Genital problems are not pleasant for anyone involved, especially the patients. Whether twisted (ex, Ovarian Torsion, Testicular Torsion, Appendix Testis Torsion) or inflamed (ex, phimosis, PID) they are painful and garner much attention. One condition that will unquestionably grab everyone’s attention is Paraphimosis. Let us review some strategies to manage Pediatric Paraphimosis:

Pediatric Paraphimosis: Basics

• Paraphimosis occurs when retracted foreskin become entrapped behind the coronal sulcus. [Burstein, 2017; Clifford, 2016]
  • The retracted foreskin becomes swollen and begins constricting the glans.
  • The swollen glans prevents reduction of the retracted foreskin.
  • Continued constriction leads to worsening obstruction of venous drainage, and eventually can compromise perfusion.

• Presents:
  • In young children and infants:
    • After foreskin has been forcibly retracted in attempt to clean area or insert urethral catheter.
    • Often noticed during diaper change.
  • In adolescents:
    • After foreskin has been retracted during sexual intercourse or other “endeavors,” like genital piercing. [Clifford, 2016]
    • May present in delayed fashion — possible related to embarrassment.

• May lead to severe complications:
  • Necrosis of the glans penis [Palmisano, 2018]
  • Partial amputation of the penis
  • Time needed to develop these complications is unclear, but their potential creates appropriate urgency. [Clifford, 2016]

Pediatric Paraphimosis: Management Strategies

• Pain Management
  • Attempts to reduce the entrapped foreskin should NOT be done without first addressing the significant pain that they child is/will be in.
  • While systemic analgesics may be used (ex, IN fentanyl or IN ketamine; Nitrous Oxide), often local therapies will be most helpful.
    • Regional Dorsal Penile Nerve Block [Flores, 2015]
    • Topical anesthetics applied for ~30 minutes (often with combination of slight compressive device): [Burstein, 2017]
      • LET (Lidocaine 4%, Epinephrine 0.1%, Tertracaine 0.5%)
      • Lidocaine 2% gel 
      • EMLA (cut thumb off glove; fill thumb with EMLA cream; place over affected penis; leave in place for 30 min) [Khan, 2014]
  • May require procedural sedation.
    • Some techniques have shown favorable outcomes using topical anesthetic without requiring procedural sedation, but each case needs to be considered individually. [Burstein, 2017]
    • “It always takes longer than you anticipate.” [Clifford, 2016]

• Reduce the Swelling
  • Pain must be managed first!
  • Often a combination of compression and osmotic agents is used to help reduce the edema before attempts at reduction.
  • Compressive Bandage [Clifford, 2016; Pohlman, 2013]
    • Using flexible, self-adherent bandage, wrap the penis from distal aspect to proximal.
    • Place first layer loosely, with subsequent 2nd and 3rd layer progressively tighter.
    • Some advocate to merely do this manually.
  • “Iced Glove”
    • Place ice with some water in a glove.
    • Invaginate the thumb of the glove.
    • Place affected penis in the thumb portion of the “iced glove” and hold in place.
  • Osmotic agents:[Clifford, 2016]
    • Mannitol soaked gauze [Anad, 2013]
      • Gauze soaked in 20% mannitol.
      • Wrapped gauze around prepuce and apply gentle hand pressure.
      • Re-soak gauze as needed.
      • Continue for 30-45 min.
    • Granulated Sugar
      • Cover affected area with fine, granulated sugar.
      • Can place sugar in finger of glove and insert affect penis into that.
    • Glucose 50%
      • Similar to the mannitol procedure, but using glucose instead.

• Reduce the Foreskin [Clifford, 2016]
  • Even after the application of osmotic agents and/or compression, more edema will likely remain, so be patient!
  • Gentle and steady pressure placed on the retracted foreskin in an effort to move it over the glans should be maintained.
  • While attempting to slide foreskin over glans, compression of the glans can help with reduction.

• Consider Invasive Strategies [Clifford, 2016]
  • If non-invasive techniques have not yielded success… likely need to try longer… but, if you have tried longer and need to move onward, there are some options.
  • Inject Hyaluronidase [DeVries, 1996]
    • Injection of 1mL aliquots of hyaluronidase via tuberculin syringe into one or more sites of the swollen foreskin.
    • Allows edema to more more freely within tissue.
  • Poke the Swollen Foreskin [Reynard, 1999; Barone, 1993]
    • “Perth-Dundee” technique
    • Using small gauge needle to “poke” the foreskin to assist with drainage of edema
    • May be one hole or many.
  • Aspirate the Glans
    • Apply tourniquet to shaft of penis (seems counterintuitive).
    • Insert 20-gauge needle parallel to the urethra; aspirate 3-12 mL of blood from glans to reduce its size.
  • Dorsal slit procedure
    • Incision of the constructive foreskin to aid in its reduction.
    • RARELY needed.

• Call for Backup [Clifford, 2016]
  • Consult your surgical team (ex, urologist, pediatric surgeon) if:
    • Your attempts have failed
    • You have concern for ischemic changes

• Follow-up Care [Clifford, 2016]
  • Ensure that the patient can urinate before discharging.
  • Educate family/patient:
    • Expect dysuria and/or hematuria for 1-2 days.
    • Do NOT retract the foreskin for ~2 weeks.
    • Arrange for surgical follow up in 2-3 wks to review potential need for circumcision.

Moral of the Morsel

• Be gentle.
  • Do not start without addressing Pain First!
  • Consider the topical application of LET (or similar) to get things started.
  • Could also apply LMX to region where dorsal penile nerve block may be preformed later (if needed).
• Reduce the Edema! Either by compression or osmotic agents… or both!
• Be patient! It will take longer than you think.

References