La parafimosis debe considerarse una situación urgente: la retracción de un prepucio demasiado estrecho

por detrás del glande, en el cuello del glande, puede constreñir el cuerpo del pene y producir edema.
Dificulta la perfusión distalmente a partir del anillo constrictor y entraña un riesgo de necrosis
Diagnóstico
Se realiza mediante exploración física. La parafimosis se caracteriza por un prepucio retraído con el anillo
constrictor localizado a la altura del cuello del pene, lo que impide la recolocación del prepucio sobre el
glande.
2.3 Tratamiento
El tratamiento de la parafimosis consiste en compresión manual del tejido edematoso con un intento
subsiguiente de retracción del prepucio tensado sobre el glande del pene. La inyección de hialuronidasa
por debajo de la banda estrecha puede ser útil para liberarla (18) (grado de comprobación científica: 4,
grado de recomendación: C). Si fracasa esta maniobra, se requiere una incisión dorsal del anillo
constrictor. En función de los hallazgos locales, se practica una circuncisión inmediatamente o bien puede
realizarse en una segunda sesión.

Paraphimosis
Introduction
Paraphimosis is a true urologic emergency that occurs in uncircumcised males when the foreskin
becomes trapped behind the corona of the glans penis, leading to strangulation of the glans as
well as painful vascular compromise, distal venous engorgement, edema, and even necrosis. By
comparison, phimosis is the condition when the foreskin is unable to be retracted behind the
glans of the penis.[1]
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Etiology
Paraphimosis commonly occurs iatrogenically, when the foreskin is retracted for cleaning,
placement of a urinary catheter, a procedure such as a cystoscopy, or for penile examination.
[1] Failure to return the retracted foreskin over the glans promptly after the initial retraction can
lead to paraphimosis. Other, less common causes include penile coital trauma and self-inflicted
injuries.
It is essential that all caregivers who regularly change Foley catheters routinely replace the
foreskin at the end of the procedure to prevent the development of a paraphimosis.
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Epidemiology
In uncircumcised children, four months to 12 years old, with foreskin problems, paraphimosis
(0.2%) is less common than other penile disorders such as balanitis (5.9%), irritation (3.6%),
penile adhesions (1.5%), or phimosis (2.6%).[2]
In adults, paraphimosis is most commonly found in adolescents. It will occur in about 1% of all
adult males over 16 years of age.
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Pathophysiology
If a constricting band of the foreskin is allowed to remain retracted behind the glans penis for a
prolonged period, it can lead to impairment of distal venous and lymphatic drainage as well
as decreased arterial blood flow to the glans. Arterial blood flow can become affected over the
course of hours to days. This change can ultimately lead to marked ischemia and potential
necrosis of the glans.[3]
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Histopathology
At birth, there is normal physiologic phimosis due to natural adhesions between the glans and the
foreskin. During the first 3 to 4 years of life, debris, such as shed skin cells, accumulates under
the foreskin, gradually separating it from the glans. Intermittent penile erectile activity, such as
nocturnal erections, also contributes to the increased mobility of the foreskin, ultimately allowing
it to become completely retractible.
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History and Physical

