Penile strangulation

Penile Strangulation: Analysis of Postextrication Follow-Up, Sequelae, and a Review of Literature

Numerous case reports exist on penile strangulation injuries and extrication methods; however, the care and long-term consequences of penile strangulation injuries have been under-reported. Our aim is to investigate the long-term outcomes and sequalae following penile strangulation injuries. The PubMed Medline database was searched using the keyword string "penile strangulation," "penis strangulation," and "constriction" for all studies reporting outcomes of published penile strangulation injuries. Articles were evaluated for follow-up after strangulation injury, strangulating agent, extricating agent, and sequelae of injury. Fifty-six studies resulted with reports of 100 cases of penile strangulation and extrication from January 2000 to December 2019. The mean patient age was 41 (range: 3-86) years. Twenty-four (24/100) cases reported sequalae following extrication. Follow-up ranged from 2 weeks to 7 years with median follow-up time in the 7- to 12-month grouping. Metal rings comprised 36% (36/100) of strangulation agents and 50% of reported incidents were attributed to sexual activity. To our knowledge, this is the only study focusing on long-term outcomes after penile strangulation. This review provides a summary of 56 studies that document penile strangulation injuries over the last 20 years. Although a wide array of penile strangulation injuries have been documented in the literature, reports lack secondary management and long-term outcomes after removal of the strangulation device. We recommend that providers report long-term penile strangulation outcomes for future urologic evaluations after extrication.

Strangulated penis in a prison inmate: Complete penile degloving and full-thickness skin graft

Introduction

Penile strangulation is a rare urological emergency that necessitates urgent management. The reasoning behind it may include sexual pleasure, erection reinforcement, or a psychiatric disorder.

Case presentation

Despite being an uncommon complication of penile strangulation, we report a 45-year-old prison inmate who presented with penile shaft necrosis secondary to using a non-metallic constriction object. The patient reported a 5-day history of progressive penile pain, edema, and skin injury but no urinary symptoms. The patient underwent complete penile skin degloving, circumcision, and insertion of a suprapubic catheter. Postoperatively, the penile tissue appeared healthy, and the wound was granulating. On the eleventh day following degloving, a full-thickness skin graft was taken from the groin area. The patient remained in the hospital for 20 days, during which he was clinically stable with clean, healing wounds.

Conclusion

Early management of penile strangulation is vital in order to prevent vascular and mechanical complications.

Penile incarceration with weight plate: An unusual case with review of literature

Penile incarceration from constricting metallic or non-metallic objects is a urological emergency which warrants immediate interventions to prevent undesirable sequalae. Various methods such as aspiration technique, string methods, cutting devices and surgery has been described in the literature but each case needs individualized approach due to lack of consensus in the management. We report a case in a 24-year male who incarcerated his penis with a metallic weight plate weighing around 3 kg. To our knowledge this is the first case reported in the literature where a heaviest constricting object was successfully removed via circumcoronal incision.

[PENILE STRANGULATION CAUSED BY A METALLIC RING SUCCESSFULLY TREATED BY PENILE PUNCTURE PLUS BLOOD REMOVAL INSTEAD OF DESTROYING THE RING]

A 63-year-old man visited our hospital with a complaint of penile swelling caused by metallic ring entrapment in the penis. He had put the ring around his penis 4 hours prior and was subsequently unable to remove it. We attempted to remove the ring using a ring cutter but that was unsuccessful. We then inserted two 18 G needles into the corpus cavernosum through the glans penis and removed blood by manual compression according to a technique called the "string method." The swelling gradually decreased, and we successfully removed the ring without destroying it. The total duration of strangulation was about 5 hours. The patient was subsequently discharged after ensuring he had no urinary difficulties. No complications were observed during the follow-up period.In almost all penile strangulation cases caused by hard objects, such as metallic rings, reported in Japan, the objects were typically destroyed and penile puncture and blood removal, as was performed in our case, was rare. Although penile puncture and blood removal is not commonly performed in Japan, this technique can be performed quickly and inexpensively in the emergency room and should be considered an initial treatment for penile strangulation caused by hard objects.

Self-inflicted genital ulcer: An intriguing case report

Self inflicted genital ulcer due to penile constriction injury is a rare clinical entity, which requires urgent management to prevent its devastating outcomes such as penile gangrene and auto amputation. Although this is common, definitely, it is of interest because of the genital involvement. Here, we present a case report on an unusual case of rubber band induced penile constriction injury.

