{ "schema_version": 1, "kind": "condition", "id": "paraphimosis", "name": "Paraphimosis (boys and adults)", "category": "emergency", "sources": "Paraphimosis - StatPearls (NCBI Bookshelf NBK459233) - https://www.ncbi.nlm.nih.gov/books/NBK459233/ · Paraphimosis - disease-level clinical article (paraphimosis-full.txt) · Paraphimosis - disease-level clinical article (paraphimosis-clinical.txt) · Egyptian National Drug Formulary - Cardiovascular 2024 (lidocaine monograph, p84) · Paraphimosis - StatPearls (NCBI Bookshelf NBK459233) for the technique, the sites and the volume: 2.5 mL of 1% lidocaine without epinephrine at 10 o'clock and a further 2.5 mL at 2 o'clock, through a 25-gauge or 27-gauge needle just deep to Buck's fascia. The ceiling is the Egyptian National Drug Formulary - Cardiovascular 2024 (lidocaine monograph, p84), whose local injection entry says the dose varies with the procedure and sets cutaneous infiltration at a maximum of 4.5 mg/kg per dose not exceeding 300 mg, not repeated within 2 hours. · Paraphimosis - StatPearls (NCBI Bookshelf NBK459233) - the article names the cream by its constituents and their strengths, 2.5% lidocaine and 2.5% prilocaine, and gives the glove-sleeve technique and the approximate 30 minutes it is left in place. It states no quantity of cream and no maximum.", "review_status": "reviewed", "verified_against": "Paraphimosis - StatPearls (NCBI Bookshelf NBK459233) - https://www.ncbi.nlm.nih.gov/books/NBK459233/ · Paraphimosis - disease-level clinical article (paraphimosis-full.txt) · Paraphimosis - disease-level clinical article (paraphimosis-clinical.txt) · Egyptian National Drug Formulary - Cardiovascular 2024 (lidocaine monograph, p84) · Paraphimosis - StatPearls (NCBI Bookshelf NBK459233) for the technique, the sites and the volume: 2.5 mL of 1% lidocaine without epinephrine at 10 o'clock and a further 2.5 mL at 2 o'clock, through a 25-gauge or 27-gauge needle just deep to Buck's fascia. The ceiling is the Egyptian National Drug Formulary - Cardiovascular 2024 (lidocaine monograph, p84), whose local injection entry says the dose varies with the procedure and sets cutaneous infiltration at a maximum of 4.5 mg/kg per dose not exceeding 300 mg, not repeated within 2 hours. · Paraphimosis - StatPearls (NCBI Bookshelf NBK459233) - the article names the cream by its constituents and their strengths, 2.5% lidocaine and 2.5% prilocaine, and gives the glove-sleeve technique and the approximate 30 minutes it is left in place. It states no quantity of cream and no maximum.", "verified_date": "2026-08", "treatments": [ { "id": 1369, "generic": "Lidocaine", "line": 1, "is_adjunct": false, "form": "injection", "strength_mg": null, "adult_dose": "Dorsal penile block: 2.5 mL of 1% lidocaine without adrenaline at the 10 o'clock position, at the junction of the penis and the suprapubic skin and off the midline to spare the superficial dorsal vein, then a further 2.5 mL at 2 o'clock - 5 mL of 1%, which is 50 mg in all. Use a 25-gauge or 27-gauge needle and place it just deep to Buck's fascia, 3 mm to 5 mm beneath the skin, aspirating for blood before each injection. Never exceed 4.5 mg/kg or 300 mg.", "adult_duration": "A single block before the reduction; no repeat within 2 hours.", "dose_source": "Paraphimosis - StatPearls (NCBI Bookshelf NBK459233) for the technique, the sites and the volume: 2.5 mL of 1% lidocaine without epinephrine at 10 o'clock and a further 2.5 mL at 2 o'clock, through a 25-gauge or 27-gauge needle just deep to Buck's fascia. The ceiling is the Egyptian National Drug Formulary - Cardiovascular 2024 (lidocaine monograph, p84), whose local injection entry says the dose varies with the procedure and sets cutaneous infiltration at a maximum of 4.5 mg/kg per dose not exceeding 300 mg, not repeated within 2 hours.", "rationale": "Paraphimosis is reduced at the bedside, and the article makes a formal penile anaesthetic block the answer when the paraphimosis is long-standing, extremely painful or severe - the cases where manual pressure alone will not be tolerated. It is the one anaesthetic technique in the article that comes with a volume, so it is the one that can be printed as a dose.", "cautions": [ "Use a plain preparation. Never use lidocaine premixed with adrenaline on the penis.", "Aspirate before injecting and inject slowly. Accidental intravascular injection