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You are seeing an 11-year-old uncircumcised boy whose foreskin became retracted over his glans penis, and then stuck (paraphimosis). It has been this way for 8 hours before he gathered the courage to tell his parents, and there is considerable swelling. There is no discoloration to the head of the penis. The patient did manage to urinate just before coming to the ED. Your attempt at reduction is unsuccessful. You do not have a urologist on call available to you tonight.
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June 25, 2024 at 7:56 pm
B) Apply topical EMLA, wrap in a compression bandage for 20-30 minutes to reduce swelling, give intranasal fentanyl, then re-attempt reduction
Manual reduction can often be performed by the ED provider but decreasing swelling and adequate analgesia (and sometimes procedural sedation) may be needed. Compression bandages, osmotic agents (table sugar, 50% dextrose, 20% mannitol), and ice (but placed in a slurry in a bag or glove; do not place the penis directly into the ice water slurry) can be used to decrease swelling. Prolonged paraphimosis can lead to ischemia, so the patient should never be discharged without reduction. Dorsal slit procedure (usually performed by a urologist) may be needed if multiple attempts at manual reduction (with adequate reduction in swelling and analgesia) are unsuccessful – the patient has not yet had multiple attempts and is not showing evidence of complications yet. Any transfer would be accomplished hospital to hospital via transfer protocols and would not involve calling 911.