Letters to the Editor

Paraphimosis in a Middle-Aged Adult After Intercourse

TO THE EDITOR: Although rare, paraphimosis is common among the urologic emergencies that present to a family physician. Given the importance of prompt diagnosis and treatment, family physicians should be familiar with the management of paraphimosis, including the clinic-based, nonsurgical treatments that are available. In addition, preventive efforts exist to help patients who may be at high-risk of paraphimosis. Our review of the general practice literature only found one comprehensive review.¹ We present a highly unusual case of paraphimosis in a healthy adult after sexual intercourse.

A 38-year-old man presented with painful penile swelling and inability to reduce his foreskin for four days. He described a preceding three-month history of phimosis. He had had intercourse with his wife four days before and noted that this allowed complete foreskin retraction for the first time in months. He fell asleep without replacing the foreskin, and by morning was unable to return the foreskin to its usual location. He experienced increasing swelling and pain. He denied having had a sexually transmitted disease, urinary tract infection, previous paraphimosis, instrumentation, piercings, or obstructive symptoms. On examination, there was tenderness and dramatic edema of the foreskin, which formed a tight collar around the glans, that remained pink and warm. There was no evidence of skin or sexually transmitted disease. Urgent urologic consultation was sought. To reduce edema, the urologist squeezed the glans for several minutes, which successfully allowed reduction of the foreskin. The patient was counseled to always replace the foreskin. Circumcision was discussed as an option if problems continued.

Paraphimosis occurs in uncircumcised males when retracted foreskin constricts blood and lymphatic flow, risking necrosis. Most commonly, this occurs in children and the elderly. In children, it is commonly related to a congenitally narrow preputial opening or urinary obstruction. In elderly patients, it is typically iatrogenic, involving failure to return the foreskin to its normal location, classically after catheter placement.² Paraphimosis in middle-aged adults is usually linked with unusual causes, including piercings, lichen sclerosis, Plasmodium, contact allergy, chancroid, and unusual cultural practices. Prevention includes cleaning under the foreskin daily, and reducing a retracted foreskin. Paraphimosis is not always painful. A detailed history should explore manipulation, instrumentation, and circumcision. Penile viability is investigated by inspection and palpation.

Although an urgent urology consultation is critical, many creative, office-based, nonsurgical options exist. Common techniques to reduce edema and facilitate reduction include squeezing the glans, injecting hyaluronidase, and applying circumferential, compressive dressing, ice, or granulated sugar. Other options include a "puncture" technique and direct blood aspiration.^1,3 Emergency dorsal slit ultimately may be appropriate. Pain control includes topical or oral agents, or nerve block. Given the likely recurrence, follow-up circumcision is recommended .

Interestingly, three previous reports involving erotic dancers also linked paraphimosis to erection and intercourse.^4,5 As in our patient, these cases involved a pre-existing tight foreskin; however, unlike our patient, they also involved delayed detumescence.

Our case contributes to the unusual variety of presentations of paraphimosis. Family physicians should be aware of measures for prevention and treatment.

DAVID R. BERK, A.B.
Stanford University School of Medicine
300 Pasteur Dr.
Stanford, CA 94305

RICHARD LEE, M.D.
Stanford University School of Medicine
211 Quarry Rd., N329
Stanford, CA 94305

REFERENCES

1. Choe JM. Paraphimosis: current treatment options. Am Fam Physician 2000;62:2623-6.
2. Williams JC, Morrison PM, Richardson JR. Paraphimosis in elderly men. Am J Emerg Med 1995;13:351-3.
3. Olson C. Emergency treatment of paraphimosis. Can Fam Physician 1998;44:1253-4.
4. Higgins SP. Painful swelling of the prepuce occurring during penile erection. Genitourin Med 1996;72:426.
5. Ramdass MJ, Naraynsingh V, Kuruvilla T, Maharaj D. Case report. Paraphimosis due to erotic dancing. Trop Med Int Health 2000;5(12):906-7.

Exercise-Induced Bronchospasm vs. Exercise-Induced Asthma

TO THE EDITOR: I enjoyed reading the article¹ in American Family Physician on exercise-induced bronchospasm (EIB). It is apparent that more knowledge and patient education are needed about this prevalent and underdiagnosed condition. I would like to clarify the difference between EIB and exercise-induced asthma (EIA). Although the difference between them has not been fully elucidated, EIB is a bronchospastic disorder, and EIA is an inflammatory condition. As the authors state, "80 to 90 percent of patients with asthma also have EIB."¹ In addition, 5 to 10 percent of patients with EIB have no concomitant respiratory or allergic disease.

