The symptoms of paraphimosis include the inability to return the retracted foreskin over the glans penis, resulting in swelling, severe pain, and possible discoloration of the glans. Recent catheter use could predispose to paraphimosis. If untreated, it can lead to tissue necrosis, infection, and urinary retention. In severe cases, the glans may turn dark due to restricted blood flow, and delayed treatment increases the risk of complications.

The clinical findings in paraphimosis typically include:

1. Swollen Glans and Foreskin: The glans penis and the foreskin are visibly swollen and may appear red or darkened due to impaired blood flow.
2. Tight Constricting Band: The retracted foreskin forms a tight, constricting band around the base of the glans, which is often a key diagnostic feature.
3. Pain and Tenderness: The patient usually experiences significant pain and tenderness in the affected area, which may intensify as the condition worsens.
4. Discoloration: The glans may show signs of ischemia, such as bluish or purplish discoloration, indicating reduced blood supply.
5. Urinary Retention: In some cases, the swelling and constriction can obstruct the urethra, leading to difficulty urinating or complete urinary retention.
6. Foreskin Inability to Move: The foreskin cannot be moved back over the glans and attempts to do so can be extremely painful and ineffective.

If left untreated, these clinical findings can progress to more severe complications like necrosis of the glans or infection.

The differential diagnoses of paraphimosis in sub-Saharan Africa include conditions that present with similar symptoms of penile pain, swelling, and urinary difficulties. These include:

1. Phimosis: Unlike paraphimosis, phimosis is a condition where the foreskin cannot be retracted over the glans. It can lead to discomfort, difficulty with urination, and an increased risk of infection, but the foreskin is not retracted and trapped as in paraphimosis.
2. Balanitis: This is the inflammation of the glans penis, often accompanied by redness, swelling, pain, and sometimes discharge. Balanitis can occur in uncircumcised males and may be associated with poor hygiene, infections, or irritants.
3. Balanoposthitis: This condition involves inflammation of both the glans and the foreskin. Symptoms include pain, swelling, redness, and possibly discharge. It can be due to infections, poor hygiene, or irritants and may resemble paraphimosis if the foreskin becomes swollen and tight.
4. Penile Fracture: Although rare, a penile fracture can cause acute pain, swelling, and discoloration of the penis. This condition usually results from trauma during vigorous sexual activity and is distinguished by the characteristic "cracking" sound and immediate pain.
5. Sexually Transmitted Infections (STIs): Certain STIs, like genital herpes or syphilis, can cause penile ulcers, swelling, and pain. These symptoms may mimic those of paraphimosis, particularly if there is significant swelling or secondary infection.
6. Penile Edema: This can result from various causes, including heart failure, kidney disease, or lymphatic obstruction. The penis may appear swollen, but there is no constriction of the glans by the foreskin, which is a key feature of paraphimosis.
7. Penile Cancer: Advanced penile cancer can cause mass formation, ulceration, and swelling of the glans and foreskin, which could be mistaken for paraphimosis. However, cancer typically presents with a longer history of symptoms and visible growth or ulceration.
8. Insect Bites or Allergic Reactions: These can cause localized swelling, redness, and discomfort on the penis, potentially resembling paraphimosis, though the tight constriction of the foreskin would not be present.
   Each of these conditions should be carefully considered and ruled out when diagnosing paraphimosis, especially in settings like sub-Saharan Africa, where access to healthcare may delay diagnosis and treatment.

For the diagnosis and management of paraphimosis in sub-Saharan Africa, the primary focus is on clinical assessment. However, certain investigations may be necessary to evaluate the extent of complications or rule out differential diagnoses. These include:

1. Clinical Examination: This is the most crucial "investigation." A thorough physical examination of the penis will reveal the characteristic findings of paraphimosis, such as the swollen glans, the constricted foreskin and inability to easily reduce the retracted prepuce.
2. Ultrasound: If there is concern about compromised blood flow to the glans, a Doppler ultrasound can be used to assess the blood flow. This investigation can help in determining the severity of ischemia and the urgency of intervention.
3. Urinalysis: If urinary retention or infection is suspected, a urinalysis can help detect the presence of urinary tract infections (UTIs), haematuria (blood in the urine), or signs of systemic infection.
4. Blood Tests:

   - Complete Blood Count (CBC): To check for signs of infection (elevated white blood cell count) or anaemia, which may occur in cases of severe or prolonged ischemia.

