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Penile Strangulation by Metallic Rings
SP Gupta*, Lalit Kumar Raiger**, Vinne Sharma***, Ruchir Maheshwari****
 

A case of penile strangulation in a 35 year old male truck driver by profession reported here. Two metallic rings were self introduced upto the base of penis, in order to prevent spontaneous ejaculation at night. There was marked oedema of penis distal to rings, and these rings were removed with an indigenous technique, non-operatively.

Introduction
Penile strangulation by various objects (e.g. wedding rings, rubber bands, plumbing metal ring, plastic bottle neck steel bearing etc),1-3 presents a situation that challenges the surgeon to be innovative in selecting the treatment.

We report a case, in which a healthy male person with normal mental state, had put two metallic rings of stainless steel over penis and thereafter presented to emergency with extremely swollen penis, as he himself was unable to remove the rings.

Case Report
A 35 year old man presented to M.B. hospital, Udaipur with extremely swollen penis. On examination two metallic rings were seen at the base of penis.

On taking history it was revealed that he was advised by his friend to pass metallic ring over base of penis, to obviate penile erection and auto-ejaculation at night. He was practicing this method successfully since one year. On examination, gross oedema on distal part of penis was present and two metal rings were applied on base of penis (Fig.1) which could not be taken out. Patient was shifted to emergency O.T. in an effort to remove metallic rings. Lidocaine jelly was applied over penis, given multiple puncture, compression on penis was applied by hand and thin streams of fluid came out from multiple puncture sites but with all these we were unable to remove the rings and we did not get the suitable instrument to cut the rings safely. Finally an intravenous drip set tube was applied circumferentially, starting from tip of the penis to its base in order to have an even compression as a tourniquet (Fig. 2). The compression was maintained for 4 minutes and this procedure was repeated for five times. (In between the tourniquet application the penile compression was maintained by squeezing the penis with palm). This manoeuver reduced penile oedema dramatically and metallic rings could be retrieved manually over lubricated jelly. The whole procedure took around 50 minutes. The two rings were of 3.5 cm x 2.5 cm x 2 cm and 3 cm x 2 cm x 1.5 cm external diameter, internal diameter and width respectively (Fig. 3).

There was no damage to penis at strangulation site as well as on distal part. Penis was cleaned with povidone-iodine solution, an antibiotic ointment was applied and dressed with vaseline gauge and light pressure bandage applied.

Patient remained cooperative during procedure. Before starting the procedure patient was pre-medicated with inj atropine 0.6 mg, midazolam 5 mg and tramadol HCl 100 mg intravenously with a patency iv drip and 2% lidocaine jelly was applied over penis. Antibiotics and Tetanus prophylaxis was also given. Psychoanalysis later revealed no abnormality.

Comment

Penile strangulation injury are not frequent, yet most difficult to deal with. Increased oedema distal to occlusion, restricting venous and lymphatic flow; Eventually the constriction may impede arterial supply and gangrene may result, that may require amputation of penis.4

There is no standard protocol mentioned to deal with such cases. Every case needs individual approach depending upon the circumstances and facilities available.

The method described above is highly effective, cost saving, complication free and can be done by every practitioner.

 
Fig. 1 : Two metal rings applied over base of penis and gross edema of distal part of penis.
Fig. 2 : Diagrammatic representation : application of I.V. dip set tubing over penis. Fig. 3 : Metal rings after removal.

References

  1. Mclaugghlin T and Coyner W. Removal of a Strangulating metal bearing from the penis. Journal Urology 1989: 141 : 617.
  2. Perabo Fd, Steiner G, Albers P, Muller SC. Treatment of penile strangulation caused by constrictions devices. Urology 2002 : 59 (1) : 137.
  3. Kadioglu A, Cayan S, Ozcan F, Tellaloglu. Treatment of penile incarcenation in an impotent patient. International Urology and Nephrology 1995 : 27 (5) : 639-41.
  4. Osman M, Al Khadi H, Al Hafi R. Gangrene of the penis due to strangulation by a metallic ring. Scandinavian Journal Urology and Nephrolog 1996: 30 (1) : 77-8.
*Assistant Professor, Department of General Surgery, **Associate Professor, Department of Anaesthesiology; ***Registrar; ****Sr. Registrar, Department of Surgery, R.N.T. Medical College, Udaipur – 313001, Rajasthan (India).
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