Penile Strangulation by Four Stainless Steel Rings Requiring Multiple Approaches for Removal: A Case Report

ABSTRACT

Introduction

Penile strangulation is a rare urological emergency requiring prompt intervention. Stainless steel rings may resist conventional cutters because of their rigidity.

Case Presentation

A 62‐year‐old man presented with severe penile pain after applying four stainless steel rings to treat phimosis. One ring was trapped at the coronal sulcus and three at the penile base. The glans was congested with partial blistering. Initial attempts using the string method and manual ring cutters failed. Aspiration of approximately 10 mL of blood from the glans allowed removal of the distal ring. The remaining rings required general anesthesia, corporal blood aspiration, temporary penile‐base compression, partial cutting of one ring, and manual decompression. All rings were removed within approximately 6 h after application. No clinical evidence of urethral injury was found, and no sensory disturbance was noted.

Conclusion

A stepwise approach may be required for penile strangulation caused by multiple stainless steel rings.

Keynote Message

Penile strangulation by metallic objects requires prompt intervention to prevent irreversible damage. Conventional methods may fail when several stainless steel rings are involved. In such cases, aspiration, limited cutting, and manipulation under general anesthesia should be considered in a stepwise manner.

1. Introduction

Penile strangulation is caused by an encircling object that impairs venous and lymphatic drainage, resulting in congestion, edema, and, if prolonged, ischemia or necrosis [1, 2]. It is a urological emergency requiring prompt removal of the constricting object. Reported objects include soft materials such as rubber bands and strings, and hard objects such as metallic rings, bottles, and nuts [1, 2, 3]. Metal rings are particularly difficult to manage because they are rigid and may resist conventional cutting devices [2, 3, 4].

Several removal techniques have been reported, including manual compression, the string method, aspiration of blood, surgical decompression, and cutting with orthopedic or dental devices [2, 3, 5, 6, 7]. However, no single technique is universally effective, and the optimal approach depends on the material, number and location of objects, degree of edema, available equipment, and patient tolerance. We report a case of penile strangulation caused by four stainless steel rings requiring multiple removal approaches.

2. Case Presentation

A 62‐year‐old man with no significant medical history presented with severe penile pain. At a friend's suggestion, he had purchased four stainless steel penile rings online and applied them at approximately 6:00 PM in an attempt to self‐treat phimosis. This was his first use of a penile constriction device, and he denied any previous similar behavior. He presented to the emergency department at 8:00 PM because of worsening pain and inability to remove the rings.

On examination, one ring was located at the coronal sulcus and three at the penile base. The glans showed marked congestion, dark discoloration, and partial blistering (Figure 1a,b). Laboratory tests showed mild leukocytosis (11 000/uL), preserved renal function (creatinine 0.91 mg/dL, estimated glomerular filtration rate 66 mL/min/1.73 m2), and normal C‐reactive protein (0.04 mg/dL).

FIGURE 1.

Clinical images of penile strangulation by four stainless steel rings. (a) Initial presentation showing one ring at the coronal sulcus and three rings at the penile base. (b) Close‐up view of the congested glans with partial blistering. (c) Decompression of the congested glans by needle aspiration. (d) Removal of the distal ring after aspiration‐assisted decompression. (e) Removed rings placed beside the penis after removal. (f) Removed stainless steel rings of various shapes and sizes.

Bedside removal was attempted. The string method using silk thread was unsuccessful, and manual ring cutters were ineffective because of the hardness of the stainless steel. Glanular puncture with an 18‐gauge needle drained approximately 10 mL of blood and reduced congestion, allowing removal of the distal ring (Figure 1c,d). The remaining three rings could not be removed at the bedside.

Emergency removal under general anesthesia was started at 10:30 PM. Two corporal punctures were performed to reduce tumescence, and approximately 80 mL of blood was aspirated. A Nelaton catheter was temporarily applied at the penile base to reduce blood inflow. One proximal ring was cut at two points using an orthopedic pin cutter, but further cutting was abandoned because the blade was damaged. The remaining rings were removed by repeated manual compression and preputial decompressive incisions. All rings were removed by 11:59 PM (Figure 1e,f).

