Introduction

Strangulation of the genital organs is a rare presentation to the emergency department which requires urgent intervention to avoid long term complications¹. Penoscrotal constriction devices are either used for autoerotic stimulus or to increase sexual performance by maintaining an erection for a longer period². Constriction of the genitals by a circular object (metallic or non-metallic) leads to swelling of the penis distal to the ring due to initial blockage of the venous return and arterial supply. Long term complications can include erectile dysfunction, penile paraesthesia, urethral stricture or urethrocutaneous fistula³.

Removal of these devices can be challenging the size of the ring and type of metal can prove difficult to remove with standard medical equipment⁴. Furthermore, the proximity to vital structures and the degree of discomfort and agitation in the patient can provide further difficulties.

 

Case Report

A male presented to the Emergency Department with pain and swelling of his penis and scrotum, Figure 1. Seven hours previously, he applied titanium penoscrotal constriction device to himself. He reported no voiding difficulty. Attempts were made to remove the device manually. Ice packs were applied but failed to reduce the swelling. Orthopaedic instruments (bolt and bone cutters) failed to grasp or even indent the device. Under sedation with Ketamine 100mg, Fentanyl 50mcg and Propofol 150mg in divided doses- the Fire Brigade Department divided the penoscrotal constriction device with an electric hand operated axel grinder. Cool irrigation was running throughout to prevent overheating or thermal damage to the skin. A metal forceps was placed under the ring to prevent past pointing of the axel grinder. Protective fire protection sheets were used to protect the patient and staff from sparks. The procedure took approximately 20 minutes. There was immediate response of distal penile pulsations, sensation and capillary refill following removal with partial improvement of the oedema. On review one month later, he reports no voiding or sexually issues.

 

Discussion

Penile strangulation is a rare presentation however the potential organ threatening complications warrant urgent treatment and resolution of blood flow. In our case- the penoscrotal constriction device was a titanium based ring (5cm x 4cm x1.5cm) - due to the durability and size of the ring, standard medical tools were not sufficient for removal. Prompt response from the fire brigade and the use of an electric hand held angle grinder successfully removed the ring. A wedge was resected from the ring which enabled the ring to be rotated 180 degrees to facilitate a cut on the opposite side. Despite the ring being in place for near 7 hours, full functioning recovery was achieved.

 

Penile strangulation injuries are graded on the severity of injury:

Grade 1: oedema of the distal penis, no evidence of skin ulceration or urethral injury.

Grade 2: injury to the skin and constriction of the corpus spongiosum but no evidence of urethral injury; distal penile oedema with decreased penile sensation

Grade 3: injury to skin and urethra but no urethral fistula; loss of penile sensation

Grade 4: complete division of the corpus spongiosum leading to urethral fistula and constriction of corpora cavernosa with loss of distal penile sensations

Grade 5: gangrene, necrosis or complete amputation of the penis.

 

Based on this description by Bhat et al⁴ our patient suffered a grade 2 injury. A variety of techniques have been described for removal of penoscrotal constriction rings.  There is no standard technique or recommendations- each case requires an individualised approach based upon the presentation, the size and type of object, the time from injury to presentation and the local facilitates. Bolt cutters of varying sizes have been successful in removing constriction rings from the penis¹. Bolt cutters were attempted unsuccessfully in our case; the titanium-based ring was too strong and wide and to grip and the oedema was too severe to allow anything more than a flat forceps underneath.

Wu et al. described a challenging case of a larger thick metallic ring causing constriction for over 48hours⁵. They described a three step technique involving aspiration under general anaesthesia similar to a Winter’s procedure using a 16 gauge trucut biopsy gun. Secondly, ribbon gauze was strapped around the ring in four quadrants to apply traction. Finally the penis and scrotum were serially strapped to reduce oedema and subsequently the lubricated ring was pulled off.

Removal by cutting is the most commonly described method^2,6,7. Orthopaedic tools such a Giggle saws and bone cutters as well as motorised drills normally used by dentists^8,9. Motorised saws have also been employed as was necessary in our case^4,10. Mechanical saws can be associated with thermal and mechanical injuries. Regardless of the presentation of injury, prompt removal can result in full functional recovery. Full utilisation of available disciplines including the non-medical faculties such as the maintenance or fire brigade departments may be required to remove unusual foreign bodies.

 

Correspondence:

Mr Gregory Nason, Specialist Registrar in Urology, Mater Misericordiae University Hospital, , Dublin 7,  Ireland

Email: [email protected]

Phone: +35314037576

Conflict of Interest:

No conflicts of interest from any author

References

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2. Horstmann M, Mattsson B, Padevit C, Gloyer M, Hotz T, John H. Successful removal of a 3.6-cm long metal band used as a penile constriction ring. J Sex med. 2010 Nov;7(11):3798-801
3. Bhat AL, Kumar A, Mathur SC, Gangwal KC. Penile strangulation. BJU Int.1991;68(6)618-621
4. Santucci RA, Deng D, Carney J. removal of metal penile foreign body with a widely available emergency-medical-services-provided air-driven grinder. Urology. 2004;63(6):1183-1184
5. Wu X, Batra R, Al-Akraa M, Seneviratne LN. Penoscrotal entrapment: a safe, innovative technique for removing metal constricting devices. BMJ Case Rep. 2012 Sep 25;2012
6. Kadioglu A, Cayan S, Ozcan F, Tellaloglu S. Treatment of penile incarceration in an impotent man. Int Urol nephrol. 1995;27(5):639-41
7. Wiedemann A, Muller H, Rabs U. Inappropriate use of a titanium penile ring. An interdisciplinary challenge for urologists, jewellers and locksmiths. Urologe A. 2005 Dec;44(12):1473-5
8. Etetafia MO, Nwajei CO. Successful removal of strangulating meal epnile ring using a dental handpiece. BMJ Case Rep. 2014 Jul 11;2014
9. McLaughlin T, Coyner W. Removal of a strangulating metal bearing from the penis. J Urol. 1989 Mar;141(3):617
10. Sathesh-Kumar T, Hanna-Jumma S, de Zoysa N, Saleemi A. Gentitalia strangulation- fireman to the rescue! Ann R Coll Surg Engl. 2009 May;91(4):W15-6

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