• 
• 

Three Part Question

In [an adult male with irreducible paraphimosis] is [ice better than multiple puncturing or sugar] at [reducing swelling and allowing reduction]?

Clinical Scenario

You are asked to see a 19 year old man who has presented to the Emergency Department with paraphymosis. He states that he fell asleep after sex the night before and woke up with swelling. Simple traction has failed to cure the problem (but has brought tears to his eyes). A surgeon, a specialist registrar in emergency medicine and a urologist are already in attendance. The first says that multiple punctures should be made with a needle, the second that an iced glove should be used and the third that sugar should be applied. You wonder whether any of the suggested methods are evidence-based.

Search Strategy

Medlilne 1966-10/03 using the OVID interface.
[paraphymosis.mp OR paraphimosis.mp OR exp paraphimosis OR (foreskin.mp AND retraction.mp)] AND [reduc$.mp OR exp ice OR ice$.mp OR puncture$.mp OR exp punctures OR sugar.mp]

Search Outcome

Altogether 33 papers found, of which 3 were relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Gonzalez FM et al, 2001, Spain	3 patients with paraphimosis Application of granulated sugar for 1-2hr	Case series	Reduction	All reduced	Small numbers No controls
Kumar V and Javle P, 2001, UK and India	45 patients with paraphimosis Multiple puncture in patients with glans engorgement (39)	Case series	Reduction	All reduced if no skin changes	Small numbers No controls
Houghton GR, 1973, England	10 patients with paraphimosis aged 8 – 91 years. Iced glove placed for 5 minutes	Case series	Reduction	9 out of 10	Small numbers No controls

Comment(s)

There are no comparative or randomised trials in this area. Current treatment is based wholly on custom, practice and word of mouth. Further research is warranted.

Clinical Bottom Line

All three methods have been shown to work, but there is no evidence to show which is best. Local guidelines should be followed.

References

1. Gonzalez FM, Sousa EMA, Parra ML. Sugar: treatment of choice in irreducible paraphimosis. Actas Urol Esp 2001;25(5):393-5.
2. Kumar V, Javle P. Modified puncture technique for reduction of paraphymosis. Ann Roy Coll Surg 2001;83(2):126-7.
3. Houghton GR. The "iced-glove" method of treatment of paraphimosis. BJS 1973;60(11):876-7.