© The Canadian Journal of Urology™; 21(Supplement 2); June 2014
excises the “distal fibrotic ring,” leaving the remaining
softer foreskin that can then be retracted. This allows
partial coverage of the glans, which a lot of men prefer.
The controversy over full circumcision has existed
for a long time. Every 10 years or so, pediatric
associations change their recommendations for routine
infant circumcisions. Anumber of organizations have
spoken out quite vigorously about infant circumcision,
as described in other articles.
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Paraphimosis
Paraphimosis is when a foreskin has been retracted
behind the head of the penis, and because of the
tightness of the foreskin and usually some swelling of
the glans, the patient is not able to bring the foreskin
back over the head of the penis. As a result, there is
decreased venous drainage that causes more swelling
of the glans that makes the “collar” even tighter. This
may actually cause strangulation of the head of the
penis and necrosis.
If severe, this is an emergency.
Management
1) Ice to the glans will decrease the swelling as well
as numbing it.
2) If still very severe and painful, then a penile block
using local anesthetic can be performed.
3) Physically squeeze the glans to encourage some
venous drainage and reduce the swelling.
4) Use gloves and two pieces of gauze to allow you to
grasp the foreskin on either side, and as you pull the
foreskin forward, push the glans back inside with
your two thumbs.
5) If you are successful, the patient will have immediate
pain relief. If not, one may have to perform an
emergency dorsal slit to relieve the pressure.
6) Often after a patient has recovered from a bout of
paraphimosis, he will request a circumcision.
Acute scrotal pain
When a man presents with acute scrotal pain, he may
have a condition that is an emergency and requires
surgery or medical treatment OR he may have a
condition that requires no medical intervention.
Paratesticular problems include hernia/hydrocele,
painful testicle, testicular torsion, and epididymitis/
orchitis.
Hernia
A hernia is the result of the bowel or mesentery that
either protrudes through the floor of the inguinal
canal or along the potential connection between the
peritoneal cavity and the scrotum (the path that the
testicle follows in development), attached to the
gubernaculum.
The patient presents with a bulge that is usually not
tender anddoes not transilluminate in a darkened room.
If the neck of the hernia starts to get tight around the loop
of the bowel, it may become incarcerated, meaning that
it cannot be reduced or pushed back when the patient
is lying on his back, usually without his head being
elevated on a pillow. If the lump can be reduced, this
usually indicates the patient has a hernia. The lump
shouldbe above the testicle. If the neck of the hernia is so
tight that it reduces venous return, then infarction of the
bowelmay occur, causing a serious condition and sepsis.
An incarcerated, painful hernia is a surgical emergency.
If fluid is tracking down from the peritoneal cavity
through the patent processus vaginalis, then one will
present with a non-tender, transilluminable scrotal
mass called a “communicating hydrocele.”
Hydrocele, spermatocele
If the neck of the processus vaginalis closes off or if the
fluid collection is loculated within the tunica vaginalis
(that potential envelope outside of the coating of
the testicle), then the patient has a simple hydrocele.
Hydroceles that occur as a result of trauma, inflammation,
or infectiondonot require urgent treatment. Ahydrocele
that develops as a reaction to a testicular tumor must be
treated urgently by removing the tumor.
A spermatocele is a cystic structure found at the
upper pole of the testicle. It usually arises from the
head of the epididymis. Usually one can feel the testicle
separate from the spermatocele. It is also non tender,
may be transilluminated in a darkened room, and is not
an acute emergency. It occurs as a result of blockage
of some of the channels in the epididymis, usually as
a result of minor trauma, which results in back-up of
sperm causing the development of a cystic structure. It
is totally benign and will not become cancerous.
Painful testicle
Apatient—usually a younger boy—may present with
acute pain and tenderness in the upper pole of the
testicle, separate from the epididymis. By shining a
light on this area, after determining that the whole
testicle is not tender and swollen, one can often see the
“blue dot” sign—a small blue lesion that represents
the “torsion of the appendix testicle.” This is not an
emergency. The pain is short-lived and there is no
significant swelling.
If in doubt, or concerned about testicular torsion
(described further in this article), a Doppler ultrasound
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Barkin ET AL.