Studies on EIB are lacking. Two studies^2,3 examined subjects after exercise and were unable to document increased inflammation on bronchoalveolar lavage or in blood histamine levels. This evidence suggests that EIB may not have an inflammatory base.

Other researchers have included patients with chronic asthma in studies determining the efficacy of treatment of EIB. This erroneous inclusion has led to the assumption that anti-inflammatories, such as inhaled steroids, help patients with EIB, when, in actuality, they help patients with EIA.

Although this sounds like semantics, I think it is important to properly define the terms. Diagnosing patients with asthma and initiating anti-inflammatory therapy still can be associated with stigmas, inability to enter military professions, and changes of insurance premiums. It also can be confusing for patients to hear they have "exercise-induced asthma" (a chronic disease) when in truth they only have "exercise-induced bronchospasm" (a transient problem). As more research is done to elucidate the relationship between EIA and EIB, we can better define the terms and appropriate treatments.

CHRISTIAN L. HERMANSEN, M.D.
Elmer Family Practice
330 West Front St.
Elmer, NJ 08318

REFERENCES

1. Sinha T, David AK. Recognition and management of exercise-induced bronchospasm. Am Fam Physician 2003;67:769-74.
2. Jarjour NN, Calhoun WJ. Exercise-induced asthma is not associated with mast cell activation or airway inflammation. J Allergy Clin Immunol 1992;89:60-8.
3. Karjalainen EM, Laitinen A, Sue-Chu M, Altraja A, Bjermer L, Laitinen LA. Evidence of airway inflammation and remodeling in ski athletes with and without bronchial hyperresponsiveness to methacholine. Am J Respir Crit Care Med 2000;161: 2086-91.

IN REPLY: We thank Dr. Hermansen for raising the issue of the differences between exercise-induced asthma (EIA) and exercise-induced bronchospasm (EIB). The terms EIA and EIB often are used interchangeably in the literature. In our review of the literature we were unable to discover a consensus regarding the pathophysiology of EIA, EIB, and the relationship, if any, between the two terms. Therefore, we have chosen to follow the National Asthma Education and Prevention Program (NAEPP) guidelines,¹ in which the expert panel has preferred the term EIB and has used the functional definition of EIB rather than a pathophysiologic one. Currently, there are several theories that attempt to explain the mechanism of EIB. The two with the most consensus are the thermal and osmolarity theories.

The thermal theory is based on the assumption that hyperventilation during exercise causes loss of heat and drying of the airways that in turn causes a transient bronchoconstrictive response.² The osmolarity theory³ suggests that it is the heat lost during exercise and the rapid rewarming of the airways after exercise that causes a reactive hyperemia of the microvasculature and edema of the airways that sets up an osmotic gradient, which stimulates the release of proinflammatory substances from mast cell and other inflammatory cells. This therapy could possibly explain why steroids and other anti-inflammatory agents^4-6 have been shown to improve symptoms in patients with EIB.

As Dr. Hermansen has noted, more research is needed to elucidate the pathophysiology of EIB. Because our article was in the series "Practical Therapeutics," we stayed away from too many details regarding pathophysiology.

TARU SINHA, M.D.
Mountainside Family Practice Associates
799 Bloomfield Ave.
Verona, NJ 07044

REFERENCES

1. National Asthma Education and Prevention Program (National Heart, Lung, and Blood Institute). Guidelines for the diagnosis and management of asthma: expert panel report 2. National Institutes of Health, National Heart, Lung, and Blood Institute. NIH publication no. 97-4051. Bethesda, Md.: U.S. Dept. of Health and Human Services, Public Health Service, 1997.
2. Langdeau JB, Boulet LP. Prevalence and mechanism of development of asthma and airway hyperresponsiveness in athletes. Sports Med 2001;31:601-16.
3. Anderson SD, Daviskas E. The mechanism of exercise-induced asthma is... J Allergy Clin Immunol 2000;106:453-9.
4. Cavallo A, Cassaniti C, Glogger A, Magrini H. Action of nedocromil sodium in exercise-induced asthma in adolescents. J Investig Allegol Clin Immunol 1995;5:286-8.
5. Kelly KD, Spooner CH, Rowe BH. Nedocromil sodium versus sodium cromoglycate in treatment of exercise-induced bronchoconstriction: a systematic review. Eur Respir J 2001;17:39-45.
6. Henriksen JM, Dahl R. Effects of inhaled budesonide alone and in combination with low-dose terbutaline in children with exercise-induced asthma. Am Rev Respir Dis 1983;128:993-7.