A 2-year-old boy presented with paraphimosis. This condition occurs when retraction of the foreskin behind the corona of the penis forms a tight ring that impairs blood and lymph flow from the glans and prepuce. Untreated, paraphimosis can lead to pain, urethral obstruction with urine retention and hydronephrosis, or tissue ischemia (with ulceration, penile gangrene, and auto-amputation of the penis).1
Paraphimosis is most common in infants and young children. The condition is almost always iatrogenic or inadvertently induced in uncircumcised boys after retraction of the foreskin during penile examination, cleaning, or urethral catheterization.1,2 In this child, the most likely cause was penile self-manipulation. The history should include questions about penile manipulation, catheterization, cystoscopy, and self-retraction or retraction by others—including caregivers—during cleaning.
In infants, paraphimosis is often identified by parents during diaper changes. In this case, the father had noticed the abnormality while bathing the child. Affected infants may present with inconsolable crying, whereas older boys may complain of localized pain and voiding difficulties. This patient was in pain on genital examination. However, pain is not always present. The glans appears enlarged with a ring of edematous foreskin surrounding the coronal sulcus. A tight, constricting band of tissue appears behind the head of the penis, while the rest of the penile shaft remains flaccid.3
Evaluation includes inspection of the penis for the presence of foreskin, color of the glans, degree of constriction around the penile corona, and turgor of the prepuce.3 A glans with a pink hue indicates a good blood supply. Also, inspect the scrotum for color, texture, and turgor, and palpate its contents for tenderness, hydrocele, and tumor.
Paraphimosis is a urological emergency. Pain relief, reduction of penile edema, and restoration of the prepuce to its original position are the goals of treatment. Topical or oral analgesia, conscious sedation, or a penile nerve block can relieve the pain.1-3 Ice packs, wraps or manual compression, granulated sugar on the swollen tissue to increase the osmotic gradient, and injection of hyaluronidase(Drug information on hyaluronidase) into the tissue can lessen edema.1,4
Mild to moderate swelling can often be manually reduced, as was the case in this patient. This involves compression of the glans penis with the thumbs while pulling the retracted foreskin over the glans with the fingers. If initial attempts at reduction are unsuccessful, a urologist should be consulted emergently for surgical intervention. Patients with tissue ischemia require a dorsal slit procedure. Circumcision is often recommended to prevent recurrent episodes.