Page 34 - Journal of Special Operations Medicine - Spring 2017

The puncture technique, also known as the Dundee
technique, is often used when anatomic references are
not discernable (Figure 9). A 25-gauge needle may be
used to make puncture holes in the edematous prepuce.
The edema is then expressed from the foreskin with firm
pressure until it is decompressed sufficiently to allow re- Figure 11 The incisions
duction of the prepuce. 15 are approximated with
4-0 rapidly absorbing
sutures after the foreskin
is reduced. Illustration
by Jillian Rae Zehring.

Figure 9 The puncture,
or Dundee, technique
is often used when
anatomic references
are not discernable.
Illustration by Jillian If there is no further tightness or phimotic ring on re-
Rae Zehring. tracting the foreskin during the follow-up, then circum-
cision is only needed for cosmetic reasons. However, if
the methods described failed, then circumcision is the
definitive treatment. Patients with history of recurring
paraphimosis are candidates for circumcision.
The dorsal-slit method is performed with two hemostats
placed at the 12 o’clock position perpendicular to the
corona to crush the foreskin for 2 minutes (Figure 10). Conclusion
4
The foreskin is incised between the hemostats by using Attempting conservative methods before invasive reduc-
a scalpel or Metzenbaum scissors. This will release the tion of paraphimosis is appropriate. It is important for
constricting band of tissue to allow reduction, and the providers to maintain patience and be able to improvise
incisions are approximated with 4-0 rapidly absorbed during procedures. As seen in this case report, multiple
sutures after the foreskin is reduced (Figure 11). 7 methods were required and, ultimately, a circumcision was
performed. The decision to perform the circumcision was
due to the tight appearance of the foreskin on the glans pe-
nis, the concern for poor subsequent follow-up with local
Figure 10 The dorsal
slit method is performed nationals, and the desire of the patient’s parents.
with two hemostats
placed at the 12 o’clock There are no published randomized trials to suggest
position perpendicular to the success of one method over another, likely because
the corona to crush the of limited patient population numbers. However, the
2
foreskin for 2 minutes. methods performed in this case have been shown to be
Illustration by Jillian safe and successful in austere deployed environments
Rae Zehring. with limited resources by providers with limited experi-
ence. Minimal instruments are required: two hemostats,
one Metzenbaum scissors, one 25-gauge 1-inch needle,
and 4-0 Vicryl sutures were the primary instruments
The patient should be instructed to abstain from geni- used for the reduction. Also, telemedicine consultation
tal stimulation for 1 week after successful reduction proved to be easy and effective in supporting the provid-
by conservative methods and up to 6 weeks after in- ers in this time-dependent case in which a patient’s penis
vasive reduction, to prevent suture and incision break- was functionally preserved. Inexperienced providers at
down. Some surgeons may prescribe broad-spectrum all levels would be able to assess and perform the proce-
16
antibiotics and instruct the patient to apply bacitracin dures in a step-wise fashion guided by the consultation.
or petroleum jelly to suture sites daily for 1–2 weeks.
It is recommended that patients wear loose clothing, Acknowledgments
perform proper hygiene, and keep the site dry to avoid
infection. Patients should follow up with a urologist in We thank Dr Janelle Fox and Dr Charles Henderson for
2–3 weeks to assess signs of infection, wound healing, their assistance with the case through virtual consulta-
and need for circumcision. tion, Dr Thomas Lewis for his assistance in reviewing

12 Journal of Special Operations Medicine Volume 17, Edition 1/Spring 2017