Use of dental drill handpiece to remove steel nut causing penile strangulation: a case report and review of the literature

BACKGROUND

Penile strangulation is an uncommon urological emergency that requires prompt intervention to avoid potentially serious sequelae including loss of the distal penis secondary to ischemia and subsequent gangrene. We present a case report of a patient who presented to the hospital with penile strangulation injury of 10-hour duration secondary to the presence of a thick hexagonal steel nut. This case is presented in accordance with Consensus Surgical Case Report guidelines.

CASE PRESENTATION

A 24-year-old Vietnamese man presented to the emergency room with urinary retention and decreased penile sensation following a 10-hour history of penile strangulation due to the presence of a thick hexagonal steel nut that he had placed around the shaft of the penis for the purpose of sexual enhancement during masturbation. The hexagonal nut was tightly entrapping the penile shaft, resulting in edema, congestion, and swelling of the distal 5 cm of the phallus. Given the thickness of the foreign body as well as the degree of penile swelling, we were unable to remove the hexagonal nut using traditional methods of alleviating penile strangulation injuries. Following consultation with a dental colleague, a dental diamond drill handpiece was utilized to cut the foreign body without injury to the underlying penile skin. Subsequent follow-up in clinic demonstrated no significant urinary or sexual sequalae from this episode.

CONCLUSION

We report a case of penile strangulation requiring novel instrumentation and collaboration for successful treatment.

Using a fretsaw in treating chronic penial incarceration: A case report

BACKGROUND

Penial incarceration (PI) is a rare situation. It is usually caused by a foreign object which strangulates at the base of the penis. PI may derive from pranks, sexual demand, mental disease, or intention to prohibit urinary disease. Generally, these situations are emergent and immediate treatments are needed. Cases of chronic PI are less reported, and their treating methods are yet to be discussed.

CASE SUMMARY

We reported a case on treating a 73-year-old male who had PI with a metallic hoop for three months. After multidisciplinary consultation, the operation was performed successfully with the help of a fretsaw. Despite the chronic strangulation, the prognosis of the patient was satisfying. To the best of our knowledge, this case was rare and precious as it featured the longest strangulating time, which might enlighten the treating process of future PI cases. Also, we have reviewed and summarized major published cases to encapsulate appropriate approaches when facing diverse strangulation situations.

CONCLUSION

The selection of surgical tools depends on the material of the strangulating objects, the availability of equipment, and the severity of the penial damage. The urination function may not be affected after three months of incarceration as in our case, whilst prudent preoperative measures and multidisciplinary evaluations are always essential. Although using a fretsaw is comparatively slow, it is safe and feasible to treat metallic penial incarceration.

Penile Entrapment With Thick Penile Ring: A Case Report and Literature Review

The penis is one of the end-artery organs in the human body. The blood supply of the penis depends on the internal pudendal artery, which arises from the anterior division of the internal iliac artery. Subsequently, the penis is one of the organs that are highly affected by peripheral vascular disease. Furthermore, erectile dysfunction is a clinical sign that might precede coronary heart disease. Artificial entrapment of the blood into the cavernous bodies is one of the treatment options for erectile dysfunction. In addition, the same concept might be utilized in some sex aids to increase self-pleasure; hence, penile rings are widely used in some cultures. We present here a case of metal penile ring entrapment, which was managed successfully with the help of the hospital maintenance team. Therefore, it is of tremendous importance in unusual cases to seek advice from all possible resources. Such complications should be highlighted to increase the awareness of the users and the medical professionals as well.

Penile strangulation by a metallic nut in an 8-year-old male: A rare case report of urological emergency

INTRODUCTION AND IMPORTANCE

Penile strangulation due to metallic objects in pediatric age groups is a rare urological emergency that warrant emergency management. Removal of metallic ring from strangulated penis poses a great challenge to urologist as it may require industrial gadgets. Multidisciplinary management involving psychiatrist is required. To the best of our knowledge, this is the first reported novel case of penile strangulation by a metallic nut in children in Tanzania. Furthermore, this case report shows that Industrial Manual Scissor metal (IMSMC) cutter offers a safe way of removing metallic nut from strangulated penis with few complications.

