Penile Tourniquet Syndrome in a Child with Nocturnal Enuresis

Sir,

A 5-year-old male child presented to us in the pediatric emergency with an inability to pass urine for the last 8 h. Detailed history from parents revealed that the child had complaints of nocturnal enuresis, for which they were consulting a doctor in the locality. A rubber band was deployed on the child's penis 3 days ago to deal with his urinary symptoms but was never removed. On examination, the penile shaft was dry and black with a line of demarcation. There was moderate edema on the penile shaft just proximal to the edge of demarcation. His bladder was distended and reached up to the umbilicus. A careful examination under anesthesia revealed a rubber band braced within the necrotic tissue which was immediately removed [Figure 1]. We performed a suprapubic cystostomy for urinary diversion. After 1 month, the necrotic penile tissue had auto-amputated leaving behind a stump of approximately 3 cm. The child is under regular follow-up and planned for penile reconstruction later.

Figure 1.

The clinical image showing that the entire penile shaft was gangrenous (a-anterior view and b-lateral view). There was edema on the penile shaft just proximal to the edge of demarcation at the site of rubber band application (arrow in b). The rubber band itself is not seen as it had got embedded within the necrotic and edematous tissue

The first case of penile strangulation was described in 1612.[1] In children, penile tourniquet syndrome is common after strangulation with twines of hair. This type of strangulation due to hair coils wrapped around the coronal sulcus is commonly seen in uncircumcised boys. However, other materials including rubber bands, threads, and metal rings have also been reported. In some religions, penile constriction is a common practice to treat urinary symptoms such as nocturnal enuresis.[2] Immediate treatment includes urinary drainage by either urethral catheter or suprapubic diversion and analgesics. While no definitive treatment is required for superficial skin necrosis, children with partial or complete urethral transection are candidates for a formal reconstructive urethroplasty.[3] In the index case, a rubber band was intentionally deployed at the shaft of the penis as an improvised penile clamp for treating enuresis but was never removed, leading to gangrene of the distal shaft. It is to be noted that the use of penile incontinence devices (commonly used in adults) or their improvised versions should be condemned in children. Further, it is crucial to educate parents about the potential dangers of using elastic or rubber bands at home and play areas. It is important to underscore that careful examination, and if required, an examination under anesthesia is mandatory, since the offending agent may be missed as it can get embedded easily within the tissues, more so if the offending agent has got elastic properties as in our case. Removal of the constricting agent has to be done promptly unless it becomes too late leading to organ loss as seen in our case.

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Conflicts of interest

There are no conflicts of interest.