Paraphimosis

PARAPHIMOSIS, paraphimosis (popular names: "noose" according to the mechanism of origin and "Spanish collar" according to external appearance), entrapment of the glans penis by the prepucial sac wrapped behind it (Fig. 1).

A necessary condition for the formation of paraphimosis is the presence of a foreskin (the disease is impossible in circumcised individuals). Normally, the prepucial fold is sufficiently elastic and wide so that even in the erect state of the penis it can easily be pulled back behind the glans and uncover it completely. But under certain conditions, such as a short and inelastic frenulum, the glans of the penis when the foreskin (praeputii) is pulled back is deflected downwards, the sulcus behind the upper circumference of the glans (sulcus retroglandularis) becomes deeper, the prepuce gathers into a taut fold, and its reverse reduction is hindered. In some cases, the opening of the prepucial sac is congenitally narrow and therefore uncovering the glans is impossible (see Phimosis). With a moderate degree of narrowing of the prepucial opening, uncovering of the glans occurs with difficulty and the narrowed part pulled behind the glans of the penis is not corrected to its initial position. A long foreskin under unhygienic conditions, under the influence of the decomposition of accumulated smegma, is subject to frequent inflammations (see Balanitis and balanoposthitis) of the inner leaf with the development of erosive processes and subsequent scarring. The development of gonorrheal ulcerations, as well as soft chancre disease located along the edge of the prepucial opening or on the inner leaf, provide the chances for the development of cicatricial strictures, and hence phimosis as the initial moment of paraphimosis. A moment contributing to the drawing of the constricting ring behind the glans is sexual intercourse or an onanistic act. The erect glans of the penis hinders the reverse return of the prepuce into place, the outflow of blood from the cavernous tissue of the glans is prolonged, and this leads to the prolonged presence of the constricting ring behind the glans. By virtue of this, stagnant phenomena develop both in the glans and in the entrapped inner leaf of the foreskin. Following this, edema of the inner leaf develops, and the constricting ring very quickly becomes gangrenous and ulcerates. In childhood, the development of paraphimosis is possible either as a result of mischief or when it is necessary to uncover the glans of the penis in order to carry out certain hygienic measures.

Diagnosis does not present difficulties. Upon examination, the penis is club-shaped and thickened downwards, the glans is dry, dark blue, surrounded by a glassy-shiny, sometimes transparent roll of the edematous inner leaf, which usually covers the tightening ring. When examined in profile, the penis immediately behind the glans is curved downwards. When turning back the roll, it is possible to see changes in the form of ulcerations or gangrene of the tightening ring and surrounding areas. The prevention of paraphimosis boils down to timely incision or circular circumcision of the prepuce in phimosis. Treatment in the initial stages of paraphimosis boils down to an attempt at reduction. The glans and the inner leaf of the prepuce are lubricated with vaseline. The penis is grasped with the thumb and forefinger of the left hand behind the constricting ring (Fig. 2).

With the right hand, with light pressure and kneading, they try to reduce the edematousness of the glans and the inner leaf of the prepuce, pushing the edematous fluid behind the ring. Then gradually, starting from the dorsal part, the glans is reduced behind the constricting ring. The reduction operation is painful and requires a preliminary injection of morphine. Local anesthesia is inappropriate because it increases tissue edema. If reduction fails, incision of the constricting ring is performed under local anesthesia. A grooved probe is brought under it from behind and an incision is made on it. After reduction or incision, the penis is tied upwards (towards the abdomen) for better outflow of edematous fluid. As soon as the edema disappears and the formed ulcerations heal, it is necessary to perform the operation of incision or circular circumcision of the foreskin in order to avoid a repetition of paraphimosis.