causes the tingling lips, ringing ears, confusion and fits of local anaesthetic toxicity.", "Work the ceiling out for the patient's weight before drawing up: 4.5 mg/kg in an adult, 5 mg/kg in a child, never more than 300 mg, and no repeat within 2 hours.", "The ordinary case needs none of it - the article says a mild, uncomplicated paraphimosis is usually reduced by hand without sedation or analgesia.", "The formulary contra-indicates a local lidocaine preparation where there is bacterial, viral or fungal infection at the site of application, and any amide local anaesthetic in someone hypersensitive to one.", "A dark, dusky, pale, blue or black glans is ischaemia and goes to a urologist immediately. Anaesthetising it buys no time.", "Egypt stocks lidocaine 1% as 10 mg/mL ampoules, which is the strength the article's block is written in." ], "peds_mgkg_low": null, "peds_mgkg_high": null, "peds_max_mg": null, "peds_basis": null, "peds_unit": null, "peds_note": "In a child use a solution weaker than 2%, so the volume can be larger, and keep the total below 5 mg/kg and below the adult ceiling of 300 mg per dose, with no repeat inside 2 hours (Egyptian National Drug Formulary - Cardiovascular 2024, lidocaine monograph, p84). Most mild paraphimoses in a boy reduce by hand with no anaesthetic at all, and the article's own paediatric option is the anaesthetic cream.", "peds_min_weight_kg": null, "peds_max_weight_kg": null, "peds_age_min_months": null, "peds_age_max_months": null, "peds_age_bands": null, "peds_doses": null, "brands": [ { "trade_name": "LIDOCAINE 1% (OTSUKA) AMP. 5 ML", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "OTSUKA", "price_egp": 5.0, "pack_count": null, "unit_price": null, "strength_mg": null, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "KAHICAINE 1% 50MG/5ML 3 AMP.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "KAHIRA", "price_egp": 10.5, "pack_count": null, "unit_price": null, "strength_mg": 50.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "LIDOCAINE HYDROCHLORIDE 10MG/ML AMP. 2 ML", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "PHARCO B", "price_egp": 2.0, "pack_count": null, "unit_price": null, "strength_mg": 10.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "LIDOCAINE HCL 20MG/ML VIAL IM IV SC 20 ML (NET PRICE)", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "SIGMA TEC > VODACHEM", "price_egp": 9.75, "pack_count": null, "unit_price": null, "strength_mg": 20.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "LIDOCAINE HCL 20MG/ML VIAL IM IV SC 50 ML (NET PRICE)", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "SIGMA TEC > VODACHEM", "price_egp": 11.25, "pack_count": null, "unit_price": null, "strength_mg": 20.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "DEBOCAINE HCL 2% 50ML VIAL", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "ARABCOMED > DEBEIKY", "price_egp": 33.0, "pack_count": null, "unit_price": null, "strength_mg": null, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "ULTRACAINE 20MG/ML VIAL 50 ML", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "MEMPHIS", "price_egp": 33.0, "pack_count": null, "unit_price": null, "strength_mg": 20.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "LIDOCAINE 2% 10 AMP.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "ALEXANDRIA", "price_egp": 90.0, "pack_count": null, "unit_price": null, "strength_mg": null, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null } ], "condition_id": "paraphimosis" }, { "id": 1370, "generic": "Lidocaine + Prilocaine", "line": 1, "is_adjunct": false, "form": "topical", "strength_mg": null, "adult_dose": "Lidocaine 2.5% with prilocaine 2.5% cream, left on the trapped foreskin and the glans for about 30 minutes before the reduction is attempted. The article's technique is to cut the thumb from a surgical glove, empty a tube of the cream into the sleeve and slide it over the penis. No weight of cream and no maximum is stated in the article, so none is printed.", "adult_duration": "One application, about 30 minutes before the reduction.", "dose_source": "Paraphimosis - StatPearls (NCBI Bookshelf NBK459233) - the article names the cream by its constituents and their strengths, 2.5% lidocaine and 2.5% prilocaine, and gives the glove-sleeve technique and the approximate 30 minutes it is left in place. It states no quantity of cream