madman
Super Moderator
ABSTRACT
INTRODUCTION: Penile ring entrapment during self-sexual satisfaction is one of the rare cases in general and urologic surgery. When the penile shaft is entrapped in a metal ring, one risks a possible complete loss of the distal penis to strangulation and gangrene. We present management of a case of the entrapped penile ring with penile strangulation in a resource-limited setup amidst the absence of management guidelines. The case has been reported in line with SCARE criteria (1).
PRESENTATION OF CASE: A 43-year-old male presented after 72 h of pilot ball bearing ring penile insertion for the sustainability of an erection, with 24 -h history of painful penile swelling and acute urine retention. The patient had a history of using recreational drugs and erectile dysfunction with evidence of high-grade penile injuries at presentation. The ring was cut using an electrically powered angled grinder, with full penile recovery on conservative management in eight months of follow-up.
DISCUSSION: The entrapped penile ring is clinically diagnosed but establishing incentive of insertion is difficult just like identifying a correct technique to remove it. Entrapped ring obstructs blood and lymphatic flow leading to edema and ischemia with associated penile tissue injuries. High-grade penile injuries or penile amputation are sequels of delayed ring removal and good outcomes are tangible through a timely multidisciplinary approach.
CONCLUSION: Eroticism and erectile dysfunctions are known incentives to use penile rings to sustain an erection. Delayed ring removal results in its entrapment and penile strangulation and related complications. Timely removal of rings requires a multidisciplinary approach and local management protocols.
1. Introduction
Penile ring entrapment is when a ring previously inserted onto the penis is left for an extended period of recommended time resulting in edema, urethra fistula, gangrene, and complete loss of distal penis leading to penile strangulation. Penile strangulation by a constricting entrapped ring is a rare urological emergence that presents immense challenges to a general surgeon in resource-limited centers globally [2]. The motivation of inserting a ring or any object on a penis in adult males has been erotically associated with the management of erectile dysfunction [3].
The non-metallic or metallic object is used as rings and the duration of insertion seems directly proportional to the complications irrespective of the location of the ring on the penis [3]. Since the first reported case in 1755, the management of entrapped penile rings is challenging [4].
We present a case of penile ring entrapment with strangulation using ball-bearing pilot rings and how it was managed in a resource limited hospital after 8 months of follow up and has been reported inline with SCARE criteria [1].
2. Presentation of case
A 43-year-old male presented at casualty unit with swollen penis for 72 h and failure to pass urine for 24 h, following insertion of the metallic ring and failure to remove it. The patient was a married addict to pornography and recreation drugs (khart), smoked 30 pack-years of cigarette and drank 60 units of crude alcohol weekly. He denied use of erectile enhancing drugs or sexual intercourse with the spouse in 4 days prior to the incident and had no comorbidities of diabetes mellitus, hypertension, or mental illness.
On physical examination, he had normal vital signs and graded his pain as unbearable. Locally, had a circumcised penis with an entrapped copper-like ring distal to the scrotum, grossly edematous penile shaft with serosanguinous fluid discharge from mottled penile shaft skin lesions with areas of necrosis (Fig. 1). Self-inflicted needle pricks and cuts to relieve the swelling were noted. The glans penis was cold, erythematous with reduced distal sensation and capillary refill of more than two seconds. There was severe tenderness proximal to the ring and a deepening discharging cut wound around the ring. The hypogastrium was distended, tender, and dull to percussion.
The patient was clinically diagnosed with penile ring entrapment with strangulation, high-grade penile shaft skin injuries, and acute urine retention. The pus swab culture and sensitivity showed mixed bacterial infection sensitive to cephalosporin antibiotics. The patient was blood group O rhesus positive with normal glycaemic levels and hemogram on admission. Our facility did not have flexible cystoscopy to evaluate for urethral injuries.