CASE PRESENTATION

We report a case report of penile strangulation in an 8 year-old boy by a metallic nut which stayed for 11 h prior to arriving at a tertiary hospital in Northern Tanzania. The reason for insertion of nut by a child was not clear.

CLINICAL DISCUSSION

On arrival to the hospital the child was clinically stable but in pain. Local examination revealed a metallic nut at proximal penis with grossly edematous penis. A diagnosis of penile strangulation by metallic nut was reached and the child was planned for emergency surgery to remove the metallic nut. The metallic nut was successful removed by IMSMC. This technique has been used in adult with success with few complications and therefore opted in our setting. The child was also diagnosed with oppositional defiant disorder.

CONCLUSION

Industrial Manual Scissor Metal cutter is a safe way of managing penile strangulation by a metallic nut in children.

Penile strangulation with a plastic bottle neck: Intervened by an atypical instrument: A case report

INTRODUCTION AND IMPORTANCE

Strangulation of penis, a surgical emergency, is often encountered in patients with psychiatric disorders and patients attempting to increase sexual arousal. Materials ranging from metallic to non-metallic like plastic bottles are used by the patients. The important factors to be considered for the successful treatment include the availability of instruments and the surgical skills of the doctor.

CASE PRESENTATION

A 45 year-old man with a comorbidity of severe depression presented to Emergency with a two months long history of penile strangulation with a plastic bottle neck. The gross appearance of the penis showed edema and proliferative growths. He was intervened with a cable wire cutter as standard instrument failed to do so. The patient was discharged on the same day of intervention. However, he was lost to subsequent follow up.

DISCUSSION

Penile strangulation which is common in people with mental disorders should be considered as a surgical emergency as it can present with devastating complications. No specific methods and tools have been recommended for the removal of those objects. The shame felt by patient is the root cause for late surgical consultation and are prone to develop complications. Simple instruments can be used for the intervention provided good surgical skills are demonstrated.

CONCLUSION

Common in psychiatric patients who deny medical attention due to shame, penile strangulation should be intervened quickly and simple instruments not routinely used in surgical practice can be effectively used to remove the offending objects.

Removal of a Steel Ring Causing Penile Strangulation Without the Use of Powered Tools or Sharp Blades

Penile strangulation is an uncommon urologic emergency that requires prompt evaluation and treatment to avoid disastrous consequences. Strangulation has been reported with objects ranging from hair tourniquets, to plastic rings, to iron rings. Strangulation with these devices can result in vascular congestion of the penis, swelling and eventual gangrene of the penis distal to the constricting device. We present a case report of a 43-year-old male who had a 2-day history of penile pain and swelling secondary to a metal ring constricting the proximal phallus. Ring removal was achieved with an orthopedic bolt cutter to cut the ring in two places, using a malleable retractor to act as a "backboard" to prevent iatrogenic injury to the penis.

Two cases of penile strangulation: varied presentations and vastly different outcomes

Background

Penile strangulation by various metallic and non-metallic objects is a true urological emergency that requires prompt emergency management. The cases in this report will help in highlighting the varied presentations one can face in the emergency department. Management of such cases at times needs out-of-the-box thinking and improvised skills as resources to remove the foreign body are often scarce within the hospital.

Case presentation

We present two such cases of penile strangulation in adult patients. Both patients presented to us in the emergency department, one with a large metallic cone and another with a rubber band constricting their penises. Both the patients had hugely different grades of injuries and were managed accordingly. Both the patients required different methods to remove the constriction objects as per the need of the situation. One of the patients required total penectomy with permanent perineal urethrostomy; however, in the other case, we were able to save the penis.

Conclusion

Penile strangulation needs urgent medical attention and timely removal of the offending object. Grade of injuries and complications are directly proportional to the type of object and the duration of the strangulation. The non-metallic objects are easy to cut and remove. However, one should be aware of the challenges and the complications in managing metallic foreign bodies which at times may need out-of-the-box thinking, like use of motorized cutting tools.

A Rare Case of Penile Strangulation by a Hard Plastic Bottleneck

Penile strangulation is an uncommon condition that mandates emergent management to remove the constricting device and restoring penile blood flow. Different kinds of metallic and non-metallic objects were placed over the penis due to various reasons but mostly due to autoerotic intentions. We present a case of a middle-aged male who presented to the emergency with penile strangulation by a hard plastic bottle, which was successfully removed using a bone-cutter. The patient had an uneventful recovery without any immediate complications. Treatment aims at decompressing the penis to restore blood flow and maintain urethral continuity. Early removal of the constricting object with minimal discomfort to the patient prevents long term complications such as urethral stricture and priapism.