and no maximum.", "rationale": "It is the article's alternative to a needle, and it does two things at once: it anaesthetises the skin and softens it, which is what makes the foreskin reducible. The article records it as the technique used in children and infants.", "cautions": [ "It can make the reduction harder rather than easier. The article says the cream gives some analgesic relief but leaves the skin more slippery and harder to manipulate.", "It is an anaesthetic, not the treatment. What makes the foreskin reducible is steady squeezing of the glans and the swollen foreskin for some minutes, or an elastic bandage wrapped from the glans towards the base over a gauze pad and left on for 10 to 20 minutes.", "Do not pack the penis in ice. The article records that many experts advise against it, because a tight fibrous ring has already cut off the blood supply and cooling can reduce the arterial inflow further.", "The formulary contra-indicates a local lidocaine preparation where there is bacterial, viral or fungal infection at the site of application.", "Waiting 30 minutes for a cream is only acceptable while the glans is pink. A dusky glans goes to a urologist at once." ], "peds_mgkg_low": null, "peds_mgkg_high": null, "peds_max_mg": null, "peds_basis": null, "peds_unit": null, "peds_note": "The glove technique was described in children (Khan, Riaz and Rogawski, Ann R Coll Surg Engl 2014), and the article carries it as the gentler option in a boy. It gives no weight of cream and no maximum, so none is printed.", "peds_min_weight_kg": null, "peds_max_weight_kg": null, "peds_age_min_months": null, "peds_age_max_months": null, "peds_age_bands": null, "peds_doses": null, "brands": [ { "trade_name": "PRIDOCAINE TOPICAL CREAM 15 GM", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "GLOBAL NAPI PHARMACEUTICALS", "price_egp": 32.0, "pack_count": null, "unit_price": null, "strength_mg": 15000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "MELACAINE 5% CREAM 15 GM", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "> MELANO PHARMA", "price_egp": 36.5, "pack_count": null, "unit_price": null, "strength_mg": 15000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "ANASEZIAGO CREAM 30 GM", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "AL ESRAA PHARMACEUTICAL OPTIMA > ELIXIR PHARMA", "price_egp": 55.0, "pack_count": null, "unit_price": null, "strength_mg": 30000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "AVRISURG TOPICAL CREAM 30 GM", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "MEDIZEN PHARMACEUTICAL INDUSTRIES", "price_egp": 55.0, "pack_count": null, "unit_price": null, "strength_mg": 30000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "PRIDOCAINE TOPICAL CREAM 30 GM", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "GLOBAL NAPI PHARMACEUTICALS", "price_egp": 55.0, "pack_count": null, "unit_price": null, "strength_mg": 30000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "EMLA 5% CREAM 5 GM 5 TUBES", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "ASTRA ZENECA > PHOENIX GROUP", "price_egp": 120.0, "pack_count": null, "unit_price": null, "strength_mg": 5000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "MANOVIPERCAINE PLUS TOPICAL SPRAY 15 ML", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "EVA PHARMA", "price_egp": 56.0, "pack_count": null, "unit_price": null, "strength_mg": null, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null } ], "condition_id": "paraphimosis" }, { "id": 1371, "generic": "Referral & safety-netting (no drug therapy)", "line": 1, "is_adjunct": false, "form": null, "strength_mg": null, "adult_dose": null, "adult_duration": null, "dose_source": "Paraphimosis - StatPearls (NCBI Bookshelf NBK459233) - https://www.ncbi.nlm.nih.gov/books/NBK459233/", "rationale": "Paraphimosis is a trapped foreskin strangling the glans, and it happens to adults as often as to boys - most often after somebody retracted the foreskin to clean it or to pass a catheter and did not put it back. Reduction is a bedside manoeuvre and the clock is vascular. The article names local anaesthesia and a topical antibiotic afterwards but states no amount for either, so no dose is printed.", "cautions": [ "IT IS AN EMERGENCY BECAUSE THE GLANS IS BEING STRANGLED - paraphimosis is a genuine urological emergency of the uncircumcised male: the foreskin is caught