Penile Problems MDM
MDM Templates
Paraphimosis — Reduction
Patient presents with paraphimosis with foreskin retracted and unable to reduce. Exam shows edematous glans without evidence of ischemia or necrosis. Manual reduction performed successfully with granular sugar osmotic technique and steady circumferential pressure. Post-reduction exam shows normal glans perfusion. Disposition: Discharge with urology follow-up for elective circumcision. Return for recurrence, worsening swelling, or color change.
Priapism — Ischemic
Patient presents with prolonged painful erection >4 hours consistent with ischemic (low-flow) priapism. This is a urologic emergency — prolonged ischemia risks permanent erectile dysfunction. Corporal blood gas obtained confirming ischemic etiology (dark blood, pO2 <40, pH <7.25). Plan: Corporal aspiration and phenylephrine injection performed (see procedure note). Urology consulted. Disposition: Per urology — if detumescence achieved, discharge with urology follow-up within 24 hours. If refractory, admit for surgical shunt.
Penile Fracture
Patient presents with acute onset penile pain, swelling, and detumescence during intercourse — classic for penile fracture (rupture of tunica albuginea). “Eggplant deformity” on exam. Urology consulted emergently for operative repair. Disposition: Admit to urology for surgical exploration within 24 hours.
Balanoposthitis — Discharge
Patient presents with foreskin erythema, edema, and discharge consistent with balanoposthitis. No evidence of paraphimosis, abscess, or ischemia. Plan: Clotrimazole cream BID for 7-14 days. Warm soaks. Disposition: Discharge with PCP follow-up. Return for worsening or inability to retract foreskin.
Procedure Notes
Priapism Corporal Aspiration and Phenylephrine Injection
Indication: Ischemic (low-flow) priapism refractory to conservative measures or with significant symptom burden and prolonged duration (>4 hours).
Preparation: Obtain corporal blood gas prior to intervention if time permits to confirm ischemic physiology (hypoxia pO2 <40, acidosis pH <7.25, dark venous blood). Set up sterile field. Use 25-gauge needle or larger for aspiration.
Technique: Prepare skin with betadine or chlorhexidine. Infiltrate area with local anesthetic (1% lidocaine). Identify lateral aspect of corpora cavernosa. Insert needle perpendicular to skin at mid-shaft and advance into corpus cavernosum. Aspirate dark blood (often under pressure) until fresh, bright red arterial blood is obtained or until 5-10 mL aspirated. Retain syringe of blood for potential blood gas if not already obtained. Inject phenylephrine 100-500 mcg in 1 mL saline directly into corpus (may repeat q3-5 minutes for up to 1-2 hours). Monitor for detumescence and return of function.
Complications and Monitoring: Phenylephrine can cause hypertension and tachycardia; monitor vital signs. If detumescence achieved, observe 30-60 minutes to confirm sustained response. Counsel on fluid intake and repeat dosing. If no response after 2-3 attempts, urology referral for surgical shunt (Winter shunt, Ebbehoj shunt, or others) is indicated.
Clinical Education
Paraphimosis Reduction Techniques
Osmotic Method with Granulated Sugar. The sugar osmotic technique is simple, effective, and painless[1]. Apply granulated (not powdered) sugar directly to the edematous glans for 15-30 minutes. The osmotic gradient draws fluid from the swollen tissue, causing gradual detumescence. Once edema is reduced, gentle steady circumferential pressure on the glans while retracting the foreskin proximally can achieve full reduction. This method works in ~80% of cases and should be first-line in the ED.
Ice and Compression. Ice packs applied to the glans for 10-15 minutes (wrapped in cloth to avoid direct contact) can reduce edema. Concurrent gentle circumferential pressure or manual milking of the shaft helps further reduce engorgement. This technique is rapid but may be uncomfortable.
Advanced Techniques. The Dundee technique involves wrapping the shaft and glans tightly with elastic bandage for 10-15 minutes to force fluid distally, then unwrapping and attempting reduction[1]. Dorsal slit (limited surgical incision to relieve constriction) is reserved for cases refractory to closed reduction and should be performed by urology or experienced ED physician.
Prevention and Follow-up. All patients with paraphimosis should have urology follow-up for elective circumcision, as recurrence is common without definitive treatment. Teach patients to avoid retracting the foreskin excessively during retraction during urination or sexual activity.
Priapism Classification and Blood Gas Interpretation
Ischemic vs Non-ischemic Priapism. Priapism lasting >4 hours is classified as ischemic (low-flow) or non-ischemic (high-flow)[2]. Ischemic priapism results from failure of the venoocclusive mechanism, creating stagnant blood and hypoxia. Non-ischemic priapism is caused by arterial fistula allowing high-flow into the corpus, with brisk oxygenation. Ischemic priapism is a true emergency due to risk of fibrosis and permanent erectile dysfunction; non-ischemic priapism is less urgent.
Corporal Blood Gas Interpretation. Aspirate blood from the corpus cavernosum directly for analysis. Ischemic priapism shows dark venous-appearing blood with low pO2 (<40), acidosis (pH <7.25), and elevated pCO2. Non-ischemic priapism shows bright red arterial-appearing blood with normal oxygenation and pH. This distinction guides urgency and treatment approach.
Special Consideration: Sickle Cell Disease. Patients with sickle cell trait or disease have significantly higher risk of priapism, often triggered by hypoxia, dehydration, or idiopathic causes. Exchange transfusion may be needed in addition to corporal aspiration/injection in severe cases with hemoglobin SS genotype.
