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.
