After the foreskin is trapped behind the coronal sulcus, swelling ensues. This swelling results in a tightening ring around the glans. Further edema, with impairment of venous and lymphatic drainage from the glans, leads to increased swelling (3,4). The resultant pressure can cause tissue ischemia and, if unrecognized, can ultimately result in infection or autoamputation (3). Young children can experience acute urinary obstruction (1). Once recognized, it is imperative that the foreskin be reduced to restore blood flow to the glans and prepuce. The edema then rapidly resolves following reduction (5,6).

Paraphimosis reduction is indicated when the foreskin cannot be restored to its anatomic position. The penis should first be inspected and a history obtained to confirm the child is uncircumcised or partially circumcised. The genitals should be inspected for other causes of swelling, including circumferential foreign bodies such as hair or other objects (2). If a diagnosis of paraphimosis is confirmed, reduction techniques should be employed. In general, the least invasive method is first employed, with escalation of interventions as less aggressive measures fail.

Anxiety and pain are two key elements to consider in approaching paraphimosis reduction. Young children often require distraction or sedation to allow further interventions to successfully take place. Enlisting the help of the parents or a child-life specialist, if available, can greatly help in easing anxiety. If the child is still unable to cooperate, the use of sedative agents or restraints are then indicated (see Chapter 33).