Chapter 33

• • Reduction of retracted, constricting foreskin.

### Relative

• • Recent penile surgery.

• • Nonsterile gloves.

• Ice packs.

• 2 × 2 or 4 × 4 gauze.

• Topical anesthetic or buffered 1% lidocaine solution, or both.

• • Failure of reduction (success rates depend on duration of paraphimosis and degree of edema).

• Psychological stress (common; child is restrained for procedure).

• Pain (certain; can be limited somewhat with anesthesia).

• Cold injury.

• • Use gauze to grasp the foreskin.

• If swelling is pronounced, try manual compression prior to reduction.

• Timid attempts at reduction in an effort to reduce pain ultimately result in delayed reduction and increased overall pain.

• If initial attempts are unsuccessful, urgent referral to a urologist is recommended.

• • The child is placed supine.

• Distract the child by having the parent or assistant lean over the examining table, placing his or her body between the child’s upper torso and the genital area. This also prevents the child from getting up and allows the parent or assistant to engage the child face to face.

• • The child is placed supine in the frog-leg position.

• If the child is uncooperative, his legs and pelvis should also be restrained by an assistant.

• • Early paraphimosis (retracted foreskin) is illustrated in Figure 33–1B.

• Late paraphimosis (retracted foreskin with significant edema) is shown in Figure 33–1C.

###### Figure 33–1.

A: Normal penis and foreskin. B: Early paraphimosis. C: Late paraphimosis.

• • Consider the use of a dorsal penile block in advance of the procedure, particularly when there is severe edema.

• With gloved hands, grasp the retracted foreskin between the thumb and the index and middle fingers of each hand.

• Using a gauze pad to grasp the foreskin improves traction.

• Simultaneously pull the foreskin distally as you compress the glans with both thumbs (Figure 33–2).

• • Apply constant and firm pressure.

• When sufficient pressure is applied, the foreskin suddenly reduces, popping over the glans.

• If the initial attempt is unsuccessful, consider manual decompression before subsequent attempts.

• Place your hand around the distal foreskin and glans and apply constant circumferential pressure for approximately 5 minutes.

• Then, attempt reduction again as described above.

• Alternatively, you can apply an ice-water slurry (sealed in either a specimen collection bag or a tied-off glove) to the paraphimotic foreskin and glans.

• You may apply the ice pack for up to 3 minutes at a time, taking care to monitor for cold or pressure injury.

• There is a significant amount of discomfort associated with ice packs, so they may not be tolerated in the absence of ...

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