Angle grinder as surgical tool for incarcerated penoscrotal steel ring

Penile strangulation with concomitant scrotal entrapment by a steel ring is an extremely rare urological emergency that requires immediate intervention. Any delay may lead to irreversible complications. Metal rings increase penile engorgement and are usually associated with an attempt to improve sexual pleasure or to maintain a prolonged erection. The removal of steel rings can be challenging and may require a multidisciplinary approach. We present a unique case report of an 18-year-old male with a penoscrotal steel ring retained for 24 hours that was safely removed using an angle grinder as a surgical tool.

Penile Rings: No Innovation without Evaluation

Penile strangulation is a rare clinical entity which if left untreated can cause serious urogenital problems. We present the case of 45-year-old male patient who presented with penile strangulation after applying a metallic ring. Strangulation of the external male genitalia is a serious problem that requires urgent intervention in order to avoid serious complications. If left untreated, it can result in gangrene and penile amputation. Management of penile strangulation is a real challenge for the treating surgeon and should be treated as an emergency in order to avoid vascular compromise.

LEARNING POINTS

Penile strangulation by metallic rings is not routinely encountered in daily emergency practice and can be a challenge for the treating surgeon.Problem awareness is a crucial part of the management of such a rare entity.Every attempt should be made as early as possible to preserve penile arterial supply.

Stepwise approach in the management of penile strangulation and penile preservation: 15-year experience in a tertiary care hospital

Objective: To present our stepwise approach to the management of penile strangulation and penile preservation with 15 years’ experience in a tertiary care hospital, as penile strangulation is a rare urological emergency that requires immediate attention.

Patients and methods: A prospective observational study was performed from March 2003 to December 2018 of patients presenting with penile strangulation to our hospital.

Results: Nine patients with penile strangulation presented to us between March 2003 and December 2018. The most common motive for the application of a foreign body was sexual gratification (four patients). Three of the nine patients had a mental disorder. Objects used for strangulation included: metallic nut (three), metallic ring (two), plastic bottle (two), wooden hole (one), hammer head (one), and horse hair to control bleeding during circumcision (one). Most of the foreign bodies were located in the proximal penile region. The mean operative time was 38 min and three of the nine patients had complications.

Conclusions: Penile strangulation is one of the rare urological emergencies experienced by a urologist. Removal of the foreign body can be difficult and there is no universal method of removal, as each case differs. So, following our stepwise approach can aid in removal of foreign body quickly and preserve the penis from fatal outcomes. Urologist should be aware of all the available armamentarium used for the removal of such foreign bodies.

Abbreviation: SPC: suprapubic cystostomy

Penile ring entrapment - A true urologic emergency: Grading, approach, and management

Penile rings are used to sustain erection in order to enhance sexual pleasure. They work by reducing the outflow of blood from the cavernosal tissue. However, if left for extended periods of time severe edema, urethral fistula, gangrene, and even complete loss of the distal penis can ensue, this is known as penile ring entrapment (PRE). Management poses particular challenges due to its rarity. Herein, we report our experience with three patients from our institution that presented with PRE and include a review of the approaches others have taken. We also propose a simpler and more effective grading scale to allow for easier communication between providers, as the current grading scales do not do so.

Treatment Options and Outcomes of Penile Constriction Devices

Purpose:

To study the effect of penile constriction devices used on a large series of patients who presented at our emergency facility. We explored treatment options to prevent a wide range of vascular and mechanical injuries occurring due to penile entrapment.

Materials and Methods:

Between January 2001 and March 2016, 26 patients with penile entrapment were admitted to our facility and prospectively evaluated.

Results:

The time that elapsed from penile constrictor application to hospital admission varied from 10 hours to 6 weeks (mean: 22.8 hours). Non-metallic devices were used by 18 patients (66.6%) while the other nine (33.4%) had used metallic objects. Acute urinary retention was present in six (23%) patients, of whom four (66.6%) underwent percutaneous surgical cystotomy and two (33.4%) underwent simple bladder catheterization. The main reason for penile constrictor placement was erectile dysfunction, accounting for 15 (55.5%) cases. Autoerotic intention, psychiatric disorders, and sexual violence were responsible in five (18.5%), five (18.5%), and two (7.4%) cases, respectively. The mean hospital stay was 18 hours (range, 6 hours to 3 weeks).