When evaluating a patient with paraphimosis, a pertinent history is important. This history
should include any recent penile catheterizations, instrumentation, cleaning, or other procedures.
[1] The patient should be asked about his routine cleaning of the penis and if he or a caregiver
routinely retracts the foreskin for any reason. It is also important to ask if the patient is
circumcised or uncircumcised. It is still possible to develop paraphimosis in a patient who has
previously been circumcised. This can be due to the patient believing he was circumcised when
he was not or excessive remaining foreskin despite the circumcision.
Typical paraphimosis symptoms include erythema, pain, and swelling of foreskin and glans due
to the constricting ring of the phimotic foreskin. It may sometimes be described by patients as
"penile swelling" and may be relatively painless. Clinicians are cautioned to be suspicious of any
telephone description of "penile swelling" as potentially being a paraphimosis that requires
immediate treatment and not to dismiss such descriptions as harmless without actually
visualizing the lesion. Sometimes a photo sent from the patient's smartphone may be enough to
settle the issue.
The history usually makes the diagnosis, but if not, it will be obvious on direct physical
examination. The physical exam should focus on the penis, foreskin, and urethral catheter (if
present). A pink color to the glans indicates reasonably good blood supply, whereas a dark,
dusky, pale, bluish or black color implies possible ischemia or even necrosis.
If a Foley catheter is in place, it's recommended to review the reason why the catheter was
needed and whether any difficulties were encountered in placing it, prior to its removal. While
removing the Foley will almost certainly aid in reducing the paraphimosis, in some
circumstances it may prove to be impossible to replace the catheter and now the caregiver is
faced with a new problem. Most of the time, removal of the Foley is not necessary to
successfully reduce the paraphimosis.[1]
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Evaluation
The patient typically presents with acute, distal, penile pain and swelling, but the pain is not
always present. The glans and foreskin typically are markedly enlarged and congested, but the
proximal penile shaft is flaccid and unremarkable. A tight band of constrictive tissue is present,
often preventing the easy manual reduction of the foreskin over the glans. Diagnosis is made
clinically by direct visualization, as well as the inability to easily reduce the retracted foreskin
manually.
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Treatment / Management
Mild, uncomplicated paraphimosis may be reduced manually, usually without the need for
sedation or analgesia. More difficult or complicated cases may require local anesthesia with a
dorsal penile block, systemic analgesia, or procedural sedation.
Several methods of reduction are available and can be classified into manual reduction or
surgical repair.
Manual, non-surgical reduction of the paraphimosis is possible with or without compression
methods, using osmotic agents and puncture-aspiration techniques.
Manual reduction of paraphimosis can often be facilitated by simple compression of the glans
and the swollen, edematous foreskin for several minutes before attempting the reduction. This
allows the edematous swelling of the retracted foreskin to diminish before attempting
repositioning of the foreskin to its usual position. One simple method involves manually
compressing the edematous foreskin while pulling slowly upward on the phallus.
Manual reduction can also be attempted by placing both thumbs over the glans with both index
and long fingers surrounding the trapped foreskin. Then slow, steady pressure is applied to
advance the phimotic portion of the foreskin outwards slowly, back over the glans. This can be
facilitated with a little lubricant. Excessive lubricant should be avoided as it may make the skin
too slippery for reliable grasping.[4]
Another compression technique involves tightly wrapping the swollen portion of the penis from
the glans towards the base with a 1-inch or 2-inch elastic bandage. A gauze pad should be
applied first around the edematous foreskin. The compression bandage can remain for 10 to 20
minutes to minimize the edema. Then apply one of the manual reduction methods described
above.[5]
Ice packs or surgical gloves filled with ice and applied to edematous areas have been described
as possibly useful in conjunction with other methods to reduce the paraphimotic swelling.
However, since the main issue in paraphimosis is distal penile vascular compromise from a
constricting fibrous band of the phimotic foreskin, many experts recommend against using ice in
these situations as it may further compromise arterial inflow to the possibly ischemic portion of
the penis.
Another possible compressive treatment method involves cutting the thumb from a surgical
glove to make a "sleeve" and emptying a tube of EMLA cream (2.5% lidocaine and 2.5%
prilocaine; AstraZeneca, London, UK) or similar into the sleeve. This is then placed over the
penis and left for approximately 30 minutes. This allows for local anesthesia and softening of
affected skin to aid in foreskin reduction. However, while it does provide some analgesic relief,
it may make the skin a little more slippery and harder to manipulate.[6]
Reducing the penile edema from paraphimosis can also be achieved by directly injecting
hyaluronidase into the edematous foreskin. This has been effective, particularly in children and
infants, in resolving the edema, allowing for an easier manual reduction of the paraphimosis. The
hyaluronidase increases the diffusion of trapped fluid within the tissue planes of the
malpositioned foreskin, which reduces the swelling and edema.[7]
Osmotic methods involve applying substances with a high solute concentration on the external
