Introduction

Engorgement of penis by encircling objects is an acute emergency.

Application of foreign bodies on the penis is used by adults for sexual gratification and occurs in children as an innocent childish play⁽¹⁾. Types of strangulating objects are metallic and non-metallic. In children, strangulating objects are usually non-metallic and are applied as an innocent childish experiment. However, in adults they are used by some to achieve sexual gratification. Metallic objects are usually put on the penis by the patient himself or his female partner to get a longer sexual erection in adults^(2,3,4,5).

We share our experience of managing such strangulating metallic foreign bodies in 3 patients.

Case reports

We had 3 male patients in the age group of 50 to 60 years who presented to us with an encircling foreign body around the penis. All these male patients had put these encircling objects on their penis themselves for achieving sexual gratification. On detailed personal history, it was found that they had suffered from psychological erectile dysfunction and had not had sexual relations with their female counterparts for some time.

We hereby present a case report of one such patient with the chronological events and clinical photographs to support our line of treatment.

A 60-year-old male patient having an industry of his own producing metal rings for a vehicle manufacturer came into the emergency department with complaints of pain in the penis with persistent erection. He had applied an encircling metal ring around his penis so as to achieve erection.

Figure 1

Fig. 1: Encircling metal object around the penile base

Figure 2

Fig. 2: After reduction of venous priapism and paraphimosis

On examination, this patient had a thick metallic ring around the base of his penis. There was proximal venous engorgement causing a painful persistent priapism. Our first aim was to reduce his pain and decrease the distal penile engorgement. Under cover of antibiotics and pain relief, we introduced needles in the glans entering the corpora cavernosa, eventually draining the blood. This decreased the distal penile engorgement; however, we were unable to pull out the encircling object. As the encircling body persisted, it caused obstruction to the penile venous outflow leading to distal edema and recurrence of painful priapism. The option we had was to administer anaesthesia and try to pull out the object or cut the object using metal cutters. Looking at the clinical picture, it seemed that the possibility of pulling out the object was less likely.

Under anaesthesia, the venous priapism was drained using needles in the corpora cavernosa through the glans. The underlying paraphimosis was reduced using multiple punctures on the prepuce. Lignocaine jelly was applied to the metal ring underneath and on the distal penile surface so as to make the skin slippery and less resistant for pulling out the foreign body. A steady force was applied on the metal ring. To our surprise, the metal ring got dislodged. The penile edema gradually decreased. The patient was discharged next day. He has been advised regular follow-up for possibility of ischaemic urethral stricture at the site of constriction caused by the encircling metal ring.

Figure 3

Fig. 3: Intraoperative picture

Figure 4

Fig. 4: Muliple punctures for paraphimosis

Figure 5

Fig. 5: Removed encircling metal object, penile edema

Figure 6

Fig. 6: Removed encircling metal object, normalization of penis

Discussion

Trauma to the penis occurs both in children and adults. There is a considerable number of different causes:

• Blunt trauma, including penile fracture

• Full and partial amputation

• Avulsion injuries

• Bites

• Strangulation injuries

• Zipper injuries

• Miscellaneous injuries due to use of erection-inducing devices, sexual abuse, and torture.

Intentional wrapping of strangulating objects around the penis has been reported in some cultures in an attempt to ward off evil spirits or to treat urinary incontinence or nocturnal emissions⁽⁶⁾.The most common motive associated with foreign bodies of the genitourinary tract is sexual or erotic in nature. The most suitable method of removing a encircling penile foreign body depends on the size and mobility of the object applied to the genitourinary tract⁽¹⁾.

Foreign bodies encircling the penis cause an acute emergency. Usually there is venous obstruction that leads to distal edema and a situation like venous priapism as there is obstruction of venous outflow. It is usually recommended to remove such foreign bodies under anaesthesia.

The clinical picture in such patients leaves us an option of either cutting the encircling object using metal cutters or an attempt to dislodge the object by applying pressure.

In our experience, it is always possible to dislodge the encircling object. The trick in such cases is

Reduce the venous priapism

• Apply lignocaine jelly underneath the encircling object

• Apply lignocaine jelly on the distal penile skin to make it slippery

• Apply steady persistent forward force on the object so as to dislodge it

We believe from our experience that it is always possible to dislodge the encircling object rather than using the option of metal cutters which are unavailable in our medical set-up.

However, there remains a risk of ischaemic injury to the unsupported urethra which lies directly beneath the encircling object. It usually manifests at a later date with stricture. Two out of three patients in our institute developed a stricture in the urethra. As these are small segment ischaemic strictures, the best way of treating them is end to end uretheroplasty which we did in both patients. The third patient is asymptomatic till date and is on regular follow-up.

Conclusion

The incidence of encircling foreign bodies around the penis for sexual gratification is rare in India. However, the reported cases may just be the tip of the iceberg as many cases go unnoticed with treatment given by local physicians. There remains a lot of inhibition in Indian men to approach the urologist for erectile dysfunction and deteriorating sexual quality of life in their 6th to 7th decade. Such cases may just indicate the prevelance of erectile dysfunction in men and their inhibitions to seek medical help.

We believe that it is always possible to dislodge such encircling objects by the method described above and the use of metal cutters is never required.