Conclusion:

Penile strangulation treatment must be immediate through the extraction of the foreign body, avoiding vascular impairments that can lead to serious complications. Most patients present with low-grade injuries and use penile constrictors due to erectile dysfunction. Removal of constrictor device can be challenging. The use of specific tools for achieving penile release from constrictors is a fast, safe and effective method. Patients with urinary retention may require urinary diversion.

Penile strangulation by different objects and its removal by the modified string method: Management of four cases with review of literature

Penile strangulation is a challenging clinical situation and usually requires prompt treatment. Penile strangulation by a nonmetallic or thin metallic ring is easily overcome by severing/cutting the object; however, a heavy and long metal ring causing penile strangulation is not only difficult to sever but also it may worsen the scenario if removal is tried with inappropriate method. Here, we report four cases of penile strangulation by different objects which were successfully removed by aspiration and string method. We found that instead of using heavy cutting instruments and other surgical methods, string and aspiration technique is much better.

The Fire Service for the Removal of a Metallic Penile Constricting Device: A Ready Help When All Else Fail

The placement of a constricting device around the penis is a urologic emergency. Though injuries from constricting penile devices are generally rare, they may be associated with serious complications. There is no standard modality for the removal of penile constricting devices and the management of the patient can therefore prove to be a formidable challenge to the urologist. Timely intervention is always important in preventing complications especially penile gangrene. Depending on the type of device used along with the duration and severity of penile constriction caused, significant resourcefulness may be required in the treatment of the patient. Achieving a timely and successful outcome may require a multidisciplinary approach involving equipment only available with the fire service or other agencies. We report the case of a 30-year-old man with a background psychiatric illness who had his penile constricting device removed under conscious sedation in the emergency room with the aid of a power driven arc saw from the fire service with a successful outcome.

Strangulation of the Penis by a Metallic Ring: Prevention Is Better Than Cure

Strangulation of the penis is a rare condition that requires emergency management. Several objects, metallic or not, can be placed on the penis to increase sexual performance or for self-erotic intentions especially in psychotic patients with unusual sexual impulses. The problem of removing the foreign body and repairing the damage is a real challenge for the practitioner and a great stress for the patient. We report a case of a 42-year-old schizophrenic patient who presented to the emergency department for a strangulation of the penis secondary to a metal ring placed at the base of the penis 10 days before the consultation without urinary disorder. A review of the literature allowed us to highlight the different clinical pictures of penis strangulation and the therapeutic methods and to highlight the importance of psychiatric care of sexual behaviour in chronic psychotics.

Penile and Scrotal Strangulation due to Metal Rings: Case Reports and a Review of the Literature

Penile and scrotal entrapment from a metal ring placed at the base of the penis is a rare, but important clinical dilemma encountered in urology. Emergent presentation to the urologist, after ring placement far longer than safely practiced, risks ischemic and permanent injury to penile, scrotal, and intrascrotal structures. Treating urologists should be aware of the prevalence of metal ring use, their potential complications, and the surgical approach to their safe removal. We present two patients who were identified at our institution with strangulating injuries of retained penile rings. The first patient was a healthy, 43-year-old male with a metal ring retained for 24 hours that was safely removed with industrial bolt cutters. The second patient, a 74-year-old male, died as a result of sepsis from injuries secondary to penoscrotal ischemia after >48 hour ring retention despite prompt removal at emergent presentation. Although rare, sexual practices may include the use of penoscrotal rings. When retained, ischemic injury and edema may lead to strangulation. Emergent removal may require industrial equipment that is not within the confines of normal operating room tools. Tissue injury may be severe and sepsis life-threatening, even after ring removal.

Penile strangulation by iron metal ring: A novel and effective method of management

Penile strangulation by metal ring is a rare urological emergency situation which requires urgent decompression of the penis to avoid adverse effect. It is usually associated with an attempt to improve sexual act and/or to prolong erection. But sometimes, cutting of the ring to decompress the penis safely is a very difficult task particularly when the strangulating object is a hard metal object as in our case. Here, we present a case which was managed by cutting in a novel way with the help of dental micromotor with wheel shape bur.