   - C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR): These inflammatory markers may be elevated in the presence of infection or severe inflammation.

5. Swab or Culture: If there are signs of infection, such as discharge or ulceration, a swab of the area can be taken for culture and sensitivity testing. This can identify any bacterial pathogens and guide antibiotic treatment.
6. Penile X-ray or MRI (if available): In rare cases, especially if there is suspicion of trauma (e.g., penile fracture) or underlying malignancy, imaging might be considered to rule out these conditions.

In resource-limited settings like many parts of sub-Saharan Africa, the emphasis will often be on clinical diagnosis and prompt manual reduction or surgical intervention, with more advanced investigations reserved for complicated cases or when initial management fails.

Treatment of paraphimosis in sub-Saharan Africa, as in other regions, focuses on prompt reduction of the trapped foreskin to restore blood flow and prevent complications. The specific approach may vary based on the resources available. Key treatment options include:

1. Manual Reduction: 

   - Compression Technique: The most immediate and commonly used method involves manual reduction. The glans is gently compressed to reduce swelling, often using a cool compress or gauze soaked in saline. After reducing the swelling, the foreskin is manually pulled forward over the glans.

   - Lubrication: Using a sterile lubricant or an anaesthetic gel can ease the reduction process by reducing friction.

2. Osmotic Methods: If manual reduction is difficult due to severe swelling, osmotic agents like sugar, salt, or gauze soaked in hypertonic solutions may be applied to draw out fluid and reduce oedema before attempting reduction.
3. Dorsal Slit Procedure:   - If manual reduction fails or the swelling is too severe, a dorsal slit (a small surgical incision on the foreskin) may be performed. This relieves the constriction and allows the foreskin to be repositioned. 

      - This procedure is relatively simple and can be performed under local anaesthesia, making it feasible in resource-limited settings.

4. Circumcision:

      - In recurrent cases or when manual reduction and the dorsal slit are ineffective, circumcision might be necessary. This can be done electively after the initial emergency is managed to prevent future episodes.

      - Circumcision is a definitive treatment that eliminates the risk of paraphimosis but may require more specialized surgical expertise and post-operative care.

5. Antibiotics: 

      - If there is evidence of infection or if the foreskin is necrotic, antibiotics may be prescribed. This is particularly important in regions with a high prevalence of infections or poor hygiene conditions.

6. Analgesia and Anaesthesia:

      - Pain management is crucial. Local anaesthetics (like lidocaine) may be used during manual reduction or surgical procedures. Systemic analgesics or sedation might also be needed, particularly in children

7. Post-Reduction Care:

      - After successful reduction, careful monitoring is essential to ensure that the foreskin remains in place and that there is no recurrence. Patients should be educated on proper hygiene and the importance of avoiding forceful retraction of the foreskin.

8. Referral:

      - In cases where initial treatment attempts are unsuccessful, or complications arise (such as gangrene or severe infection), referral to a higher-level healthcare facility with surgical capabilities may be necessary.

   In sub-Saharan Africa, where access to healthcare resources may be limited, early intervention and basic surgical skills are crucial for effective treatment. Education on the prevention of paraphimosis, including proper foreskin care, is also important to reduce the incidence of this condition.

 The follow-up of paraphimosis involves monitoring for complications, ensuring proper wound care and hygiene, and managing any ongoing pain. Patients should be assessed for urinary function and educated on preventing recurrence, including the gentle handling of the foreskin. Regular follow-up appointments are important, and in cases of recurrent paraphimosis, circumcision may be recommended. Community education on proper foreskin care and the risks associated with traditional practices can also help prevent future episodes.

Preventing paraphimosis involves educating caregivers on proper foreskin care, ensuring safe circumcision practices, and emphasizing correct post-circumcision care. Improving access to healthcare and community health education also plays a key role in early detection and management.