A Case of Penile and Scrotal Strangulation by a Metal Ring

CS Lim, S Tibrewal, WLJ Mok1

Department of Urology, Barts and the London NHS Trust, London, UK

1 Medical Student, Barts and the London Medical School, University of London, UK

Correspondence: Mr. Chung Sim Lim: cslim@doctors.org.uk

SMJ 2008 53(1): 60

 

Abstract

Strangulation of the penis and scrotum with a constricting device is very rare compared to the penis alone. We report a case of a 47-year-old gentleman who presented with a metal ring constricting the base of his penis and scrotum. The metal ring was successfully removed with a hydraulic-driven cutter. He recovered with no complication.

Key Words :  Penis, scrotum, foreign bodies, oedema, injury

 

Introduction

Constricting devices strangulating the male external genital is not common but presents a challenging emergency problem to the urologists. Most cases reported in the literature involved the penis only. We report a case of a metal ring, strangulating the penis and scrotum.

 

Case Report

A 47 year-old homosexual and HIV-positive gentleman presented to the Accident and Emergency (A&E) Department with a stainless steel ring strangulating the base of his penis and scrotum for about 29 hours. The metal ring, which he bought from a sex shop, was used to enhance sexual pleasure during intercourse. After the intercourse, he left the ring around his penis and scrotum. His genitals became gradually swollen after he played a game of golf the following day. Throughout this time he was able to micturate.

By the time he attended the A&E Department, his penis and scrotum were grossly swollen. Initial attempts to apply direct pressure to remove the ring failed. Standard hospital mechanical and electrical ring cutters were also utilised but removal of the ring was still unsuccessful. The fire brigade was then called. They tried cutting the metal ring with a hacksaw but failed too. We then applied ice, dextrose 50% solution and direct pressure for 30 minutes while the patient was sedated. The swelling reduced by about 30% but the ring was still fixated. A Gigli saw and ring cutters were subsequently used to cut the metal ring but again proved unsuccessful. Finally, the fire brigade managed to cut the ring with a hydraulic-driven cutter. Throughout all the attempts, the penis and scrotum were lubricated with lubricant jelly and ice to prevent frictional and thermal injury.  Two superficial lacerations were inflicted during these attempts. They were treated conservatively. A 12Ch transurethral catheter was inserted. He was discharged 36 hours later when the swelling subsided and the sensation around his penis and scrotum returned to near normal.

 

Discussion

Various metallic and non-metallic devices including finger ring,1, 2 metallic nut,1 barbell retaining ring,3 hammerhead,2 rubber band,1 thread,1 and plastic bottle neck2 have all been described to have caused strangulation to the male external genital in the literature. These constricting devices may impede the venous and lymphatic return causing distal oedema of the external genital. This causes vicious cycles of further outflow obstruction and swelling which eventually leads to ischemia of the external genital.

 

Very few cases of strangulation of both the penis and scrotum by constricting objects have been reported in the literature as compared to either only the penis1, 2, 3 or scrotum4, 5 was involved. Perabo et al. (2002) described a case of a bullring constricting the penis and scrotum which was successfully cut with a bolt cutter.2 In cases of penile strangulation with metallic devices, various methods have been described, including ring cutter,1, 2, 6 hammer and chisel,1 metal saw,1, 2 air-driven-drill,3 string method with7 or without corporal aspiration.8 It is important to protect the skin of the external genital from injury with cool fluid irrigation,1, 3, 9 jelly lubricants, and wooden or metallic blade.2, 9 Analgesia, sedation or even general anaesthetics2, 9 may be needed to relieve the pain and anxiety of the patient.

 

Most patients recover without any major problem after the removal of the constricting devices. A few complications have been reported including gangrene of the penis,6 urethral stricture,1 and degloving skin requiring skin grafts.10

 

References

  1. Bhat AL, Kumar A, Mathur SC, Gangwal C. Penile Strangulation. Br J Urol. 1991; 68: 618-21.

  2. Perabo FGE, Steiner G, Albers P, Muller SC. Treatment of penile strangulation caused by constricting devices. Urology. 2002; 59: 137.

  3. Mooreville M, Meller M. Penile incarceration with barbell retaining ring. J Urol. 2001; 166: 618.

  4. Tobe T, Igarashi T, Murakami S. Strangulation of the scrotum by a metal ring. Br J Urol. 1994; 73: 711.

  5. Zermann DH, Schubert J. Strangulation of the scrotum. Scand J Urol Nephrol. 1997; 31: 401-2.

  6. Snoy FJ, Wagner SA, Woodside JR, Orgel MG, Borden TA. Management of penile incarceration. Urology. 1984; 24: 18-20.

  7. Vähasarja VJ, Hellström PA, Serlo W, Kontturi MJ. Treatment of penile incarceration by the string method - 2 case reports. J Urol. 1993; 149: 372-73.

  8. Noh J, Kang TW, Heo T, Kwon DD, Park K, Ryu SB. Penile strangulation treated with the modified string method. Urology. 2004; 64: 591.

  9. McLaughlin T, Coyner W. Removal of a strangulating metal bearing from the penis. J Urol. 1989; 141: 617.

  10. Tiwari VS, Razdan JL, Yadav VNS. Strangulation of the penis by a metallic nut. Int Surg. 1977; 62: 558

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