to the editor: Although rare, paraphimosis is common among the urologic emergencies that present to a family physician. Given the importance of prompt diagnosis and treatment, family physicians should be familiar with the management of paraphimosis, including the clinic-based, nonsurgical treatments that are available. In addition, preventive efforts exist to help patients who may be at high-risk of paraphimosis. Our review of the general practice literature only found one comprehensive review.¹ We present a highly unusual case of paraphimosis in a healthy adult after sexual intercourse.

A 38-year-old man presented with painful penile swelling and inability to reduce his foreskin for four days. He described a preceding three-month history of phimosis. He had had intercourse with his wife four days before and noted that this allowed complete foreskin retraction for the first time in months. He fell asleep without replacing the foreskin, and by morning was unable to return the foreskin to its usual location. He experienced increasing swelling and pain. He denied having had a sexually transmitted disease, urinary tract infection, previous paraphimosis, instrumentation, piercings, or obstructive symptoms. On examination, there was tenderness and dramatic edema of the foreskin, which formed a tight collar around the glans, that remained pink and warm. There was no evidence of skin or sexually transmitted disease. Urgent urologic consultation was sought. To reduce edema, the urologist squeezed the glans for several minutes, which successfully allowed reduction of the foreskin. The patient was counseled to always replace the foreskin. Circumcision was discussed as an option if problems continued.

Paraphimosis occurs in uncircumcised males when retracted foreskin constricts blood and lymphatic flow, risking necrosis. Most commonly, this occurs in children and the elderly. In children, it is commonly related to a congenitally narrow preputial opening or urinary obstruction. In elderly patients, it is typically iatrogenic, involving failure to return the foreskin to its normal location, classically after catheter placement.² Paraphimosis in middle-aged adults is usually linked with unusual causes, including piercings, lichen sclerosis, Plasmodium, contact allergy, chancroid, and unusual cultural practices. Prevention includes cleaning under the foreskin daily, and reducing a retracted foreskin. Paraphimosis is not always painful. A detailed history should explore manipulation, instrumentation, and circumcision. Penile viability is investigated by inspection and palpation.

Although an urgent urology consultation is critical, many creative, office-based, nonsurgical options exist. Common techniques to reduce edema and facilitate reduction include squeezing the glans, injecting hyaluronidase, and applying circumferential, compressive dressing, ice, or granulated sugar. Other options include a “puncture” technique and direct blood aspiration.^1,3 Emergency dorsal slit ultimately may be appropriate. Pain control includes topical or oral agents, or nerve block. Given the likely recurrence, follow-up circumcision is recommended.

Interestingly, three previous reports involving erotic dancers also linked paraphimosis to erection and intercourse.^4,5 As in our patient, these cases involved a pre-existing tight foreskin; however, unlike our patient, they also involved delayed detumescence.

Our case contributes to the unusual variety of presentations of paraphimosis. Family physicians should be aware of measures for prevention and treatment.