The patient received emergence care within 20 min and definitive intervention in 12 h of arrival to the facility. In order to relieve the acute urine retention, we performed supra-pubic cystostomy under local anesthesia and sterile conditions inserting a two-way F20 Foleys catheter and drained 2500 mL of clear urine instantly. We attempted to slide the ring off with continuous compression and lubrication while protecting the underlying skin with a tongue blade but the ring was tight to the penile shaft. Finally, we cut the ring using an electrically powered angle grinder saw of Einhell 2015/10/EB050252 brand [5] and expander circlip angled pliers from the hospital’s engineering department (Fig. 2). The patient was counseled and consented to the procedure and asked to report any heat generated during the cutting of the ring. The procedure was kept clean with a moist saline gauze pad under the penis, an elastic rubber was firmly wrapped over the penile shaft and a tongue depressor was pushed under the ring to protect the tissue from cut and excessive heat. Saline irrigation was used to cool the machine and avoid thermal injuries to the penile tissue. Whenever the patient-reported heat, the procedure was interrupted and cold damp gauze applied to the penile shaft to cool before resuming. Two interruptions were made and no anesthetic drugs were used. The ring was cut at 180◦ and used internal circlip expander pliers to separate it off the penile shaft. The parts of the ring were reassembled to obtain the internal diameter, width, and thickness (Fig. 3). The ring was 2 mm thick with an internal diameter of 2.5 cm and made of hard metal. Fasciotomy (Corporotomy) was performed through bilateral penile shaft longitudinal incisions distal to the ring-mark up to the corona (Fig. 4) to prevent further tissue ischemia and necrosis to avert the pending penile amputation.
The patient had a prolonged hospital stay of 90 days for local wound care as he could not afford the cost of plastic surgery and was followed up in a surgical outpatient clinic for eight months. We did serial surgical debridement, regular dressing, and broad spectral antibiotic guided by pus swab culture and sensitivity. Nutritional, psychological, and physiotherapeutic care was provided through consultations. He developed early morning painful erections in the second week and local wound sepsis but recovered fully with minimal ventral phallus hypertrophic scaring (Fig. 5).
4. Conclusion
In a nutshell, penile ring entrapment presents treatment challenges in absence of a local treatment protocol and designated instruments in resource-limited settings. Use of electrically powered angled grinder to cut hard metal rings is a viable option in our experience and we recommend its availability in hospital theatres. For guidelines, we propose a ring removal approach based on the tightness of the ring and distal damage by cutting and fasciotomy should be performed whenever distal penile tissue edema is present to prevent ischemia as you mobilize resources and skilled expert to remove.
Long-term follow-up with clear erectile dysfunction assessment tools, cognitive assessment, psychological counseling on recreational drug use is key for complication while community engagement and health education, in this case, are important preventive measures. The urological surgical societies should customize equipment and draft a penile ring entrapment management protocol for inclusion in standard text books as a chapter
INTRODUCTION: Penile ring entrapment during self-sexual satisfaction is one of the rare cases in general and urologic surgery. When the penile shaft is entrapped in a metal ring, one risks a possible complete loss of the distal penis to strangulation and gangrene. We present management of a case of the entrapped penile ring with penile strangulation in a resource-limited setup amidst the absence of management guidelines. The case has been reported in line with SCARE criteria (1).
PRESENTATION OF CASE: A 43-year-old male presented after 72 h of pilot ball bearing ring penile insertion for the sustainability of an erection, with 24 -h history of painful penile swelling and acute urine retention. The patient had a history of using recreational drugs and erectile dysfunction with evidence of high-grade penile injuries at presentation. The ring was cut using an electrically powered angled grinder, with full penile recovery on conservative management in eight months of follow-up.
DISCUSSION: The entrapped penile ring is clinically diagnosed but establishing incentive of insertion is difficult just like identifying a correct technique to remove it. Entrapped ring obstructs blood and lymphatic flow leading to edema and ischemia with associated penile tissue injuries. High-grade penile injuries or penile amputation are sequels of delayed ring removal and good outcomes are tangible through a timely multidisciplinary approach.
CONCLUSION: Eroticism and erectile dysfunctions are known incentives to use penile rings to sustain an erection. Delayed ring removal results in its entrapment and penile strangulation and related complications. Timely removal of rings requires a multidisciplinary approach and local management protocols.
1. Introduction
Penile ring entrapment is when a ring previously inserted onto the penis is left for an extended period of recommended time resulting in edema, urethra fistula, gangrene, and complete loss of distal penis leading to penile strangulation. Penile strangulation by a constricting entrapped ring is a rare urological emergence that presents immense challenges to a general surgeon in resource-limited centers globally [2]. The motivation of inserting a ring or any object on a penis in adult males has been erotically associated with the management of erectile dysfunction [3].
The non-metallic or metallic object is used as rings and the duration of insertion seems directly proportional to the complications irrespective of the location of the ring on the penis [3]. Since the first reported case in 1755, the management of entrapped penile rings is challenging [4].
We present a case of penile ring entrapment with strangulation using ball-bearing pilot rings and how it was managed in a resource limited hospital after 8 months of follow up and has been reported inline with SCARE criteria [1].
