UROLOGY, Volume 48, Number 3: Pages 464-465.
September 1996.

Surgeon's Workshop


Catherine R. DeVries, Alan K. Miller, and Michael G. Packer


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 out- patient setting. Hyaluronidase is widely available and keeps well if refrigerated. It is effective for children and adults. UROLOGY 48: 464-465, 1996.

Paraphimosis is painful, and reduction of it by classical methods even more so (Fig. 1). Recommendations for its reduction involve reassurance, followed by wrapping the penis with elastic, squeezing the prepuce or exerting considerable pressure to force the foreskin over the glans.1,2 The use of hyaluronidase for reduction of paraphimosis is not well known, although it has been used for this purpose for at least 11 years (C. D., personal experience, and personal communication with Robert Kindrachuk, M. D.). Subdermal introduction of hyaluronidase obviates the need for forceful reduction of the prepuce or a dorsal slit procedure.


        A topical anesthetic such as 2% lidocaine gel or EMLA cream (2.5% prilocaine and 2.5% lidocaine, Astra Pharmaceuticals, Westboro, Mass) may be applied to the skin for several minutes to 1 hour with an occlusive dressing such as plastic film. Using a tuberculin syringe, approximately 1 cc of hyaluronidase (150 U/cc available as Wydase; Wyeth-Ayerst Laboratories, Philadelphia, PA is injected into one or more sites in the edematous prepuce. Resolution of the edema is almost immediate, and the foreskin can then be gently retracted over the glans with minimal patience discomfort (Fig. 2).


        Hyaluronidase has been used in ophthalmology and plastic surgery for many years as a spreading agent. It is the natural protein responsible for hydrolysis of the extracellular mucopolysaccharide, hyaluronic acid. The commercially available enzyme is prepared from mammalian testes and is available as a lyophilized powder or as as stabilized clear solution or injection.3,4 Hyaluronidase acts by modifying the permeability of intercellular ground substance in connective tissue. The breakdown of the viscous hyaluronic acid decreases tissue resistance and enhances diffusion of substances between tissue planes. Clinically, it has been used to enhance the effects of locally infiltrated toxins from intravenous sites.4 In paraphimosis, it immediately reduces preputial edema. Adverse effects are exceedingly rare4 Hyaluronidase is contraindicated in the presence of infection or cancer because it could facilitate the spread of bacteria or malignant cells. Increase in ecchymosis has been reported, as have isolated cases of anaphylaxis, shock, and hypovolemia when the medication is given intravascularly. There have been no complications in our experience or in the experience of other series where hyaluronidase has been used to facilitate local anesthetic block for dermatologic surgery.5


  1. Devine, CJ, Jordan, GH, and Schlossberg SM: Surgery of the penis and urethra, in Walsh PC, Retik AB Stamey TA and Vaughan ED (Eds): Campbell's Urology, 6th ed. Philadelphia, WB Saunders, 1992, vol. 3 p 2972.
  2. Bloom, DA, Wan J, and Kay D: Disorders of the male external genitalia and inguinal canal, in Kelalis PP, King LR and Belman AB (Eds): Clinical Pediatric Urology, 3rd ed. Philadelphia, WB Saunders, 1992, p 1017.
  3. Reynolds, JEF (Ed): Hyaluronidase, in Martindale: The Extra Pharmacopoeia, 30ed. London, The Pharmaceutical Press, 1993, pp 1376-1377.
  4. McEvoy GK (Ed): Hyaluronidase: chemistry and stability, in American Hospital Formulary Service Drug Information, Bethesda, MD, American Society of Health System Pharmacists, 1995, pp 1744-1745.
  5. Clark, LE, and Mellete JR: The use of hyaluronidase as an adjunct to surgical procedures. J Dermatolog Surg Oncol 20: 842-844, 1944.

        From the Medical College of Georgia, Augusta, Georgia, Naval Medical Center, San Diego; and University of California, San Diego, Children's Hospital and Health Center, San Diego, California
        The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.
        Reprint requests: Catherine R. deVries, M.D., Pediatric Urology, BA8408, Medical College of Georgia, Augusta, GA 30912
        Submitted: March 28, 1996, accepted April 15, 1996

Copyright 1996 by Elsevier Science Inc.

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(File revised 02 January 2001)

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