Bone Cutting Forceps: A Safe Approach for Saving Strangulated Penis

Penile strangulation is considered a rare andrological emergency that may lead to a wide range of complications. Penile strangulation may be related to mental retardation in children or hypersexuality, abnormal sexual preferences in adults. This case report shows a 23-year-old male who presented to the emergency room with agonizing pain related to a metallic ring placed at the base of the penis for more than 8 hours during an attempt of masturbation. Removing this metallic ring and saving the patient's penis from gangrene without causing injury were very challenging. Patient was successfully managed and had an uneventful recovery.

Post coital penile ring entrapment: A report of a non-surgical extrication method

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Removal of an entrapped penile ring where possible should be done in a simple non-invasive way.

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Milking the oedematous penis through the thick metallic ring in a slippery field complemented by levering with a blunt end paediatric bone lever, was the technique used to remove the ring.

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The ring was extricated without any morbidity and the patient went home on the same day.

This case report shows how a simple but painstaking method of milking and levering in a slippery field was used to remove a thick metallic ring entrapped at the root of the penis after sexual intercourse. A ring can be removed easily from an organ if the inter-phase is made slippery. However this must be weighed against the handling difficulties posed by a wet slippery surface. With perseverance and the use of unconventional instrument, the ring was successfully extricated as a day case and without a surgical incision.

Penile incerceration-A tight affair

A patient presents with penile ring incarceration after using it for penile enlargement and prolonging tumescence. We present a case study of removal of the penile ring under local anaesthesia in a setting where cutting tools were inadequate.

Penile self-harm: a case report and concise clinical review

Male genital self-mutilation is extremely rare and may be associated with severe psychopathology. This study reports the case of a 26-year-old man who presented after incising his prepuce with a knife and placing a rubber band around his foreskin. A plastic ring was also found underneath the prepuce. Clinical examination revealed a lateral preputial laceration with gross preputial oedema and dark red discoloration with a clear demarcation where the elastic band had been placed. A pelvic X-ray revealed no other foreign bodies. Following 72 h of observation he developed signs of preputial necrosis, which prompted urgent circumcision; this revealed a healthy underlying glans. In conclusion, male genital self-harm requires urgent urological and psychiatric assessments to prevent surgical and psychiatric sequelae including necrotizing fasciitis and suicide.

Penile strangulation due to plastic bottle neck: a surgical emergency

Use of various metallic and non-metallic constricting objects on the external male genitalia for increasing sexual performance or because of autoerotic intentions is an unusual practice that can potentially lead to penile strangulation with severe consequences. Depending on the type of constricting material, emergency removal of such an object is a challenge. We report a case of a 45-year-old man who presented to our hospital with a hard plastic bottle neck at the base of his penis that led to penile strangulation. The constricting agent was successfully removed. The patient had an uneventful recovery.

Penile incarceration with encircling metallic objects: a study of successful removal

OBJECTIVE

This article aimed to study the various treatment options according to the grading scale for penile incarceration.

MATERIALS AND METHODS

A retrospective review, of all the case files of patients presented with penile incarceration with encircling metallic object was performed. The patients were analyzed for age, marital status, motive, object used, who applied it, trauma grade, duration of incarceration, removal technique, removal time, anesthesia used and recovery time.

RESULT

A total of seven patients were identified. The average age was 46.71 years. Self-sexual gratification was the most common motive (five patients). Six patients presented within 24 hours. Grade II of injury was commonest type of injury seen in five patients.The technique of removal chosen was according to grade of penile injury, duration of incarceration and type of object used. Spinal anesthesia was used in most of the cases (five patients).

CONCLUSION

Penile incarceration with encircling metallic objects is a rare presentation and requires urgent intervention according to trauma grade to prevent complications.

Strangulation of the penis: two case reports

Till now numerous reports have depicted the different constricting devices (CDs) previously threaded on the penis for obtaining of sexual pleasure or/and prolonged erection. The causes of CD bearing on the penis are sexual or autoerotic actions.

Here we present two cases of successful removal of a metal device from a penis that was associated with trauma grade II according to Bhat et al. The techniques used are also described. In both cases the essential features of successful device removal were its motionless fixation by nippers or vice combined with placing a metal plate under the constricting ring. The CDs were successfully removed without complications.