skin surfaces of the edematous tissue. This would tend to draw water along an osmotic gradient
and thereby reduce the edema. For example, a generous topical application of granulated sugar to
the affected glans and foreskin has been shown to be effective in helping reduce edema from
paraphimosis.[8]
Gauze soaked in 20% mannitol solution has also been used as an osmotic agent to reduce the
edema from paraphimosis. The gauze is left in place for 30 to 45 minutes. It has been reported to
completely eradicate the troublesome edema allowing for easy resolution of the paraphimosis
with manual techniques, as described above. This technique is relatively painless and is well
suited for children.[9]
In many cases, no additional local anesthetic or analgesia is needed, but if the paraphimosis is
long-standing, extremely painful, or severe, then a formal penile anesthetic block can be used. A
dorsal penile block is performed using a 25-gauge or 27-gauge needle, infiltrating approximately
2.5 mL of 1% lidocaine without epinephrine into the base of the penis at the junction of the penis
and suprapubic skin at the 10 o'clock position, off the midline to avoid the superficial dorsal
vein. Another 2.5 mL is injected at the 2 o'clock position. Inject the lidocaine just deep to Buck's
fascia, approximately 3 mm to 5 mm beneath the skin, ensuring negative blood aspiration before
injecting. Ultrasound guidance has been shown to be effective in helping to identify landmarks
for this procedure.[10]
Puncture and aspiration methods are more invasive and should be reserved for cases refractory to
other less-invasive techniques. The puncture technique involves puncturing the edematous
foreskin several times with a hypodermic needle followed by manual expression of edematous
fluid through the puncture holes. Experienced emergency practitioners can consider penile
corporal aspiration of blood.
Surgical treatment of the paraphimosis will be required if the previously described manual
reduction methods are unsuccessful. Prepare the penis and prepuce with a povidone-iodine or
similar antiseptic solution. This can be achieved after the previously-described penile block. One
method involves applying two straight hemostats to grab the dorsum of the constricting foreskin
at the 12 o'clock position. This is followed by making a 1 cm to 2 cm longitudinal incision of the
constricting band of edematous foreskin between the hemostats, which allows for passage over
the glans. The incised foreskin is not reapproximated after reduction, but the edges are oversown
with a 3-0 or 4-0 absorbable suture. This will leave the phimotic portion of the foreskin widely
separate and open to prevent recurrences.
Ischemia leading to necrosis and gangrene of the glans and distal urethra can occur.
Management of such a severe complication of paraphimosis is typically partial penectomy,
resection of the glans and/or excision of the necrotic penile tissue. Recently, conservative
management of a case of necrosis of the glans from paraphimosis in a 25 year old was described
with suprapubic tube drainage and careful surgical debridement which provided a reasonably
good result without penile amputation.[11]
An elective circumcision or dorsal slit procedure is strongly recommended in all patients
who have had a significant paraphimosis due to the very great risk of a recurrence.
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Differential Diagnosis
 Acute angioedema
 Allergic contact dermatitis
 Anasarca
 Balanitis
 Balanitis xerotica obliterans
 Cellulitis
 Foreign body tourniquet
 Insect bites
 Penile carcinoma
 Penile fracture
 Penile hematoma
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Prognosis
The prognosis with paraphimosis is excellent if diagnosed and treated promptly. There may be
some bleeding during skin retraction, but long-term negative outcomes are rare. The condition
can commonly recur; circumcision can preclude recurrence once the inflammation has subsided
and the patient is a viable candidate for the procedure.[12] An alternative to a circumcision,
especially in an older or sicker patient, would be a dorsal slit. Either is satisfactory in preventing
a recurrence of the paraphimosis.
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Complications
Complications that can occur with paraphimosis include pain, infection, and inflammation of the
glans penis. If the condition is not relieved in a sufficiently prompt timeframe, the distal penis
can become ischemic or necrotic. Operative complications include bleeding, infection, injury to
the urethra, and shortened penile skin.
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Deterrence and Patient Education

After reduction or surgery, patients should be counseled that their prognosis is quite good. They
should receive instruction on hygiene, be sure and return their foreskin to its normal position if it
has been retracted, and avoid using any penile jewelry if that has contributed to the condition.
The patient may wish to consider circumcision to preclude future episodes, particularly if
recurring cases.
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Pearls and Other Issues

After a successful manual reduction, the foreskin should carefully be cleaned. Any superficial
abrasions or tears to the foreskin should be treated with a topical antibiotic ointment such as
bacitracin. Patients should be instructed to avoid retracting the foreskin for one week and avoid
any offending activities contributing to the paraphimosis.
Reducing the paraphimosis successfully is insufficient long-term therapy. All such patients
should be evaluated for further treatment involving a dorsal slit or circumcision procedure to
definitively deal with the tightened foreskin and permanently prevent any recurrences of the
paraphimosis.

Bragg BN, Kong EL, Leslie SW. Paraphimosis. [Updated 2023 May 30]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK459233/

Bibliografía
Murillo, M. (2012). Parafimosis. Revista Médica de Costa Rica y Centroamérica, LXIX(604), 477-479.