In paraphimosis the foreskin is pulled back behind the head of the penis and cannot return, so it acts like a tight band that blocks blood and lymph flow. It is a urologic emergency, often seen after a catheter placement or cleaning when the foreskin was not put back.
Key symptoms
- Painful swelling of the head of the penis
- A tight ring of foreskin stuck behind the glans
- Recent catheter, exam, cleaning or sexual activity
- Trouble urinating in some cases
What you find on exam
- Retracted foreskin forming a tight band behind the glans
- Swollen glans; pink color is reassuring, dark or black suggests poor blood flow
- Look for an indwelling catheter or a piercing
- Tell it apart from balanitis, where the foreskin is not trapped
Tests
- Clinical diagnosis from the exam; imaging is not needed
- Check glans color and capillary refill to judge blood flow
- Urinalysis if there are urinary symptoms or infection is suspected
Treatment basics
- Pain control with a dorsal penile nerve block or topical anesthetic
- Reduce swelling with firm manual compression, ice or small needle punctures
- Manual reduction: push the glans back while pulling the foreskin forward
- If reduction fails, urgent urology for a dorsal slit; circumcision later to prevent repeats
- Always put the foreskin back after catheter placement or cleaning
Red flags
- Dark, black or cold glans suggesting loss of blood flow
- Manual reduction that does not work
- Inability to urinate
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.