Other etiologies of penile swelling must be ruled out prior to making the diagnosis of paraphimosis, including tourniquet syndrome, angioedema and balanoposthitis.

• Foreskin remains retracted behind the glans penis, cutting off venous drainage and eventually arterial blood flow to the glans.
• Penile necrosis and infarction of the glans can result in rare cases.

• Diagnosis is clinical. Penile pain and swelling of the glans penis with presence of foreskin in a constricting band proximal to the coronal sulcus.
• Discolouration of the glans hints at potential ischemia or necrosis, and necessitates more prompt treatment.

• Treatment centres around prompt reduction of the foreskin.
• Only attempt manual reduction if necrosis or urinary obstruction is not present.
  • Provide pain control with topical or local infiltrative anesthetic prior to beginning. Procedural sedation often required in younger patients.
  • Provide manual circumferential compression of glans and foreskin for several minutes. When edema has reduced, attempt reduction.
• Other agents to facilitate reduction in swelling can be used, including ice, compression bandages, and osmotic agents such as dextrose solutions and mannitol. These approaches should only be used in non-emergent cases lacking signs of ischemia.
• If these manual strategies fail, surgical approach is used. Consultation to urology should be initiated if time permits.
  • Regional anesthesia with dorsal penile block. Procedural sedation as required.
  • Dorsal incision made to release foreskin.
  • Alternative approaches include needle aspiration of glans, traction with forceps or multiple punctures of the foreskin with a small gauge needle.
  • All patients undergoing dorsal slit procedure should be ultimately treated with delayed circumcision upon complete resolution of symptoms.

Admission to hospital is not typically required for patients presenting with paraphimosis.

Patients requiring urgent surgical reduction may be transferred to a site with urologist coverage, although these procedures should not be delayed for transport if there is a threat of necrosis and permanent damage.

Urology specialist should be consulted in cases of paraphimosis with penile necrosis, complete urinary obstruction, and if manual reduction attempts are unsuccessful.

• Patients should be advised to not retract foreskin for at least one week, and avoid sexual activity for several days.
• Urology follow up is required for patients that underwent surgical management of paraphimosis or those with recurrent paraphimosis.

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