Removal of a penile constriction device with a large orthopedic pin cutter

Penile strangulation is an infrequent clinical condition that has widely been reported. It usually results following placement of a constriction device to enhance sexual stimulation. Early treatment is essential to avoid potential complications, including ischemic necrosis and autoamputation. We describe the use of a Large Orthopedic Pin Cutter to remove a metal penile constriction device in the Emergency Department (ED). This case report describes the relatively safe technique of using an instrument available in many hospitals that can be added to the physician's arsenal in the removal of metal constriction devices.

Penile incarceration with metallic foreign bodies: management and review of literature

INTRODUCTION

Penile strangulation from constricting metallic objects disorders is an uncommon urological emergency which requires prompt intervention to prevent complications. The treatment modalities are diverse and characterized by lack of consensus.

MATERIAL AND METHODS

Three cases with penile incarceration due to constricting metallic objects who presented to our department were included in this study. All 3 patients required different management options highlighting the diversity of clinical presentation and need for customization of treatment as per the clinical scenario.

RESULTS

The 3 patients required different approach for treatment. First patient could be managed by degloving of penile skin while second patient required mechanical removal of the foreign body and debridement of local necrotic tissues. The third patient had to undergo excision of gangrenous penile skin and skin grafting.

CONCLUSION

The study emphasizes the diversity of clinical presentations and the need for employing different surgical techniques to achieve the desired results.

Penile strangulation by a substantial metal napkin ring: successful removal with medtronic midas rex® legend® stylus® drill system

We report the case of a 34-year-old with penile constriction by a large solid steel ring napkin holder in whom attempts of removal by conventional techniques failed. Standard instruments available in urology and general surgical theatres proved too weak to sever the ring and those offered by the fire services were grossly oversized and dangerous to use around the genitalia. Orthopaedic staff offered an instrument not previously used within our urology department: the Medtronic Midas Rex© Legend EHS Stylus High-Speed Surgical Drill. This intricate electronic powered drill allowed quick, controlled and safe incision of the metal ring, relieving the constriction. In addition to this first report of a metal penile constriction device removed using the Medtronic Midas Rex® Legend® Drill System, we review the literature on penile constriction and management strategies.

Extrication of penile entrapment in a polyethylene terephthalate (PET) bottle: a technique of suture traction and Dundee and literature review

OBJECTIVE

To describe the use of a technique of suture traction and Dundee in penile entrapment in the polyethylene terephthalate (PET) bottle case. MEASURES AND METHODS: The technique of suture traction in conjunction with Dundee was performed for the management of penile entrapment in PET bottle neck. First, the technique of Dundee (manual compression after multiple prepuce punctures) was used to alleviate and resolve the preputial edema; second, the persistent suture traction power was applied to achieve the removal with lubrication. A review of the literature is also summarized in this report. Current treatment options and outcomes are also evaluated.

RESULT

The PET bottle neck was removed intact successfully in 50 min. Follow-up revealed he got full recovery without any complications. Literature review shows that penile incarceration in PET bottle is frequently described as an isolated case report or small series, the approach for dealing with these problems are often described using cutting instruments, the PET bottle could produce a fatal harm in extreme situation.

CONCLUSIONS

The technique combined suture traction with Dundee could be easy to perform without any special tools required in the management of penile entrapment involving PET bottles. It could be applied safely for the low-grade penile injury.

Insertion of foreign bodies (polyembolokoilamania): underpinnings and management strategies

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. Such consultations require the integration of medical and psychiatric knowledge. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss the diagnosis and management of conditions confronted. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.Dr Unruh is an attending psychiatrist at McLean Hospital, Belmont, Massachusetts, and an instructor in psychiatry at Harvard Medical School, Boston, Massachusetts. Dr Nejad is an instructor in psychiatry at Harvard Medical School, Boston, Massachusetts, an attending physician on the Psychiatric Consultation Service at Massachusetts General Hospital, Boston, and the director of the Burns and Trauma Psychiatric Consultation Service at Massachusetts General Hospital, Boston. Mr Stern is a research assistant in the Department of Psychiatry at Massachusetts General Hospital, Boston. Dr Stern is chief of the Psychiatric Consultation Service at Massachusetts General Hospital, Boston, and a professor of psychiatry at Harvard Medical School, Boston, Massachusetts.Dr Stern is an employee of the Academy of Psychosomatic Medicine, has served on the speaker's board of Reed Elsevier, is a stock shareholder in WiFiMD (Tablet PC), and has received royalties from Mosby/Elsevier and McGraw Hill. Drs Unruh and Nejad and Mr Stern report no financial or other affiliations relevant to the subject of this article.

