Page 33 - Journal of Special Operations Medicine - Spring 2017

Figures 6 and 7 Status post day 2 of reduction of
paraphimosis and day 1 of circumcision.

Figure 8 Manual
pressure is applied
to the edematous
portion of the shaft
and glans penis while
the foreskin is pulled
distally. Illustrations
by Jillian Rae Zehring.

by using the provider’s thumb to push down on the glans
penis while the palm of the other hand encircles the dis-
tal foreskin to help achieve reduction. Blunt Babcock
3
forceps or sharp Adson forceps may be used to grasp and
Discussion
help pull the constricting band over the glans penis. 8,9
Paraphimosis is most common among adolescents and
occurs in 0.7% of uncircumcised boys; however, it can Osmotic agents are used by wrapping gauze soaked with
be seen at any age. In pediatric cases, it may be related mannitol or 50% dextrose around the edematous pre-
3
to congenitally narrow preputial opening. Causes of puce, with minimal intermittent hand compression and
4
paraphimosis in elderly patients are often iatrogenic frequent resoaking of the gauze for 30–45 minutes. 10,11
when the foreskin has failed or forgotten to be returned Another osmotic agent involves applying granulated
to its normal anatomy after catheter placement. In mid- sugar directly to the edematous glans penis and prepuce,
5
dle-aged adults, it can be linked with piercings, lichen which are contained by a finger of a rubber glove for
sclerosis, Plasmodium spp. infection, contact allergy, 1–2 hours. 2,12 After the swelling has decreased, the pre-
chancroid, erotic dancing, and sexual intercourse. puce can be reduced manually. Reported advantages of
4,6
Presentation to a medical care provider can often be de- osmotic agents are their association with minimal pa-
layed by adolescent boys because of embarrassment and tient discomfort compared with other methods. 10
propensity for adventurous activities. 2
The iced-glove technique is used to reduce edema over
The treatment of paraphimosis is an urgent reduction the prepuce and glans penis. Using a glove filled with ice
of the prepuce to its normal anatomy. Removal of an water, the provider invaginates a finger of the glove and
indwelling urethral catheter before manipulation may entraps the edematous portion of the penis. The iced
aid in the success of reducing the paraphimosis; how- glove is left on for 5–10 minutes before attempting the
ever, it is important to know the reason for the initial reduction. 2
placement of the catheter so that it can be replaced fol-
lowing the reduction. It is also recommended that, if Compression bandages can be used to reduce edema
7
necessary, reduction be attempted with adequate anal- by compressing the edema from the glans penis and
gesia and sedation because of the distressing nature of prepuce. The provider wraps an elastic bandage or non-
the condition and treatments. Topical lidocaine gel, a stick, self-adherent tape from distal to proximal over
penile nerve block, and/or procedural sedation may be three increasingly tighter layers. The wrap is left in place
used. Conservative methods include manual pressure, for 20 minutes before attempting reduction. 2
osmotic agents, iced glove, compression bandage, and
injection of hyaluronidase. Invasive techniques include Direct injection of hyaluronidase (250U/mL) into the
the puncture technique and the dorsal slit. There are few prepuce is another nonsurgical treatment. Hyaluroni-
published comparative studies for the success of various dase can break down hyaluronic acid in the extracel-
methods, likely because of the high rates of circumcision lular fluid, decreasing tissue resistance and increasing
in the Western world. 2 solute diffusion between tissues. Using hyaluronidase
13
can delay circulation from returning to the glans penis
Manual pressure is a technique that places pressure on for up to 2 hours and should only be considered if other
the edematous portion of the shaft and glans penis while nonsurgical interventions were unsuccessful and the pa-
the foreskin is pulled distally (Figure 8). It is performed tient desires to keep his foreskin. 14

Paraphimosis Reduction in an Austere Environment 11