behind the corona and strangles the glans, cutting off its blood supply painfully, so that the tissue beyond engorges with venous blood, swells, and may in the end die.", "IT IS NOT PHIMOSIS, AND THE DIFFERENCE IS THE DIRECTION - in phimosis, by contrast, the foreskin is the one that will not go back behind the glans at all.", "IT IS NOT A CHILDREN'S PROBLEM ONLY - among adults it turns up most often in adolescents, and it will happen to roughly 1% of men past 16 years of age. Between four months and 12 years of age it is the rarest of the foreskin problems, at 0.2%.", "IT IS USUALLY SOMETHING A CARER DID - most cases are iatrogenic: the foreskin gets pulled back to clean, to pass a urinary catheter, for a procedure such as cystoscopy, or simply to examine the penis. Leave it retracted rather than drawing it forward over the glans promptly, and paraphimosis follows.", "SO THE PREVENTION IS ONE SENTENCE - anybody who changes Foley catheters as part of their work must draw the foreskin forward again at the end of it, every time, or a paraphimosis is what results.", "NEVER TRIAGE A REPORT OF PENILE SWELLING OVER THE PHONE - treat any telephone account of a swollen penis as a possible paraphimosis needing treatment at once, and do not write it off as harmless without laying eyes on it. The pain is not always there.", "THE COLOUR OF THE GLANS IS THE TRIAGE - a pink glans means the blood supply is reasonably intact; dark, dusky, pale, blue or black means ischaemia, and perhaps necrosis already. A dusky glans goes to a urologist immediately.", "HOW LONG THERE IS - the arterial flow can fail over a span of hours to days, and once it does the glans is left severely ischaemic and may die.", "SQUEEZE THE SWELLING DOWN FIRST, THEN REDUCE - reduction by hand often goes much better if the glans and the swollen, oedematous foreskin are simply squeezed for some minutes beforehand. The technique: both thumbs on the glans, with the index and middle fingers of both hands around the trapped foreskin; then press slowly and steadily to work the tight portion outwards, forward over the glans. A little lubricant helps. Too much makes the skin so slippery that you cannot keep hold.", "A COMPRESSION BANDAGE BUYS TWENTY MINUTES - another way to compress it is to wrap the swollen part of the penis firmly from the glans towards the base with an elastic bandage 1 inch or 2 inches wide, laying a gauze pad around the oedematous foreskin first. Leave the bandage on for 10 to 20 minutes to bring the swelling down.", "DO NOT PACK IT IN ICE - what is wrong in paraphimosis is that a tight fibrous ring of foreskin has cut off the blood supply beyond it, and many experts therefore advise against ice, which can further reduce the arterial inflow to a part of the penis that may already be ischaemic.", "PAIN RELIEF WHEN SIMPLE PRESSURE IS NOT ENOUGH - a mild, uncomplicated paraphimosis can usually be reduced by hand with neither sedation nor analgesia. Harder or complicated cases may call for a local anaesthetic by dorsal penile block, which is dosed above, or for systemic analgesia or procedural sedation, for which the article names no drug, strength or volume - so none is printed for those.", "REMOVING A CATHETER IS USUALLY UNNECESSARY - taking the Foley out will almost certainly make the reduction easier, but you may then find you cannot get it back in, and you have swapped one problem for another. In most cases the paraphimosis reduces perfectly well with the catheter left where it is.", "AFTERWARDS - clean the foreskin carefully once it is reduced. Treat any surface graze or tear with a topical antibiotic ointment, bacitracin for instance. Tell the patient NOT to pull the foreskin back for one week, and to avoid whatever caused it.", "AND A SUCCESSFUL REDUCTION IS NOT THE END OF IT - getting it back is not treatment enough for the long run. Everyone it happens to is assessed for something definitive - a dorsal slit or a circumcision - to deal with the tight foreskin and stop the paraphimosis returning for good." ], "peds_mgkg_low": null, "peds_mgkg_high": null, "peds_max_mg": null, "peds_basis": null, "peds_unit": null, "peds_note": null, "peds_min_weight_kg": null, "peds_max_weight_kg": null, "peds_age_min_months": null, "peds_age_max_months": null, "peds_age_bands": null, "peds_doses": null, "brands": [], "condition_id": "paraphimosis" } ] }