3-79
Alternative: Yeast infections can be treated with alkaline washes to the glans penis, if no oral agent is
available. Dissolving a few sodium bicarbonate tablets in a small container of water can make an alkaline
solution, which can be directly applied to the skin.
Patient Education
General: If the patient has balanitis, phimosis or paraphimosis and has not been circumcised, he should
have it done electively.
Activity: Until the inflammation has subsided, activity that would cause the genital region to be wet should be
avoided. Refrain from any sexual activity until healed.
Prevention and Hygiene: Circumcision and general cleanliness will largely prevent much of the inflammatory
problems. IT IS VERY IMPORTANT TO KEEP THE GENITAL REGION DRY.
No Improvement/Deterioration: If the genital swelling and erythema spreads rapidly, return for immediate
reevaluation.
Follow-up Actions
Wound Care: Keep area clean and dry.
Return evaluation: Re-evaluate in 1 week: Phimosis/paraphimosis, balanitis, genital fungal infections. Re-
evaluate as needed: Thrombosis of penile vein (takes several weeks to months to resolve). Rapidly spreading
inflammation may be Fournier’s gangrene, requiring immediate evacuation.
Evacuation/Consultation Criteria: Evacuate as above for Fournier’s gangrene, phimosis/paraphimosis.
When lesions on the skin persist, refer for biopsy. Consult urology or dermatology as needed.
Dorsal Slit Procedure
Essential: If the patient has severe phimosis where the foreskin has scarred down to a small hole and
the patient is having significant pain and discharge from the penis, the foreskin needs to be incised (dorsal
slit). Similarly, if paraphimosis is severe, excessive circumferential swelling may compromise blood flow in the
penis, which can be relieved with a dorsal slit.
- Attempt non-surgical reduction with anti-inflammatory medications, ice water and lubricants. Evacuate
patient to a trained provider for this procedure if possible. If there are signs of systemic infection (fever,
nausea, fatigue, etc.), and prompt evacuation is not available, perform a dorsal slit. - Assemble equipment: 1% lidocaine (w/o Epi), needle and syringe, clamp, forceps, scalpel or surgical
scissors, needle driver, 4-0 suture, prep solution, alcohol. - Prep the penis as with any surgical procedure (sterile scrub, Betadine, drape), and attempt to clean
between the head and the foreskin, especially on the dorsal side. - Use 1% lidocaine and a small needle (25-26 gauge) infiltrate the skin about mid-shaft and extend the
wheal at least halfway around the shaft of the penis. - Confirm the top of the penis (dorsal side) is numb with forceps or needle.
- Use a straight clamp to crush the skin from the phimotic area back to the glans (head). Make sure the
jaw stays between the glans and the foreskin. Do NOT pass the jaw into the meatus. The glans will still
have sensation and the patient should be able to tell you if the meatus is being cannulated. - Leave the clamp on for 5 minutes to compromise blood flow in the area to be incised.
- Remove the clamp and use a scissors to cut the crushed skin where the clamp had been. Do not
incise the glans. - This should expose the glans. Control bleeding with figure 8 stitches using 4-0 non-absorbable sutures.
- Clean the penis with sterile prep solution between the head and foreskin, then wipe prep solution away
with alcohol. Allow to air dry and apply a sterile dressing leaving the meatus clear. - Monitor the patient, as this maneuver is only temporary and the slit can contract. He should have
elective circumcision later.
Symptom: Male Genital Problems: Testis/Scrotal Mass
CAPT Leo Kusuda, MC, USNIntroduction: Testis masses are alarming to the patient since they may represent cancer. Testis cancer