dr. MOCH. SYAHRONI FAR, SpU, M.Kes

BACKGROUNDPhimosis refers to the inability to retract the distal foreskin over the glans penis

Paraphimosis is the entrapment of a retracted foreskin behind the coronal sulcus. Paraphimosis is a disease of uncircumcised or partially circumcised males

PHYSIOLOGIC PHIMOSISPhysiologic phimosis occurs naturally in newborn malesPhysiologic phimosis results from adhesions between the epithelial layers of the inner prepuce and glansThese adhesions spontaneously dissolve with intermittent foreskin retraction and erections, so that as males grow, physiologic phimosis resolves with age

PATHOLOGIC PHIMOSISPathologic phimosis defines an inability to retract the foreskin after it was previously retractible or after puberty, usually secondary to distal scarring of the foreskin caused byPoor hygiene and recurrent episodes of balanitis or balanoposthitisForceful retraction of the foreskin leads to microtears at the preputial orificeElderly persons are at risk of phimosis secondary to loss of skin elasticity and infrequent erections

PATOPHYSIOLOGYPARAPHYMOSISPatients with phimosis, both physiologic and pathologic, are at risk for developing paraphimosisthe patient or caretaker forgets to replace the foreskin after retractionPenile piercings increase the risk of developing paraphimosis if pain and swelling prevent reduction of a retracted foreskin

PATOPHYSIOLOGYPARAPHYMOSISWith time, impairment of venous and lymphatic flow to the glans leads to venous engorgement and worsening swellingAs the swelling progresses, arterial supply is compromised leading to penile infarction/necrosis, gangrene, and eventually, autoamputation

PHYSIOLOGIC vs PATHOLOGIC

PHYMOSIS : PHYSICAL FINDINGSThe foreskin cannot be retracted proximally over the glans penis.In physiologic phimosis, the preputial orifice is unscarred and healthy appearing.In pathologic phimosis, a contracted white fibrous ring may be visible around the preputial orifice

PARAPHYMOSIS

PARAPHYMOSIS : PHYSICAL FINDINGSThe foreskin is retracted behind the glans penis and cannot be replaced to its normal position.The foreskin forms a tight, constricting ring around the glans.With time, the glans becomes increasingly erythematous and edematous.The glans penis is initially its normal pink hue and soft to palpation. As necrosis develops, the color changes to blue or black and the glans becomes firm to palpation

DIFFERENTIAL DIAGNOSISOedema anasarca, Angioedema Balanitis, Bites, Insects , Cellulitis, dermatitis, Contact Foreign body tourniquet, including hair, thread, metallic object, or rubber bands Penile carcinoma Penile fracture, Penile hematomaPhimosis and paraphimosis are clinical diagnoses, and laboratory and imaging studies are not indicated.

PHYMOSISMANAGEMENT

Betamethasone dipropionate 0.1 -0.05% applied to the preputial orifice twice a day for 4-6 weeks, or hydrocortisone 1 %Dorsal Slit or CircumsisionAntibiotic and anti-inflamatory drug for balanopostitis or after surgery treatment

DORSAL SLIT ANDCIRCUMSISION

PARAPHYMOSISMANAGEMENT

Manual reductionOsmotic methodPuncture methodHyaluronidase methodAspirationVertical incision

MANUAL REDUCTIONThe glans is pushed back through the prepuce with the help of constant thumb pressure while the index fingers pull the prepuce over the glans.Soaking the penis in a glove full of ice for 5 minutes before manual reductionAn elastic bandage can also be wrapped from the glans to the base of the penis for 5 minutes to minimize edemaNoncrushing clamps can be placed on the constricting portion of the foreskin at the 3- and 9-o'clock positions to apply gentle continuous symmetrical traction

OSMOTIC METHODHoney or Granulated sugar spread over the glans and foreskin for 2 hours has been shown to facilitate manual reductionAlternatively, a swab soaked in 50 mL of 50% dextrose (more readily available in the ED) can be wrapped around the glans and foreskin for an hour prior to attempting reduction

PUNCTURE METHOD

This method requires the use of a 21- to 26-gauge needle to puncture openings into the foreskin to allow edematous fluid to escape from the puncture sites during manual compression. Successful reductions have been reported with single and up to 20 punctures

HYALURONIDASE METHOD

The puncture method can be enhanced by the injection of 1-mL aliquots of hyaluronidase (using a tuberculin syringe) into one or more sites of the edematous prepuce. It is thought that hyaluronidase disperses extracellular edema by modifying the permeability of intercellular substance in connective tissue

ASPIRATION

A tourniquet is applied to the shaft of the penis. A 20-gauge needle is then used to aspirate 3-12 mL of blood from the glans, parallel to the urethra. This reduces the volume of the glans sufficiently to facilitate manual reduction.

VERTICAL INCISION

Dorsal Slit / dorsumsisiIf none of the above methods are successful, the constricting band of the foreskin should be incised using a 1-2 cm longitudinal incision between two straight hemostats placed in the 12-o'clock position for hemostasis

THANKs A LOT..

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