Management of Penile Strangulation by Multiple Metallic Rings: Innovation at a Time of Tribulation

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Dear Sir, We present the case of a 45-year-old male with no significant psychiatric or medical history who presented in painful distress with a grossly swollen penis and scrotum, following a 14-h history of five retained metallic penile rings inserted by his partner to enhance performance. Attempts by the patient and his partner to remove the rings were unsuccessful. There was no history of hematuria or urinary retention, and his full blood count and renal function were normal. He was given analgesia and subsequently managed under general anesthesia. Examination revealed a grossly edematous penile shaft and scrotum with erythematous penile and scrotal skin. Five constricting metallic rings, each 0.5 cm in thickness, were trapped at the root of the penis dorsally and part of the scrotum ventrally, without evidence of necrosis [Grade I penile injury or low-grade injury;[1]Figure 1]. The orthopedic team on call and the fire service were consulted for instruments that could aid in the removal of the rings. Manual decompression and attempts using lubricant to remove the rings, followed by a handheld electric diamond cutter, were unsuccessful. The rings were then cut individually at two opposite ends (the 6 and 12 o’clock positions) using an industrial-grade bolt cutter, resulting in immediate detumescence.Figure 1: Anterior and lateral views of the constriction at the root of the penis and the removed rings cut individually at two opposite endsFlexible cystoscopy was performed, revealing a completely normal urethra. A size 16F urethral catheter was inserted to reduce penile edema and pain. Postoperatively, the patient had an uneventful recovery. The urethral catheter was removed, and he was discharged on postoperative day 1 with a significant reduction in penile and scrotal edema. A 1-month follow-up showed normal erectile function and no urinary symptoms. Penile and scrotal strangulation caused by penile rings is an uncommon urological emergency that can result in mechanical and vascular complications without early intervention.[1,2] Thin, nonmetallic objects are more easily removed compared to metallic ones.[3] The most common reasons for the use of penile rings in adolescents and young men are masturbation and sexual curiosity, whereas in middle-aged and older adults, as in this case, it is mainly to cure erectile dysfunction or enhance sexual performance.[4] Because there are no standardized guidelines for the management of penile strangulation and presentations can vary, treatment is individualized based on clinical findings and operative settings. Various methods have been reported for removing rings, as listed in Figure 2.[1–7] The attending urologist should understand that every case must be individualized, making optimal use of available resources and adopting a multidisciplinary approach to prevent iatrogenic injuries and achieve the best outcomes. The use of industrial-grade steel bolt cutters, as in this case, can be safely employed to remove thick multiple metallic rings.Figure 2: Different methods used in the treatment of different objects causing penile strangulation.[ 1–7 ] The prompt intervention is likely to prevent ischemia and autoamputationDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Research quality and ethics statement The authors followed applicable EQUATOR Network (https://www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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