For many practitioners, paraphimosis is a daunting condition to treat. Horses with paraphimosis are often presented to referral institutions after delayed or ineffective therapy has allowed the condition to evolve to a point where it appears that no progress is being made and that complications are resulting in further deterioration. By implementing a few basic techniques in the treatment of the condition, irreparable complications and the need for referral can often be avoided.
Paraphimosis is the inability of the horse to retract its penis into the preputial cavity. It most commonly occurs in stallions as a result of breeding trauma, but geldings can also be affected. Penile prolapse occurs initially, which then results in excessive edema and swelling of the penis and prepuce. The horse cannot fully retract the penis and prepuce or maintain them within the preputial cavity (Fig. 1). Although trauma is usually the first differential considered in the etiology of the condition, other causes should also be considered, particularly when a traumatic incident is absent from the history. These include, but are not limited to, use of phenothizine tranquilizers, systemic diseases such as equine herpesvirus-1, purpura hemorrhagica, dourine, and severe debilitation [1-3]. Priapism and penile paralysis are frequently complicated by secondary paraphimosis.
Prolonged penile and preputial prolapse, regardless of the cause, impairs venous and lymphatic drainage of these tissues; this leads to edema and excessive swelling [2-3]. As the internal preputial lamina swells, the preputial ring can constrict and decrease drainage. The penis distal to the ring becomes larger, heavier, and more swollen, and a vicious cycle ensues. In long-standing cases, the pendulous weight of the prolapsed penis and prepuce can damage the internal pudendal nerves, resulting in permanent penile paralysis . Even in the short-term, if not protected, the exposed epithelium of the penis and prepuce becomes excoriated, and areas can slough because of pressure necrosis. Fibrosis can result, and the penis loses its normal telescoping action .
2. Materials and Methods
On presentation, the penis and prepuce should be thoroughly cleaned and inspected visually and by palpation to help determine the extent of injury. Ultrasonographic examination can be helpful in determining if the swelling is solely a result of edema or if other accumulations such as seromas, hematomas, fibrin clots, or abcesses may be present that could impede the ability to reduce the penile/preputial prolapse (Fig. 2). After the penis and prepuce are cleaned and inspected, drainage of large-fluid accumulations is often helpful in reducing otherwise refractory prolapses. The most dependent area of the fluid pocket is identified by palpation, and drainage is accomplished by use of a large-gauge needle (14 - 16 gauge) or by incision(s) with a scalpel. The fluid is allowed to drain by gravity flow with massage of the area often augmenting the drainage of fluid. Judicious, aseptic removal of blood and fibrin clots can be accomplished with forceps.
Figure 1. Stallion with paraphimosis. Extensive swelling of the penis and prepuce prevent retraction into the preputial cavity. To view click on figure
Figure 2. Ultrasonographic image of ahemato main the prepuce of a stallion demonstrating (A) bloodclots with (B) blood and serum. To view click on figure
Figure 3. Application of an Esmarch bandage to the penis and prepuce. To view click on figure
Reduction of penile and preputial swellings can often be readily accomplished by using an elastic, compressive bandage [a]. The bandage application starts distally at the glans of the penis and ends proximally. It is wrapped tightly by stretching the bandage (Fig. 3). The bandage is left in place for 10 - 15 min. After that time, the penis is unwrapped, and attempts are made to replace the penis into the preputial cavity. Repeated applications of the Esmarch bandage can be performed if necessary. After the penis and prepuce are replaced in the preputial cavity, towel clamps or a heavy purse-string suture with an opening large enough to allow free voiding of urine can be placed near the preputial ring or preputial orifice to aid in retention and prevent further prolapse (Fig. 4). If the penis and prepuce cannot be replaced into the preputial cavity, they should be held close to the ventral body wall with a support bandage to prevent further swelling, which results from them remaining in a dependent position. Alternative support devices such as a mesh sling  (Fig. 5) or narrow-necked plastic bottle with elastic tubing  can also be used for support (Fig. 6). The bottom of the bottle is removed, and the edges are padded with several layers of tape. Two lengths of rubber tubing (≈ 5 ft in length) are tied around the neck of the bottle at their midpoints. The penis is inserted into the bottle so that the urethral orifice is aligned with the opening at the neck of the bottle. The penis and the overlying plastic bottle are placed as far as possible within the preputial cavity. The bottle is held in place by the tubing that runs over the lumbar area and on either side of the scrotum up over the tail head. Voiding of urine occurs through the bottle. The bottle should be cleaned and replaced twice daily until the penis can be retained in the retracted position .
Figure 4. Purse string suture placed near the preputial orifice to prevent prolapse. To view click on figure
Figure 5. Mesh supporting sling held in place with rubber tubing. To view click on figure
Figure 6. Support device made from a 500 mL plastic bottle heldin place with rubber tubing. To view click on figure
Before replacing the penis and prepuce into the preputial cavity or applying a sling, the tissues should be well lubricated with an emollient, antimicrobial ointment. Products such as silver sulfadiazine cream or a compounded product consisting of dexamethasone (80 mg) and oxytetracycline (3.88 g) per 1 lb of lanolin base are very efficacious for this purpose. When these products are applied, it is also helpful to start distally and work proximally, massaging the dressings onto the penis and prepuce to further reduce edema and swelling. Adjunct therapies include daily exercise, non-steroidal anti-inflammatory drugs such as phenylbutazone or flunixin meglumine, and hydrotherapy (10 - 20 min once or twice daily). Systemic antimicrobials, although not always necessary, can be added to the treatment regimen at the discretion of the veterinarian; however, antimicrobials are indicated if surgical drainage was attempted. The duration of treatment varies but can often take 7 - 10 days until the penis can be maintained in the preputial cavity without support. Some cases may take several weeks.
Early aggressive therapy is important, because it can minimize or avoid secondary complications. The primary goal in treating paraphimosis is to reduce the swelling and replace the prolapsed penis back into the preputial cavity as soon as possible to protect it from further injury. Unfortunately, this is the step that is most often delayed or not initially attempted. The use of anti-inflammatory drugs and hydrotherapy are very helpful adjuncts but should constitute the sole therapeutic methods. Penile support to prevent further swelling of the pendulous organ is imperative for a successful outcome. Application of an Esmarch bandage is a simple, yet very effective method of removing edema and reducing the size of the organ so that it can be replaced into the preputial cavity.
[a] Esmarch bandages, Jorgensen Laboratories, Loveland, CO 80538.
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