A urethral catheter was removed on postoperative day 1, and the patient voided without difficulty. He was discharged on postoperative day 2. At one week, residual edema was present but no urinary dysfunction was observed. At one month, he reported normal voiding and no deterioration of erectile function compared with baseline (International Index of Erectile Function‐5 score 15, pre‐incident 13). There was no clinical evidence of urethral injury; however, neither retrograde urethrography nor cystoscopy was performed. He was instructed not to use penile constriction rings again.

3. Discussion

Penile strangulation, though uncommon, presents a significant challenge in urological emergency practice. This case demonstrates the difficulty in removing hard, stainless steel objects causing penile strangulation, particularly when multiple objects are involved.

The Bhat classification is commonly used to grade penile strangulation (Table 1) [8]. In our patient, distal edema and partial blistering indicated a superficial skin injury. Although penile sensation was preserved and there was no clinical evidence of urethral injury, the presence of skin injury was considered more consistent with Grade II than Grade I. Prolonged venous and lymphatic obstruction can increase distal edema and eventually compromise arterial inflow, leading to ischemia, urethral injury, necrosis, or penile loss; therefore, prompt removal is essential. In this patient, complete removal approximately 6 h after application may have limited progression of tissue injury and contributed to preservation of urinary and erectile function [8, 9].

TABLE 1.

Bhat classification of penile strangulation severity.

Grade	Description
Grade I	Edema of the distal penis. No evidence of skin ulceration or urethral injury.
Grade II	Injury to skin and constriction of corpus spongiosum, but no evidence of urethral injury. Distal penile edema with decreased penile sensation.
Grade III	Injury to skin and urethra, but no urethral fistula. Loss of distal penile sensation.
Grade IV	Complete division of corpus spongiosum leading to urethral fistula and constriction of corpus cavernosum with loss of distal penile sensation.
Grade V	Gangrene, necrosis, or complete amputation of the distal penis.

This case illustrates two practical points. First, the different responses of the distal and proximal rings may reflect the tissues compressed at each site. The distal ring at the coronal sulcus appeared to cause predominantly venous and lymphatic congestion of the glans; direct aspiration of approximately 10 mL of blood reduced glans volume sufficiently for removal. In contrast, swelling around the three proximal rings at the penile base was likely maintained by both soft‐tissue edema and blood retained within the corpora cavernosa. Thus, glanular aspiration alone was insufficient, and removal required corporal aspiration, temporary penile‐base compression, partial cutting of one ring, preputial decompressive incisions, repeated manual compression, and manipulation under general anesthesia. Second, stainless steel rings may resist standard ring cutters. Although one ring was partially cut with an orthopedic pin cutter, the remaining rings required decompression and manipulation rather than further cutting. Grinders and other high‐speed rotary tools have been reported, but they require protection against thermal and mechanical injury [7].

Multiple metallic rings are less common than single constricting objects and may make both decompression and advancement difficult [4, 10, 11, 12, 13]. In the present case, the combination of four rings, severe edema, and different ring configurations required sequential escalation from bedside methods to operative management.

Penile rings are easily purchased online, sometimes without sufficient warnings about complications or emergency removal. Clarifying the circumstances of use and any history of similar behavior can guide recurrence‐prevention counseling. In this patient, the rings were used for the first time, following a friend's suggestion, in an attempt to self‐treat phimosis; he denied previous similar behavior and was instructed not to use penile constriction rings again.

4. Conclusion

Penile strangulation by multiple stainless steel rings can be difficult to treat with conventional methods. Aspiration, limited cutting, decompressive maneuvers, and early escalation to general anesthesia may be required. Urologists and emergency physicians should be familiar with several removal techniques to prevent irreversible penile injury.

Ethics Statement

The protocol for this case report was approved by a suitably constituted institutional review board at Jichi Medical University Hospital (approval number, A22‐023) and conforms to the provisions of the Declaration of Helsinki.

Consent

Written informed consent was obtained from the patient for publication of this case report and the accompanying clinical images.

Registry and the Registration No. of the study/trial: N/A.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.