Paraphimosis Pain Treatment with Nebulized Ketamine in the Emergency Department.

BACKGROUND: Paraphimosis is an acute urological emergency occurring in uncircumcised males that can lead to strangulation of the glans and painful vascular compromise. Ketamine has been used in the emergency department (ED) as an anesthetic agent for procedural sedation, and when administrated in a sub-dissociative dose (low dose) at 0.1-0.3 mg/kg, ketamine has been utilized in the ED and prehospital settings for pain control as an adjunct and as an alternative to opioid, as well as for preprocedural sedation. This report details the case of a pediatric patient who presented to our Pediatric ED with paraphimosis and had his procedural pain treated with ketamine administrated via a breath-actuated nebulizer (BAN). CASE REPORT: This case report illustrates the potential use of ketamine via BAN to effectively achieve minimal sedation for a procedure in pediatric patients in the ED. The patient was a 15-year-old boy admitted to the Pediatric ED complaining of groin pain due to paraphimosis. The patient was given 0.75 mg/kg of nebulized ketamine via BAN, and 15 min after the medication administration the pain score was reduced from 5 to 1 on the numeric pain rating scale. The patient underwent a successful paraphimosis reduction without additional analgesic or sedative agents 20 min after the administration of nebulized ketamine. The patient was subsequently discharged home after 60 min of monitoring, with a pain score of 0. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The use of nebulized ketamine via BAN might represent a viable, noninvasive way to provide a mild sedative and be an effective analgesic option for managing a variety of acute painful conditions and procedures in the pediatric ED.

Mannitol for paraphimosis reduction.

INTRODUCTION: Paraphimosis is a urologic emergency. Many treatment options have been devised for managing this entity. The osmotic method is one of them. We used an osmotic diuretic, mannitol, for reducing paraphimosis. Mannitol is commonly used for conditions like head injury to decrease cerebral oedema, partial nephrectomy and hepatorenal syndrome; we attempted using this diuretic for reducing paraphimosis. This is a novel technique and an application of mannitol which has never been reported before. METHODS: Starting in February 2011, we used mannitol 20% in patients presenting to urologic emergency with uncomplicated paraphimosis. Mannitol-soaked gauzes were wrapped around the oedematous prepuce, followed by minimal intermittent hand compression and frequent resoaking of the gauze with 20% mannitol. No needle punctures were made. The soaked gauze was removed and the paraphimosis was reduced easily. RESULTS: A complete reduction of paraphimosis occurred after mannitol-soaked gauze had been placed over the oedematous prepuce for about 30-45 min in 6 of our patients. This is a novel agent used for this entity; it reduces paraphimosis in a minimal time with no pain, with the added advantage of the least risk of infection after the procedure as opposed to granulated sugar or 50% dextrose previously used as osmotic agents. CONCLUSIONS: Mannitol can be applied in clinical practice for reducing paraphimosis. It requires no anaesthesia and is associated with minimal/no patient discomfort unlike that seen with multiple needle punctures and the various other non-osmotic methods of reducing paraphimosis.

Reduction of paraphimosis with hyaluronidase.

The use of hyaluronidase facilitates reduction of paraphimosis. It acts by dispersing extracellular edema, permitting easy reduction of the foreskin. Its use is applicable both in the hospital and outpatient setting. Hyaluronidase is widely available and keeps well if refrigerated. It is effective for children and adults.

Paraphimosis: current treatment options.

Paraphimosis is a urologic emergency, occurring in uncircumcised males, in which the foreskin becomes trapped behind the corona and forms a tight band of constricting tissue. Often iatrogenically induced, paraphimosis can be prevented by returning the prepuce to cover the glans following penile manipulation. Treatment often begins with reduction of edema, followed by a variety of options, including mechanical compression, pharmacologic therapy, puncture technique and dorsal slit. Prevention and early intervention are key elements in the management of paraphimosis.