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• Re: Ice, Pins and Sugar: Are they meant for reducing paraphimosis
  Stewart Teece
  Published on: 2 November 2004
• Ice, Pins and Sugar: Are they meant for reducing paraphimosis
  Raveenthiran Venkatachalam
  Published on: 5 October 2004

• Published on: 2 November 2004

  Re: Ice, Pins and Sugar: Are they meant for reducing paraphimosis

  • Stewart Teece, Specialist Registrar

  Dear Editor

  In response to the letter from Dr Raveenthiran, I feel that there are a number of issues to be addressed. Firstly, many BETs are written not to reflect and reinforce current practice in emergency departments. Often, as in this case, this is a response to advice recieved upon referring to the appropriate specialty. Many techniques require questioning whether they are acccepted practice or otherwise. As...

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  Dear Editor

  In response to the letter from Dr Raveenthiran, I feel that there are a number of issues to be addressed. Firstly, many BETs are written not to reflect and reinforce current practice in emergency departments. Often, as in this case, this is a response to advice recieved upon referring to the appropriate specialty. Many techniques require questioning whether they are acccepted practice or otherwise. As such the bestBETs procedure, looks at available evidence on a practice, appraises and shows that evidence and derives a clinical bottom line.

  Secondly, in an attempt to cast as sensitive a net as possible for that evidence, some BETs authors choose to include accepted spellings from different countries (eg tumour or tumor) and also the more common mis- spellings. The efficacy of this method was shown as the second paper (published in the Annals of the Royal College of Surgeons of England) quoted used the incorrect spelling "paraphymosis" in the title and throughout.

  Thirdly, there is some difficulty in changing the bottom line as suggested. Evidence has been found, and although this evidence appears poor with no control group and may be confounded by inadvertant pressure to the glans (particularly in the pins group). As with all BETs, the available evidence is presented in which reader's can draw their own conclusions. Based on the evidence provided, the clinical bottom line we reached was one we felt most appropriate to that evidence available, it cannot simply be dismissed as it disagreed with our belief when we approached the subject.

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  Conflict of Interest:
  None declared.

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• Published on: 5 October 2004

  Ice, Pins and Sugar: Are they meant for reducing paraphimosis

  • Raveenthiran Venkatachalam, associate professor in pediatric surgery

  Dear Editor,

  I read, with interest, the article by Jones and Teece [1]. The authors have attempted to find the best out of three procedures, which more or less resemble home remedy. They should not be offered in a modern scientific emergency department because they are based on misunderstood pathophysiology of paraphimosis [2].

  In paraphimosis, as soon as the constricting ring of prepuce gets stuck...

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  Dear Editor,

  I read, with interest, the article by Jones and Teece [1]. The authors have attempted to find the best out of three procedures, which more or less resemble home remedy. They should not be offered in a modern scientific emergency department because they are based on misunderstood pathophysiology of paraphimosis [2].

  In paraphimosis, as soon as the constricting ring of prepuce gets stuck to the coronal sulcus, vascular spaces of the glands are engorged due to venous impedance. This tumescence of glands is the real hindrance for reduction. Therefore, manual squeezing of the glands or needle aspiration of the vascular spaces is essential for reducing the stuck foreskin. (2) If left untreated, lymphatic blockage causes delayed onset of oedematous swelling of inner preputial layer. Thus, oedema is the result and not the cause of irreducibility. Very often this cause-effect relationship is misunderstood. Many authors, who erroneously incriminated preputial oedema, attempted to dissipate it by a variety of techniques such as multiple puncture of swollen foreskin, injection of hyaluronidase, application of hygroscopic agents such as granulated sugar and use of ice packs. All of them are either useless or unnecessary. Application of ice is probably dangerous as it carries the risk of spasm of penile end-artery and gangrene. If some hygroscopic agent has to be applied I wonder if it is the sweetness of sugar that made it preferable over salt!

  The spelling PARAPHYMOSIS used by the authors for Medline search is nonexistent. PARAPHIMOSIS is derived from the Greek word ‘PHIMOS’ meaning muzzle (Verb). The Greek word ‘PHYMA’, which means a tumor, has no relevance to the restraining foreskin. The clinical bottom line of the paper needs to be modified as, “Ice, pins and sugar have been claimed to aid reduction of paraphimosis, but there is no evidence to show any of them really works.” Unless these primitive methods are discouraged, one would not be surprised to read in Emergency Medical Journal, after sometime, an article entitled “Dipping in honey aids reduction of paraphimosis” - for honey is also hyperosmolar and hygroscopic as sugar!

  References

  (1) Jones KM, Teece S. Ice, pins and sugar to reduce paraphimosis. Emerg Med J 2004; 21: 77-78.

  (2) Raveenthiran V. Reduction of paraphimosis: a technique based on patho-physiology. Br J Surg 1996; 83: 1247.

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  Conflict of Interest:
  None declared.

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