2. Presentation of case
A 43-year-old male presented at casualty unit with swollen penis for 72 h and failure to pass urine for 24 h, following insertion of the metallic ring and failure to remove it. The patient was a married addict to pornography and recreation drugs (khart), smoked 30 pack-years of cigarette and drank 60 units of crude alcohol weekly. He denied use of erectile enhancing drugs or sexual intercourse with the spouse in 4 days prior to the incident and had no comorbidities of diabetes mellitus, hypertension, or mental illness.
On physical examination, he had normal vital signs and graded his pain as unbearable. Locally, had a circumcised penis with an entrapped copper-like ring distal to the scrotum, grossly edematous penile shaft with serosanguinous fluid discharge from mottled penile shaft skin lesions with areas of necrosis (Fig. 1). Self-inflicted needle pricks and cuts to relieve the swelling were noted. The glans penis was cold, erythematous with reduced distal sensation and capillary refill of more than two seconds. There was severe tenderness proximal to the ring and a deepening discharging cut wound around the ring. The hypogastrium was distended, tender, and dull to percussion.
The patient was clinically diagnosed with penile ring entrapment with strangulation, high-grade penile shaft skin injuries, and acute urine retention. The pus swab culture and sensitivity showed mixed bacterial infection sensitive to cephalosporin antibiotics. The patient was blood group O rhesus positive with normal glycaemic levels and hemogram on admission. Our facility did not have flexible cystoscopy to evaluate for urethral injuries.
The patient received emergence care within 20 min and definitive intervention in 12 h of arrival to the facility. In order to relieve the acute urine retention, we performed supra-pubic cystostomy under local anesthesia and sterile conditions inserting a two-way F20 Foleys catheter and drained 2500 mL of clear urine instantly. We attempted to slide the ring off with continuous compression and lubrication while protecting the underlying skin with a tongue blade but the ring was tight to the penile shaft. Finally, we cut the ring using an electrically powered angle grinder saw of Einhell 2015/10/EB050252 brand [5] and expander circlip angled pliers from the hospital’s engineering department (Fig. 2). The patient was counseled and consented to the procedure and asked to report any heat generated during the cutting of the ring. The procedure was kept clean with a moist saline gauze pad under the penis, an elastic rubber was firmly wrapped over the penile shaft and a tongue depressor was pushed under the ring to protect the tissue from cut and excessive heat. Saline irrigation was used to cool the machine and avoid thermal injuries to the penile tissue. Whenever the patient-reported heat, the procedure was interrupted and cold damp gauze applied to the penile shaft to cool before resuming. Two interruptions were made and no anesthetic drugs were used. The ring was cut at 180◦ and used internal circlip expander pliers to separate it off the penile shaft. The parts of the ring were reassembled to obtain the internal diameter, width, and thickness (Fig. 3). The ring was 2 mm thick with an internal diameter of 2.5 cm and made of hard metal. Fasciotomy (Corporotomy) was performed through bilateral penile shaft longitudinal incisions distal to the ring-mark up to the corona (Fig. 4) to prevent further tissue ischemia and necrosis to avert the pending penile amputation.
The patient had a prolonged hospital stay of 90 days for local wound care as he could not afford the cost of plastic surgery and was followed up in a surgical outpatient clinic for eight months. We did serial surgical debridement, regular dressing, and broad spectral antibiotic guided by pus swab culture and sensitivity. Nutritional, psychological, and physiotherapeutic care was provided through consultations. He developed early morning painful erections in the second week and local wound sepsis but recovered fully with minimal ventral phallus hypertrophic scaring (Fig. 5).
4. Conclusion
In a nutshell, penile ring entrapment presents treatment challenges in absence of a local treatment protocol and designated instruments in resource-limited settings. Use of electrically powered angled grinder to cut hard metal rings is a viable option in our experience and we recommend its availability in hospital theatres. For guidelines, we propose a ring removal approach based on the tightness of the ring and distal damage by cutting and fasciotomy should be performed whenever distal penile tissue edema is present to prevent ischemia as you mobilize resources and skilled expert to remove.
Long-term follow-up with clear erectile dysfunction assessment tools, cognitive assessment, psychological counseling on recreational drug use is key for complication while community engagement and health education, in this case, are important preventive measures. The urological surgical societies should customize equipment and draft a penile ring entrapment management protocol for inclusion in standard text books as a chapter