Penile strangulation: report of a fatal case

Penile strangulation or entrapment is an unusual entity that requires urgent treatment due to its potential complications. Several cases have been reported in the medical literature, some of them describing serious injuries such as necrosis, gangrene, and amputation of the penis. However, as far as we know, no fatal cases have been described before. We present the death of an adult male secondary to the complications due to penile strangulation with a plastic bottle neck. The time of incarceration was unknown, but according to a witness it could be about 10 to 14 days. The findings of autopsy were penile strangulation, necrosis of the penis, acute pyelonephritis, and bronchopneumonia. The subject's refusal to ask for medical help was the cause of this atypical evolution.

Strangulation of penis by a ball bearing device

INTRODUCTION

Penile strangulation is rare and usually results following placement of constricting objects to enhance sexual stimulation. It requires urgent treatment as delay may lead to irreversible penile ischemia and gangrene. Various objects causing penile strangulation have been reported. Nonmetallic and thin metallic objects can be removed easily as compared to heavy metallic objects. Cutting is the commonest method described, although procuring special cutting tools may be difficult and the process of cutting may be tedious with the possibility of iatrogenic penile injury.

AIM

To present a simple, safe, minimally invasive, effective, and feasible technique for removing heavy metallic objects constricting the penis.

METHODS

The published English literature (PubMed™) was searched for cases of "penile strangulation" using the keywords penile strangulation, penile injury, penile trauma, penile constriction, penile entrapment, and penile incarceration. The described treatment modalities were carefully reviewed and studied.

MAIN OUTCOME MEASURES

Reviewed published English literature on the various causes of penile incarceration and the various techniques used for their extrication.

RESULTS

Search results yielded several cases of penile strangulation caused by a variety of metallic and nonmetallic objects. Various modalities have been described in the English literature for their safe removal, each with its own merits and demerits.

CONCLUSIONS

Penile strangulation should be viewed and managed as an emergency in order to prevent penile necrosis and urethral injury and to preserve erectile function. The modified method described herein for managing penile strangulation due to heavy metallic rings is minimally invasive, safe, effective, does not require any special cutting instrument(s) or skill, and is free of causing iatrogenic collateral thermal or mechanical damage to the penile organ. A stepwise algorithm depicting a rational and comprehensive approach to the diagnosis and management of penile incarceration is also suggested for the clinicians.

Genitalia strangulation--fireman to the rescue!

The incidence of metallic rings causing genitalia strangulation has been widely reported. The removal of the constricting rings can be challenging and might need resources not usually available in the hospital. We report one such case where the assistance of a fire crew was required to remove the ring.

Novel use of the Gigli saw for management of penile entrapment

INTRODUCTION

Penile entrapment is a rare clinical entity requiring urgent and efficient management. If left untreated, it may result in vascular compromise to penile soft tissue structures. Management poses unique challenges to the treating physician through variable presentation as well as the lack of specifically designed treatment options.

AIM

This article describes the use of the Gigli saw for management of penile entrapment.

MAIN OUTCOME MEASURES AND METHODS

We employed the Gigli saw to remove an entrapped metallic peno-scrotal constriction ring.

RESULTS

We successfully removed the entrapped ring with no noted immediate complications.

CONCLUSIONS

The Gigli saw can be safely used, and represents an easily available and potentially effective option in the management of penile entrapment.

Wedding ring in the wrong place: an unusual presentation of penile incarceration in a child with a wedding ring

An unusual case of penile incarceration in a 13-year-old boy is presented, with lessons to be learned for Accident and Emergency Department junior doctors in particular and for all in general. The presentation was misleading and the condition would have gone undiagnosed with fatal consequences without a team effort. The object used was a wedding ring in this case. Penile incarceration is not common in routine practice. The need for development of necessary paediatric history taking and examination techniques among Emergency Department doctors and staff is highlighted. Recalling the basics, this case report emphasises the importance of thorough physical examination. With early diagnosis and treatment, lifelong disabilities can be prevented.