Abstract
Penile strangulation from a foreign body is a rare presentation to the emergency department. It must be treated as soon as possible as any delay in management can lead to complications such as gangrene and amputation of the penis. There is no superior standard of care as each case needs to be managed individually depending on clinical findings. We present a 40 year old male with a plastic bottle neck strangulating his penis requiring a medical cast saw to successfully free it.
1. Introduction
One of the rare urology presentations is penile strangulation secondary to a foreign object. This was first reported by Gauthier in 1755. It is usually associated with an attempt by an individual for sexual gratification. A metallic or non-metallic object is used by the patient to compress the tissue and underlying vasculature usually associated with an attempt to maintain a longer erection. Commonly used objects include metal rings and plastic bottle necks. This is a surgical emergency and late intervention can lead to penile necrosis, gangrene and amputation so time plays a critical role in management of these patients.1
Given the rarity of these presentations there are no standard protocol for managing these patients and in most cases clinicians have to think outside the box when dealing with these cases. We present a case of a 40 year old man with self inflicted penile strangulation stuck in a plastic moisturiser bottle neck.
2. Case description
A 40 year old Caucasian man presented to the emergency department complaining after 8 hours of his penis being stuck in a plastic bottle. Patient reported the bottle was initially used for sexual gratification however after a while he was unable to remove the bottle. He initially attempted to remove the bottle at home without success so eventually presented to the hospital given his worsening pain.
Initially attempts were made to remove the bottle with the help of lubricant without any success. Then a pair of heavy scissors were used to try and cut the plastic bottle neck free which was also unsuccessful. Eventually a medical cast saw (Fig. 1) was used with a tongue depressor protecting the penile skin to cut the plastic bottle neck.
Fig. 1.
Medical cast saw used to cut the plastic bottle neck.
Once the bottle was removed the penis looked severely oedematous with discoloration of distal penis as seen in Fig. 2. There was no blood at the meatus and patient was able to void without any issues (passing clear urine). He was admitted to the urology ward overnight for observation and was discharged day 1 given his pain and penile swelling had improved. He did not attend further follow up. Fig. 2
Fig. 2.
Penile edema and discoloration secondary to plastic bottle neck.
3. Discussion
Penile strangulation has been reported worldwide since 1755. It is commonly used in middle aged and elderly men to increase sexual arousal, sexual performance and autoerotic intentions. Penile strangulation due to foreign body is a rare clinical emergency in Urology. In these scenarios’ patients usually present late due to the associated social stigmata. However urgent intervention is vital to prevent necrosis and amputation. Erectile dysfunction may be a sequala from late presentation and treatment.2
As the objects used by patients are variable, clinicians must be creative and rely on the equipment available to them. The aim of the treatment is to decompress the constricted penis as soon as possible to allow free blood flow and micturition. In our case due to timely intervention the patient had a good clinical outcome and was discharged without requiring further intervention.3
In 1995 Bhat et al. proposed a classification of penile incarceration which composed of 5 grades ranging from edema to necrosis;
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Grade I: Edema of the distal penis.
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Grade II: Injury to the penile skin constriction of corpus spongiosum without any urethral injury. Distal penile edema with decrease sensation.
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Grade III: Injury to skin and urethra but no urethral fistula. Loss of distal penile sensation.
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Grade IV: Complete division of corpus spongiosum leading to urethral fistula and constriction of corpus cavernosa with loss of distal penile sensation.
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Grade V: Gangrene, necrosis, or complete amputation of the distal penis.4
Based on this classification our patient was in grade I.
4. Conclusion
Penile strangulation requires emergency management in order to prevent organ dysfunction. Each case must be managed exclusively depending on the object used by the patient. An orthopaedic cast saw can be used to successfully remove a plastic bottle neck from a penis.
Consent
Consent was obtained for the anonymous presentation of the case.
Declaration of competing interest
There are no conflicts of interest to report.
Contributor Information
Arya Bahadori, Email: arya.bahadori@doctors.org.uk.
Gerard Bray, Email: gerard.bray@health.qld.gov.au.
Munad Khan, Email: munad.khan@gmail.com.
References
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