To describe a man with penis strangulation caused by a steel ring and its successful removal.
A 33 year-old man presented to our emergency department with a 3-hour history of a grossly swollen and painful penis due to a stainless steel ring located at the base of the penis for erection enhancement during intercourse. After intercourse, he was unable to remove the ring and the penile pain and swelling progressively worsened.
At presentation, the patient also complained of pain in his lower abdomen and hypoesthesia in his genitalia. He had no comorbidities and no history of mental illness or substance abuse.
On examination, the patient was anxious and distressed. Abdominal bulging was absent, although guarding and tenderness were present in the lower abdomen. A 2.5-cm-diameter, 2-cm wide and 2-mm-thick ring was positioned tightly at the base of the penis.
The incarcerated penile shaft was grossly edematous and bluish with areas of exudation, cool and diminished in sensation.
The small diameter of the ring and edematous tissue made it impossible to pull out the ring from the shaft.
Hence, the fire department was contacted to obtain assistance; after consultation with them, the decision was made for the fire personnel to remove the steel ring using their hydraulic cable cutter. After disinfection, 1% lidocaine was injected at the base of the patient’s penis. The ring was sheared in two places and successfully removed without injury to skin and other tissue. After removal of the ring, circulation and skin color of the penis and scrotum were restored. At follow-up 2 weeks later, the edema had resolved and the skin had completely healed. Urination, skin sensation, and erectile function had returned to normal after 1 week. Urinalysis results were normal. On examination, a discontinuous circumferential scar was evident at the base of the penis.
The hydraulic cable cutter avoided thermal injury and shortened removal time compared with other procedures described. The patient’s recovery was uneventful, with erectile function restored after 1 week.
Ring-shaped objects are placed on the penis often to enhance sexual performance and for autoerotic purposes or curiosity.(1,2). The ring hinders venous return and leads to swelling, followed by arterial and lymphatic blockage and ischemia distal to the ring (3, 4) Timely removal of the offending object is paramount for full recovery of circulatory and urinary functions and in most cases further management is unwarranted. Delay in removal can lead to penile necrosis, urethrocutaneous fistula, and even septic shock and death (3, 4, 5, 6).
Management depends on the type and size of the constricting object, time after incarceration, degree of injury, available instruments, and experience of the physicians (2). The literature describes four approaches for removal of the object: string technique, aspiration, cutting, and surgery (2, 5, 7, 8). Special implements are often needed, which are not always available in the emergency and urology departments (1, 3, 4, 9, 10). Indeed, management delay is typically caused by locating an appropriate tool (2). However, their use introduces the risk of thermal burn or mechanical damage to genitalia tissue. Furthermore, a protective device needs to be inserted between the edematous genitalia and the ring, which can increase pressure and pain (5). The Winter procedure can be attempted, but the surgery is lengthy and poses a risk of injury (2).
We believe that ours is the second report of a hydraulic cable cutter being used to shear a constricting object. The cutter posed no risk of thermal injury and was capable of directional and power adjustments. We also did not need to insert a protective device between the ring and genitalia; thus, no ensuing injury occurred.
Genital incarceration is an urgent clinical situation requiring prompt treatment. However, suitable tools for removing the foreign object are not readily available in emergency and urology departments. Cooperation with other disciplines, even non-medical disciplines, can result in creative and timely measures for removal of the object.
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