Ask the patient if he is normally able to retract the foreskin (suggesting an otherwise normal foreskin if he can and a phimotic one if he cannot).
Paraphimosis is usually painful. The foreskin is oedematous. It may become so engorged with oedema fluid that the appearance can be very confusing for those who have never seen it. Occasionally in a paraphimosis that has been present for several days, a small area of ulceration of the foreskin may have developed, which those unfamiliar with the condition may misinterpret as a malignant or infective process.
There are several options. The patient will probably already have tried the application of pressure to the oedematous foreskin in an attempt to reduce it, and usually the attending doctor does the same, sometimes successfully reducing the foreskin, but more often than not failing to do so.
The 'iced-glove' method: Apply topical lignocaine (lidocaine) gel to the glans and foreskin. Wait for 5 minutes so you achieve anaesthesia of the area. Place ice and water in a rubber glove and tie a knot in the cuff of the glove to prevent the contents from pouring out. Also tie off the four fingers of the glove. Place the thumb of the glove over the penis so that the penis lies within it
136 J. REYNARD AND H. HASHIM
and in contact with the ice and water. This may reduce the swelling and allow reduction of the foreskin.
Granulated sugar has been used to reduce the oedema (by an osmotic effect). The sugar may be placed in a condom or glove applied over the end of the penis. The process of reduction may take several hours (Kerwat et al. 1998).
Hyaluronidase injections have been used (1 mL; 150 U/cc), injected via a 25-gauge hypodermic needle into the prepuce. This breaks down hyaluronic acid and decreases the oedema.
The Dundee technique (Reynard and Barua 1999): Give the patient a broad-spectrum antibiotic such as 500 mg of ciprofloxacin by mouth. Apply a ring block to the base of the penis using a 26-gauge needle. Use 10 mL of 1% plain lignocaine or 10 to 20 mL of 0.5% plain bupivacaine (Marcaine) to the skin at the base of the penis. Wait for 5 minutes. Touch the skin of the prepuce to check that the penis has been anaesthetised. Try pricking the skin of the penis with a sterile needle and ask the patient if he can feel it to make sure it is well anaesthetised. Occasionally adequate anaesthesia is not achieved and the patient will require a general anaesthetic. In children we have tended to use general anaesthesia. Clean the skin of the foreskin and the glans with cleaning solution. Using a 25-gauge needle make approximately 20 punctures into the oedematous foreskin. Firmly squeeze the foreskin. This forces the oedema fluid out of the foreskin (Fig. 6.5). Small 'jets' of oedema fluid will be seen. Once the foreskin has been decompressed, it can usually be returned to its normal position. We discharge the patient on a 7-day course of ciprofloxacin as a prophylactic measure and recommend daily baths with careful cleaning of the glans and skin with soap and water. The patient should be advised to dry the foreskin carefully and return it to its normal position afterward.