Distinguish three conditions: (1) Phimosis, in which the orifice of a patient's prepuce (foreskin) is too small for his foreskin to be retracted over his penis. (2) Paraphimosis, where his foreskin has retracted, and stuck behind his glans, so that it cannot be brought forward again. (3) A meatal stricture (32.28), in which the external opening of his urethra (his external meatus) is abnormally constricted.
Paraphimosis is the result of forcible retraction of the foreskin. It is common in adolescence, and is fairly common between 8 and 14. Part of his foreskin is tight, so that it becomes oedematous distally. The oedema may be severe. If it has been present for more than a few hours, the base of his penis may be oedematous also. Try to get his foreskin into its normal place over his glans.
Fig. 23-36 PARAPHIMOSIS. A, paraphimosis as the patient presents. B, use the thumbs and forefingers of both your hands to squeeze his swollen foreskin. C, slide the roll of foreskin forwards over his now thinner glans. At the same time push his glans back. D, successful reduction. E, if manual reduction fails make a small dorsal slit and then try again. This is a dorsal view.
PHIMOSIS AND PARAPHIMOSIS PHIMOSIS. Under local or general anaesthesia make a dorsal slit (A 6.15) as in Fig. 23-37.
PARAPHIMOSIS ANAESTHESIA. (1) Ketamine. (2) General anaesthesia.
METHOD. Squeeze the patient's swollen foreskin between the thumbs and index fingers of both your hands, so that the fluid which is making it swell, goes up into the tissues of the shaft. If the swelling is severe, wrap layers of gauze over it and squeeze them. When his foreskin is in its normal place, any residual swelling will usually subside in 24[nd]48 hours.
Alternatively, inject hyaluronidase (''Hyalase'), and local anaesthetic solution, into his oedematous foreskin. This will help manual reduction. If you can bring his foreskin forwards intact, circumcision or a dorsal slit will be easier.
After several minutes of firm squeezing, when the swelling is much reduced, push his glans proximally with your thumbs, and draw his foreskin over it with your fingers.
DIFFICULTIES [s7]WITH PARAPHIMOSIS If you FAIL TO REDUCE HIS PARAPHIMOSIS, the constricting band is too tight. Incise it dorsally and try again.
If HIS PARAPHIMOSIS RECURS, wind a strip of zinc oxide strapping round the end of his penis, leaving the tip of his foreskin free, so that he can micturate. Remove it in 24[nd]48 hours. He may need circumcision later (unusual).
If he PRESENTS LATE, when his foreskin has become infected as the result of a spontaneous split, give him an antibiotic and salt baths three times daily. Sloughing is unusual.
Fig. 23-37 TWO DORSAL SLITS. A, a dorsal slit for paraphimosis. The slit is in the tight circumferential ring, which causes oedema of the foreskin and glans beyond it, and which has been forced back over the shaft of the penis. B, C, and D, a dorsal slit for phimosis, to enlarge the orifice of the foreskin. Kindly contributed by Jack Lange.