REFERRAL & SAFETY-NETTING (NO DRUG THERAPY)
Paraphimosis - StatPearls (NCBI Bookshelf NBK459233) - https://www.ncbi.nlm.nih.gov/books/NBK459233/
Paraphimosis is a trapped foreskin strangling the glans, and it happens to adults as often as to boys - most often after somebody retracted the foreskin to clean it or to pass a catheter and did not put it back. Reduction is a bedside manoeuvre and the clock is vascular. The article names local anaesthesia and a topical antibiotic afterwards but states no amount for either, so no dose is printed.
- IT IS AN EMERGENCY BECAUSE THE GLANS IS BEING STRANGLED - paraphimosis is a genuine urological emergency of the uncircumcised male: the foreskin is caught behind the corona and strangles the glans, cutting off its blood supply painfully, so that the tissue beyond engorges with venous blood, swells, and may in the end die.
- IT IS NOT PHIMOSIS, AND THE DIFFERENCE IS THE DIRECTION - in phimosis, by contrast, the foreskin is the one that will not go back behind the glans at all.
- IT IS NOT A CHILDREN'S PROBLEM ONLY - among adults it turns up most often in adolescents, and it will happen to roughly 1% of men past 16 years of age. Between four months and 12 years of age it is the rarest of the foreskin problems, at 0.2%.
- IT IS USUALLY SOMETHING A CARER DID - most cases are iatrogenic: the foreskin gets pulled back to clean, to pass a urinary catheter, for a procedure such as cystoscopy, or simply to examine the penis. Leave it retracted rather than drawing it forward over the glans promptly, and paraphimosis follows.
- SO THE PREVENTION IS ONE SENTENCE - anybody who changes Foley catheters as part of their work must draw the foreskin forward again at the end of it, every time, or a paraphimosis is what results.
- NEVER TRIAGE A REPORT OF PENILE SWELLING OVER THE PHONE - treat any telephone account of a swollen penis as a possible paraphimosis needing treatment at once, and do not write it off as harmless without laying eyes on it. The pain is not always there.
- THE COLOUR OF THE GLANS IS THE TRIAGE - a pink glans means the blood supply is reasonably intact; dark, dusky, pale, blue or black means ischaemia, and perhaps necrosis already. A dusky glans goes to a urologist immediately.
- HOW LONG THERE IS - the arterial flow can fail over a span of hours to days, and once it does the glans is left severely ischaemic and may die.
- SQUEEZE THE SWELLING DOWN FIRST, THEN REDUCE - reduction by hand often goes much better if the glans and the swollen, oedematous foreskin are simply squeezed for some minutes beforehand. The technique: both thumbs on the glans, with the index and middle fingers of both hands around the trapped foreskin; then press slowly and steadily to work the tight portion outwards, forward over the glans. A little lubricant helps. Too much makes the skin so slippery that you cannot keep hold.
- A COMPRESSION BANDAGE BUYS TWENTY MINUTES - another way to compress it is to wrap the swollen part of the penis firmly from the glans towards the base with an elastic bandage 1 inch or 2 inches wide, laying a gauze pad around the oedematous foreskin first. Leave the bandage on for 10 to 20 minutes to bring the swelling down.
- DO NOT PACK IT IN ICE - what is wrong in paraphimosis is that a tight fibrous ring of foreskin has cut off the blood supply beyond it, and many experts therefore advise against ice, which can further reduce the arterial inflow to a part of the penis that may already be ischaemic.
- PAIN RELIEF WHEN SIMPLE PRESSURE IS NOT ENOUGH - a mild, uncomplicated paraphimosis can usually be reduced by hand with neither sedation nor analgesia. Harder or complicated cases may call for a local anaesthetic by dorsal penile block, for systemic analgesia, or for procedural sedation. No strength, volume or maximum is stated in the article, so none is printed.
- REMOVING A CATHETER IS USUALLY UNNECESSARY - taking the Foley out will almost certainly make the reduction easier, but you may then find you cannot get it back in, and you have swapped one problem for another. In most cases the paraphimosis reduces perfectly well with the catheter left where it is.
- AFTERWARDS - clean the foreskin carefully once it is reduced. Treat any surface graze or tear with a topical antibiotic ointment, bacitracin for instance. Tell the patient NOT to pull the foreskin back for one week, and to avoid whatever caused it.
- AND A SUCCESSFUL REDUCTION IS NOT THE END OF IT - getting it back is not treatment enough for the long run. Everyone it happens to is assessed for something definitive - a dorsal slit or a circumcision - to deal with the tight foreskin and stop the paraphimosis returning for good.