PHIMOSIS PARAPHIMOSIS STRANGULATION
A redundant prepuce is normal in the newborn and during early childhood. Phimosis is diagnosed only when the prepuce cannot be replaced over the glans penis after being retracted. If the foreskin is not retracted during early childhood and the congenital adhesions are not released, complete ﬁbrous bands can develop between the prepuce and glans penis. When adhesions are present proximal to the glans corona, the preputial cavity or sulcus behind the glans near the fold of the inner preputial skin may be obliterated. These adhesions may be easily overlooked if the foreskin is partially retracted, exposing just the glans and not the entire preputial sulcus.
Phimosis may be so marked that the opening in the foreskin is pinhole sized. Urinary obstruction is rare but possible, with ballooning of the preputial cavity with urine upon micturition. When infected, the prepuce may become edematous, enlarged, and pendulous, with purulent discharge oozing from the red and tender preputial oriﬁce. The retention of decomposing smegma, retained urine, and epithelium within this cavity may lead to ulcerative inﬂammatory conditions (see Plate 2-21), formation of calculi, and leukoplakia. A phimotic foreskin should be removed in any age group as the risk of acquiring penile cancer is greatly elevated in uncircumcised men demonstrating poor hygiene and retention of such carcinogenic decomposed secretions. Understand, however, that men who demonstrate excellent penile hygiene have no increased risk of contracting penile cancer compared to uncircumcised men. Circumcision has also been demonstrated to reduce the spread of HIV infection among heterosexual men and their partners in endemic areas.
Paraphimosis is a tight retraction of the foreskin behind or proximal to the coronary sulcus. It may result from the retraction of a congenitally phimotic prepuce or from the contraction of an essentially normal prepuce that has become swollen due to either edema or inﬂammation. In this condition, venous and lymphatic drainage is impaired resulting in marked edematous swelling of the prepuce and glans penis distal to the constricting ring. As swelling progresses, the impact of the constriction becomes more serious until the retracted preputial skin is impossible to manually reduce. Severe infection in the form of cellulitis, phlebitis, erysipelas, or gangrene of the paraphimotic foreskin may occur. Ulceration at the point of the constricting band may result in a release of the obstruction. In the event of failure of manual reduction, incisions are made in the constricting band of retracted foreskin to relieve constriction (dorsal slit) and allow for swelling to reside before a formal circumcision is performed.
Placing the penis into rigid devices such as bottles, pipes, and metal rings may result in strangulation similar to that observed with severe paraphimosis. Edema, thrombosis, inﬂammation, gangrene, and sloughing are observed in neglected cases. With small constricting bands, the edema may become so excessive that the constricting object is not visible. Reduction of the device should be attempted before operation, as it may be possible to reduce the edema under anesthesia with constant manual pressure applied distal to the constricting ring. Metal objects, even hardened stainless steel, can be removed under anesthesia with the Gigli saw or jeweler’s saws, mak ng penile amputation from gangrene rarely necessary.