Penile ring entrapment and strangulation: A case report at Kampala International University Teaching Hospital in Western Uganda

Highlights

• •Penile ring entrapment is when a ring previously inserted onto penis is left for extended period of recommended time.
• •Delayed removal of the ring lead to strangulation that presents challenges to general surgeons and institution to manage it.
• •Pilot bearing ball ring was removed by cutting with electrically powered angled grinder

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 possible complete loss of distal penis to strangulation and gangrene. We present management of a case of entrapped penile ring with penile strangulation in resource limited set up amidst 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 sustainability of an erection, with 24 -h history of painful penile swelling and acute urine retention. The patient had history of using recreational drugs and erectile dysfunction with evidence of high-grade penile injuries at presentation. The ring was cut using electrically powered angled grinder, with full penile recovery on conservative management in eight months of follow up.

Discussion

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 oedema and ischaemia with associated penile tissue injuries. High grade penile injuries or penile amputation are sequels of delayed ring removal and good outcomes are tangible through timely multidisciplinary approach.

Conclusion

Eroticism and erectile dysfunctions are known incentive to using penile rings to sustain erection. Delayed ring removal results in its entrapment and penile strangulation and related complications. Timely removal of ring requires multidisciplinary approach and local management protocols.

1. Introduction

Penile ring entrapment is when a ring previously inserted onto penis is left for extended period of recommended time resulting in oedema, 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 present immerse challenges to a general surgeon in resource limited centres globally [2]. The motivation of inserting a ring or any object on a penis in adult males has been erotically associated in management of erectile dysfunction [3].

Non-metallic or metallic object are used as rings and the duration of insertion seem directly proportional to the complications irrespective of location of the ring on penis [3]. Since the first reported case in 1755, the management of entrapped penile ring 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 in line 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 spouse in 4 days prior to 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 oedematous 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.

Fig. 1.

Showing penile ring entrapment.

Attachment Images of Penile ring entrapment and strangulation case.

The patient was clinically diagnosed of 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 anaesthesia 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 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 counselled and consented to the procedure and asked to report any heat generated during 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 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 anaesthetic 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 its thickness (Fig. 3). The ring was 2 mm thick with 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 ischaemia and necrosis to avert the pending penile amputation.

Fig. 2.

Showing the angle grinder metal cuter with its accessories.

Fig. 3.

Showing the ring piece after it was cut and reassembled to estimate diameter.

Fig. 4.

showing skin release incision 12 h after it was made.

The patient had prolonged hospital stay of 90 days for local wound care as he could not afford cost of plastic surgery and was followed up in 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).

Fig. 5.

Showing uneventful recovery with minimal ventral penile shaft scar after 8 months.

3. Case discussion

Penile ring entrapment is a rare urological emergency that can complicate with edema, strangulation, ischemia, gangrene, urethral fistula and distal penile amputation [6], particularly when it stays for more than 30 min [3]. Whilst our case presented late after 72 h of failed self-attempts to remove the ring, evidence show that the stigma associated with erectile dysfunction and masturbation result in delayed presentation in up to 92.3 % of cases [7]. Our patient presented with gloss penile oedema, mottling of penile shaft skin and impaired penile sensation, typically a grade II injury of the Bhat et al. classification [8] but a high grade injury as per the Silberstein et al. [7] modification; since the patient required serial debridement although there was no clinical evidence of urethral fistula.

Whereas the main motive of inserting a penile ring has been linked to eroticism and addressing erectile dysfunction to sustain an erection by impairing venous return [3,9,7]; on the other hand, male psychiatric patients use penile constrictors due to mental disorders. Although males younger than 50 years, like for this case, carry only 12 % risk of erectile dysfunction; low self-esteem, use of recreational drugs and delayed hospital consultation increases their risk of penile ring entrapment [10] when used.

To date, there seems to be no consensus guidelines on removing entrapped penile constrictors, but rather a variable approach depending on the material, duration and availability of resources [11,12]. Different materials such as rubber bands, hard metals and bottlenecks have been used [3], however the use of non-metallic objects is twice metallic [11]. In addition, 78 % of those who use non-metallic rings sustain high grade injuries as opposed to 22 % of those who use metallic constrictors [7,13], even though overall, most resulting injuries are low grade. Whereas previous authors have documented success of compression, lubrication and fasciotomies or both in extrication of penile rings [11,14], these can fail in presence of excessive penile oedema as was for our patient, yet failure to execute other novel approaches [15] has led to penile amputation [14]. Trivedi et al. [16] emphasises the diversity in clinical presentation and management approach resulting from penile constriction devices. Thus judgement on case-by-case basis has improved the surgical outcome of these patients [11,17].

The primary goal is to restore early arterial inflow, venous and lymphatic drainage to prevent further tissue damage. In keeping with existing literature [7,10,13,18], we used a powered electric gadget to remove the entrapped metal ring. Because we worked on already friable tissue, our patient developed minimal fibrotic scaring but had normal voiding at 2 weeks and 8 months follow up with no urethra cutaneous fistulae. Whether the reduced penile erection at 8 months preceded or followed trauma could not be validated due to social desirability bias associated with verbal autopsies.

4. Conclusion

In a nutshell, penile ring entrapment presents treatment challenges in absence of a local treatment protocol and designated instruments in resource limited setting. 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 oedema is present to prevent ischaemia as you mobilise resources and skilled expert to remove.

Long-term follow up with clear erectile dysfunction assessment tools, cognitive assessment, psychological counselling on recreational drug use are key for complication while community engagement and health education in this case are important preventive measures. The urological surgical societies should customise equipment and draft a penile ring entrapment management protocol for inclusion in standard text books as a chapter.

Conflicts of interest

All authors declare no conflict of interest.

Funding

This case report received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Ethical approval

This case report was approved by the Kampala International University Teaching Hospital research committee for publication.

Consent

Content of the case and intention to publish them was explained to the patient and in presence of his spouse on his request. The use of images and pictures with their significance was explained and informed consent was obtained, so long as the identity was kept confidential and anonymous. The signed consent is available on request.

Author contribution

Lauben Amagara Kyomukama, Corresponding Author, Guarantor, Conceptualisation, Methodology, Software, Data Curation, writing-original draft preparation, administration, Resources, & Investigation.

Ssebuufu Robinson; Guarantor, Visualization, Validation, software, writing Reviewing and editing, Shaban Wani Abdullah; Supervision & Validation, Lule Herman; Writing Reviewing and editing, Software & Validation, Musa Abbas Waziri; Data curation & Visualization.

Other contributors are;

Husnain Haider, David Wachaya, Jorge Soria Lao and Christian Oppong for the technical support in care of the case and Supervision of the author.

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Guarantor

• 1Lauben Amagara Kyomukama
• 2Ssebuufu Robinson