Penile strangulation is a rare clinical condition that was first reported in 1755 [6]. They occur as a result of a constriction force of the object applied over the penile shaft. In adults, the common reasons are sexual stimulation, prolonging erection, pranks, treatment of incontinence and phimosis [3, 7]. However, in kids, the main reason to place such objects is for managing enuresis [2, 8]. Likewise, there are a plethora of objects which have been reported in the literature as a cause of penile strangulation like metallic rings, tubes, rings, plastic bottles, rubber bands, rubber strings, hair, threads [3, 5].
These objects when applied over a flaccid penis causes obstruction of venous and lymphatic outflow, resulting in the penile engorgement. Due to the oedema and increase in the girth of the penile shaft, the applied object which was placed easily before is now difficult to remove. As the pressure increases because of the lymphatic obstruction and venous congestion, the continuous constriction force results in compartment syndrome type situation. This eventually leads to obstruction of the arterial inflow to the distal part of the penis, resulting in strangulation [1,2,3,4,5]. If the offending object is not removed timely, then the strangulation would lead to soft tissue ischaemia, necrosis, local infection, and gangrene [1, 3, 4].
In 1991, Bhat et al. graded these kinds of injuries according to the increasing severity [2].
Grade 1 Oedema of distal penis. No evidence of skin ulceration or urethral injury.
Grade 2 Injury to skin and constriction of corpus spongiosum but no evidence of urethral injury. Distal penile oedema with decreased penile sensation.
Grade 3 Injury to skin and urethra but no urethral fistula. Loss of distal penile sensation.
Grade 4 Complete division of corpus spongiosum leading to urethral fistula and constriction of corpus cavernosum with loss of distal penile sensation.
Grade 5 Gangrene, necrosis, or complete amputation of distal penis.
Most of the patients delay in seeking medical attention due to fear of social embarrassment or at times neglect the problem and seek medical help after failed self-attempts, as seen in our cases [5, 7]. The common complaints at presentation are penile swelling, pain at the local site, or difficulty in passing urine. The delay in presentation results in penile swelling out of proportion to the inner diameter of the object stuck, thus making the task of removing the foreign body even more difficult. The prolonged placement and delayed removal of these objects are likely to cause high-grade injuries [1, 4, 5].
The evaluation of such patients should include thorough history taking including the duration for which the object is stuck. History about any substance abuse or any previous/ongoing psychiatric illness should be obtained. [1, 2, 4, 9,10,11]. The patient should be specifically asked about the voiding difficulty as urethra might be compressed because of the penile strangulation [2, 5].
Local assessment should be done by recording skin temperature, skin colour, penile sensation, and pulsation distal to the strangulation to assess arterial insufficiency [2]. The penis should be examined for any urinary leak from the ventral aspect as it can happen in case of the development of urethra-cutaneous fistula due to pressure effect. Skin ulceration and local infection can be present as a result of skin ischaemia [4]. Ultrasound Doppler can be used to assess the vascularity in the case of equivocal clinical findings [2, 5]. Urinalysis and urine culture are also recommended [4, 5].
The early removal of the constriction device and restoration of venous and lymphatic drainage and arterial inflow is paramount [1, 8]. It helps in preventing ischaemic injury to the penis and urethra. Removal of the offending object can be a real challenge due to surrounding tissue oedema. Bhat et al. in their study divided the injuries based on the type of offending objects, into the metallic and non-metallic groups. They concluded that the non-metallic objects are easy to remove, but the injury caused by them is severe, as they are thin and sharp [2]. In 2008, Silberstein et al. also reported that higher-grade penile injuries are more frequently sustained by non-metallic objects due to the more elastic properties of these items and their greater propensity to exert pressure on the penis and thus create more injury [5]. As per grading system proposed by Bhat et al., in our study, the first case had grade 2 injury by a metallic cone which required the use of an electric drill for its removal and the second case had grade 4 injury by a rubber band which was cut with the help of scissors and ultimately required total penectomy with permanent perineal urethrostomy. These findings were in correlation with the findings of Bhat et al. and Silberstein et al. [2, 5].
Apart from the material of the object, other factors to be considered before taking the patient for surgery are size, length, and thickness of the object, the grade of surrounding tissue oedema, the grade of injury, and availability of the equipment [1, 2, 5].
There are a variety of techniques described in the literature like aspiration, string method, cutting devices, and degloving surgeries [1, 2, 4, 7, 8, 12]. The cutting technique is by far the most used intervention [5]. The various tools used for the same are either non-electric or electric, viz. orthopaedic equipment, ring cutters, metal saws, hammer, chisel, drills, etc. The non-electric cutting devices are easy to use but require strength and are best reserved for non-metallic items, small metal rings or wires at the most [4, 5, 7]. On the other hand, electric cutting devices are high-energy-driven tools. They are of greater help in removing large and thick metallic objects, but their handling is difficult and requires utmost care and safety precautions to avoid iatrogenic injury to the patient and the operating team members [1, 4, 5, 7, 13].
Use of protective gear for the team members is advisable [1, 4]. Placement of a metallic object underneath the foreign body before using an electric drill helps in minimizing the risk of iatrogenic injury [4, 5, 13]. We used a scalpel handle and metallic scale in our case for this purpose. On similar lines, we used continuous cold irrigation while cutting to prevent heat injury to the underneath tissue [5, 13]. When it comes to sawing the rings or cones, they should be cut at two places, 180 degrees opposite to each other for easy removal [4, 5].
Post-removal of the offending object, the underneath soft tissue and skin colour change must be examined for tissue viability. Post-removal of the constriction device as the blood supply is restored, skin colour returns to normal. This points towards the viability of the underneath soft tissues. In case of doubt, intra-operative penile colour Doppler can be helpful.
Associated injuries to the skin, corporeal bodies, spongiosum, and urethra must be evaluated. Any necrosed soft tissue or constriction band formed must be excised. Skin grafting might be necessary if the primary wound is too large to be closed primarily. In the case of urethral injuries or irreversible penile ischaemic injuries, urinary diversion in the form of suprapubic catheterization or perineal urethrostomy might be needed [2, 4, 5].
The goal of the management is the early and safe removal of the foreign body and management of associated injuries. However, there are no standard guidelines to manage such cases due to varied presentations and in most cases the surgeon must resort to improvisation which may entail arranging machinery from outside the hospital [1]. In one of our cases, we had to arrange for the electric metal cutting drill from a nearby plumber.
In post-operative period, the patient should be closely monitored and examined for resolving oedema or any signs or symptoms of post-operative ischaemic injury. It should be ensured that the patient does not have any difficulty in voiding urine. Along with it, pain management, psychological evaluation, and counselling are necessary [1, 2, 5].
Post-operative complications are more common in higher-grade injuries as reported by Bhat et al. [2]. Follow up is advised to evaluate and manage long term complications which may arise like urethra-cutaneous fistulas, urethral stricture, lymphoedema, skin necrosis, erectile dysfunction, and priapism [2, 4, 5, 7].
