Paraphimosis

Paraphimosis is a urologic emergency in which the foreskin, once retracted behind the glans penis, cannot be moved forward to cover the glans. This creates a constrictive band at the coronal sulcus, leading to venous and lymphatic congestion and potentially reduced arterial inflow if not promptly treated.

Most cases are iatrogenic, occurring after manual or instrumental retraction during catheterization, examination, or procedures when the foreskin is not returned over the glans. It can also result from trauma, infection, balanitis, or underlying phimosis in uncircumcised individuals. Risk is higher in those with preexisting phimosis or poor foreskin retractility.

Clinically, patients present with a swollen, tender glans and a retracted foreskin that cannot be advanced. Pain is common, and there may be urinary difficulty or retention. Signs of evolving ischemia or necrosis include dusky coloration, numbness, or rapidly progressive edema. Diagnosis is clinical, based on examination; imaging is rarely needed unless diagnosis is uncertain or complication is suspected.

Management requires urgent action. Initial treatment aims to reduce the edema and return the foreskin to its normal position. This is typically attempted with lubrication and gentle, steady manual reduction, sometimes aided by analgesia or a regional nerve block. If manual reduction fails, or if there are signs of ischemia or necrosis, urgent urologic consultation is required for procedures such as a dorsal slit or incision to relieve constriction, and possibly circumcision to prevent recurrence. Antibiotics are not routinely required unless infection is present.

Prognosis is favorable with prompt treatment; delays increase the risk of tissue damage, infection, and long-term complications. Prevention focuses on careful handling during procedures and ensuring the foreskin is returned to the correct position after retraction.