Penile entrapment by a metallic ring: A case report and review of management strategies

INTRODUCTION

Penile entrapment is a serious condition that requires immediate intervention.¹ Penile rings are often used to enhance sexual gratification or manage erectile dysfunction; however, they can lead to strangulation and total penile amputation if not addressed promptly.^2,3 Both metallic and non-metallic objects have been implicated in such cases. The presentation of penile strangulation can vary, including symptoms such as painful penile swelling, acute urinary retention, decreased penile sensation, and near-total amputation.^2,4,5 Due to the varied presentations, there are no consensus guidelines for managing these injuries, posing a significant challenge for trauma surgeons and urologists. We present a case of a young male in his 20s with a psychiatric illness who presented to our Trauma Department after 12 hours of penile entrapment with a metallic ring. He experienced painful penile swelling and acute urinary retention. The case was successfully managed with primary repair of the penile shaft and urethra, with no immediate and delayed complications.

CASE REPORT

A young male in his mid-20s with hearing and speech impairment presented to the Trauma Department with painful penile swelling and acute urinary retention. The symptoms began 12 hours after he inserted a metallic ring into his penis for sexual gratification. The patient had previously used plastic bottles but had never used a ring before. He denied any history of substance abuse, recreational drug use, or current medication. On physical examination, the patient had normal vital signs but had an edematous glans penis, a palpable bladder, and a metallic ring at the transition level of the glans and penile shaft [Figure 1]. He experienced severe tenderness along the penile shaft and was in considerable distress. Although the penile skin was intact, the urethra appeared disrupted entirely on clinical examination.

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Figure 1:

Metallic ring at the transition level of the glans and penile shaft

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Treatment

After obtaining informed consent, the patient was taken to the operating room. Initially, a suprapubic catheter (SPC) was placed, and a 20 Fr two-way Foley catheter was used to drain 2000 ml of urine immediately. The ring was then cut using compression and lubrication techniques and removed with artery forceps [Figures 2 and 3]. The glans was covered with a hot sponge for 30 minutes to reduce oedema. Upon exploration of the penile shaft and urethra, a circumferential injury to the urethra and complete disruption of the corpus spongiosum were noted, consistent with Bath et al Grade 4 injury.⁶ Penile skin was normal with no gangrenous changes. An intraoperative USG Doppler confirmed biphasic flow in the pudendal vessels. A two-way Foley catheter 18 French was gently inserted per urethra, and the urethra was repaired with 4-0 Prolene to have better support and less tissue reaction, followed by the repair of the penile shaft [Figure 4].

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Figure 2:

Artery forceps used for removing the metallic ring

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Figure 3:

A figure showing a metallic ring causing penile entrapment

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Figure 4:

Figure showing the primary repair of the penile shaft

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Outcome and follow-up

The patient remained under observation for 21 days for complete psychiatric and psychological evaluations. SPC was removed subsequently during hospital stay. Foley's catheter was removed at 2 months. Follow-up at two-month intervals included uroflowmetry and a micturating cystourethrogram at six months, both of which showed no signs of stricture or fistula formation [Figure 5]. The patient also never reported any loss of penile sensation or erectile dysfunction.

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Figure 5:

Figure showing follow-up of the penile shaft with no complications

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DISCUSSION

Penile entrapment is a urological emergency where any entrapment lasting more than 30 minutes increases the risk of total amputation.⁷ The duration of presentation can vary significantly, with reported cases ranging from 3 hours to as long as 8 days. In our case, the duration exceeded 12 hours. The main reason for late presentation is the stigma associated with these cases, often linked to erectile dysfunction and masturbation.⁸

It can be associated with a wide range of potential complications, including vascular obstruction, lymphedema, loss of penile sensation, skin necrosis, urethrocutaneous fistula, urethral injury, gangrene, autoamputation of the penis, and sepsis.⁹ These complications pose significant challenges for the surgical team. The exact duration after which such complications can present varies in different studies. For instance, urethrocutaneous fistula has been reported after 12 hours by Kyei et al., erectile dysfunction has been noted in a similar time period by Bray et al., and Patel et al., have mentioned the death of the patient due to septicemia when he presented after 48 hrs.^10-12 The risk of complications is lower when presentation occurs within 6 hours.

The management includes treatment of urinary retention via periurethral or suprapubic catheterization and removal of the encircling object. In our case, we used compression and lubrication followed by the removal of the ring with artery forceps.

The method of choice for removing encircling metallic objects depends on the grade of injury, the material of the device, the availability of tools, and the surgeon's experience.

Removal techniques can generally be divided into four groups.¹³

String technique: The string technique was first used by Bucy in 1968 to remove a metal ball bearing from an incarcerated penis. It can be used for injuries in Grades 1-3. After reducing turgor, a string is passed proximally below the ring, using the remainder of the string to bind the penis tightly to the glans. The proximal end of the suture is lifted and unbound from the penis so that the encircling object is pushed gently over the wrapped and molded penis. The series of steps may need to be repeated several times before the object can be completely removed from the penis.^13,14

Cutting devices: Cutting methods are often the first method for dividing an encircling device that cannot be removed with sequential compression.

These can be two types: non-electric cutting devices and electric cutting devices.

Non-electric cutting devices, such as a hammer and chisel, ring cutter, hack saw, and metal saw, are helpful but require strength to operate, and they cannot cut thick metal rings. The use of various electric cutting devices, such as rotary tools, heavy-duty drills, high-speed electrical steel saws, and pneumatic drills, has been reported in the literature. To avoid damaging the surrounding edematous tissue, a shielding device, such as a metal tongue depressor or a wooden tongue depressor, can be placed between the foreign body and the penis.^9,15

Aspiration techniques: Multiple punctures are made into the penile shaft or corpora, which decreases penile oedema and thus helps in the removal of the metal ring. This technique is more useful for Grade 2 and 3 injuries.^14,16

CONCLUSION

Penile entrapment requires prompt and careful management to prevent severe complications. Each case needs an individualized approach due to the variability in presentation and injury severity. In this case, timely surgical intervention and a multidisciplinary approach led to a successful outcome without long-term complications. There is a pressing need for the establishment of management protocols that encompass not only the surgeon's perspective but also the input of psychiatrists and psychologists.