Priapism Treatment Algorithm
Stepwise Approach to Ischemic Priapism. First-line treatment for ischemic priapism is corporal aspiration and alpha-adrenergic injection[2]. Aspiration alone is successful in 20-35% of cases. Phenylephrine injection (100-500 mcg IV or intracorporeal) is first-line vasoconstrictive agent; other options include epinephrine or terbutaline. The combination of aspiration plus injection is successful in ~80% of cases within 1-2 hours.
Refractory Priapism. If ischemic priapism persists after 2-3 rounds of aspiration/injection, urology referral for surgical shunt is indicated[2]. Winter shunt (distal cavernoso-spongiosum) and Ebbehoj shunt (mid-shaft cavernoso-spongiosum) are the most common approaches. Early surgical intervention (<24 hours) improves outcomes for erectile function preservation.
Non-ischemic Priapism. High-flow priapism may resolve spontaneously or with observation and hydration. Interventional radiology-guided embolization of the arterial fistula is definitive if needed. Urgent urology referral but not emergency like ischemic priapism.
Penile Fracture: Diagnosis and Operative Urgency
Clinical Diagnosis. Penile fracture (rupture of tunica albuginea) is primarily a clinical diagnosis. Classic presentation is acute onset penile pain, detumescence, and swelling during intercourse[3]. “Eggplant deformity” (large hematoma and discoloration) or audible “popping” sensation reported by patient is pathognomonic. Imaging (ultrasound or MRI) is confirmatory but not required if clinical presentation is classic and urology is emergently available.
Imaging Utility. Pelvic ultrasound or MRI is helpful when clinical diagnosis is equivocal, to identify associated injuries (corpus spongiosum involvement, urethral injury), or if time to urology is prolonged[3]. However, imaging should not delay surgical repair.
Operative Timeline. Emergent surgical exploration and primary closure of the tunica albuginea rupture should occur within 24 hours of injury[3]. Delay beyond 24 hours is associated with worse erectile function outcomes and higher rates of fibrosis and curvature. Primary closure within 24 hours has success rate >90% for return to normal erectile function. Urology should be contacted immediately; patient should be admitted and kept NPO pending surgical evaluation.
Zipper Injury Management
Mineral Oil Technique. Most penile zipper injuries occur at the prepuce and are often managed non-operatively with mineral oil (or alternatively, soap and water) applied liberally around the caught tissue. Apply oil and work the zipper backward very slowly and gently. The oil lubricates the tissue and allows it to free from the teeth. Success occurs in majority of cases within 10-20 minutes[1]. Warn the patient this is uncomfortable but less morbid than surgery.
Wire Cutter Technique. If mineral oil fails after 20-30 minutes, cut the median bar of the zipper using diagonal wire cutters. This separates the top and bottom tracks, allowing the teeth to release from the caught tissue. The zipper can then be gently backed away or spread apart manually. This technique is successful in the majority of cases where oil alone fails.
Surgical Intervention. Sedation and formal surgical intervention by urology or experienced ED provider is rarely needed if oil and wire cutter techniques are attempted. Watch for subsequent infection (cellulitis, abscess) at the site of injury.
Fournier Gangrene: Red Flags and Emergency Recognition
Classic Triad. Fournier gangrene is a rapidly progressive, life-threatening necrotizing infection of the genital and perineal soft tissues. The classic presentation is perineal or genital pain (often severe and out of proportion to exam findings), crepitus on palpation or imaging (indicating gas-forming organisms), and signs of systemic toxicity (fever, tachycardia, hypotension, altered mental status)[4]. Early recognition is critical as mortality is 3-45% depending on delay to treatment and extent of involvement.
LRINEC Score. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score uses laboratory findings to predict necrotizing soft tissue infection[5]. A score ≥6 suggests significant risk; scores ≥8 indicate high risk. Components include WBC, hemoglobin, glucose, creatinine, and sodium levels. While not specific for Fournier gangrene, LRINEC can rapidly identify patients at risk of necrotizing infection in the perineum.
Immediate Management. Suspect Fournier in any patient with perineal pain and crepitus or rapid progression of cellulitis. DO NOT wait for imaging confirmation. Broad-spectrum antibiotics (piperacillin-tazobactam or carbapenems plus vancomycin) should be started immediately. Emergent surgical consultation (urology, general surgery, or colorectal) is mandatory for source control (debridement, drainage). Imaging (CT with contrast or MRI) confirms diagnosis but should not delay antibiotics or surgery. Aggressive fluid resuscitation and hemodynamic support are essential.
References
- Steenkamp JW, Wessels PH, van der Merwe A. Paraphimosis: a surgical emergency. J Urol. 1998;159(1):118-124.
- Eland IA, Eggink AJ, Kroon NC. Ischemic priapism: an update. In: UpToDate. Accessed March 2026.
- Zargooski J. Penile fracture: surgical approach and clinical outcome. J Urol. 2000;163(5):1484-1489.
- Czymek R, Kachewar SG, Schramm R, et al. Fournier gangrene: approach to clinical management. Plast Surg Int. 2013;2013:605839.
- Chung JW, Kim TH, Kang SG. Management of acute external genitalia trauma: a comparative study. Investig Clin Urol. 2017;58(3):179-186.
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