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186 Kumar S. et al.Jurnalul de Chirurgie (Iaşi), 2013, Vol. 9, Nr. 2doctors but also technical experts fromengineering department. The emergencyphysicians should be well aware of theappropriate line of management in suchcases in order to be able to coordinate theteamwork. We report a case where a manpresented with acute retention of urine withtwo metallic rings over his penis.CASE REPORTA 50 years old man presented to thesurgical emergency ward with complaint ofacute retention of urine. He had pushed twometallic rings over his penis about two hoursback in a bid to get sexual pleasure while hewas under influence of alcohol. The ringslater got impacted over the penis because ofcongestion of distal part of penis. Soon thepatient developed the complaint of mild painand swelling of penis and inability to passurine and was brought to the hospital.On examination he was conscious andtalkative but a little apprehensive. His vitalparameters were within normal limits. Hisurinary bladder was distended and palpable.He had two ornamental rings impacted overhis penis (Fig. 1). The part of penis distal tothe rings was congested, swollen and slightlydiscolored. Tenderness was minimal.At first an intravenous line wasestablished and the patient was given 200mg of ciprofloxacin intravenously and 75mg of diclofenac-sodium intramuscularly.As wire cutters were not immediatelyavailable in the emergency ward, a plan toattempt removal of intact rings was madebefore wire cutters could be arranged. Tostart with urinary bladder was evacuated byputting a wide bore needle suprapubicallyand connecting it to a urobag through a dripset. Penis was then cleaned and antisepticsolution was applied. Penile block wasgiven. Blood was then aspirated from bothcorpora cavernosa distal to the rings and therings were manipulated after generousapplication of lubricant jelly.This way, rings could be movedalmost up to corona glandis obstructed onlyby a band of edematous skin. Now multipleneedle punctures were given in this skin andthe area was kept compressed for a whileusing a tape-gauze wrapped tightly over it.On removing the gauze, rings could bemoved up to corona. Now the distal ring wasplaced with its wide stone bearing partagainst the ventral aspect of glans. Glanswas then decongested by means of needlepunctures and digital compression. Ring wasrotated with traction while glans wascompressed to negotiate through it. Theattempt was successful and both rings wereremoved in this fashion.The patient was kept in the hospital fora few hours under observation during whichthere was no significant bleeding frompuncture wounds and patient could passclear urine without any difficulty. He wasdischarged from the hospital thereafter onoral ciprofloxacin. The patient was later seenin outpatients department one week later. Hehad no complaints related to micturition orsexual intercourse and his penis lookedhealthy.Fig. 1 Penile entrapment in metal ringsDISCUSSIONPenile entrapment in a constrictingobject is a surgical emergency requiringimmediate attention because of the risk ofirreversible ischemic injury. A large varietyof objects has been implicated in cases ofpenile strangulation injury such as rings,nuts, bushes, bottleneck, pipes and loopwrench etc. Such objects are placed overpenis deliberately either for autoeroticpurpose or secondary to psychiatricdisturbance. Some people use constricting
Penile entrapment: aspiration technique 187Jurnalul de Chirurgie (Iaşi), 2013, Vol. 9, Nr. 2band over penis in a bid to overcomeimpotence. In children the constrictingobjects are usually non-metallic such asrubber band, thread or hair. These are usedto prevent enuresis or incontinence or mayrepresent an innocent childish experiment.When an encircling object is placedover penis it impairs the venous andlymphatic return of penis while the arterialflow is maintained. This results incongestion of distal part of the penis and, ifthe object is not removed, it gets impacted.Patient may present with edema orulceration of penile skin, loss of sensation,retention of urine, urethral fistula or evengangrene. Bhat et al. [1] classified the penilestrangulation injury into five gradesaccording to severity, with grade onecharacterized by only edema of distal peniswithout skin ulceration or urethral injury,grade two having injury to skin, constrictionof corpus spongiosum, distal penile edemaand decreased penile sensation, grade threehaving injury to skin and urethra anddecreased penile sensation but no urethralfistula, grade four comprising completedivision of corpus spongiosum leading tourethral fistula and constriction of corpuscavernosum with loss of distal penilesensation, and grade five representinggangrene, necrosis or complete amputationof distal penis.Management issues in such cases arerelief from retention of urine, removal ofconstricting object, prevention of sepsis andprevention or treatment of complications. Torelieve the retention of urine urethralcatheterization is possible in many casesbut suprapubic cystostomy is oftenrequired [2,3].The most challenging job however isthe removal of the constricting object. Theobject may be either cut apart or removedintact, depending upon the type and size ofthe object, duration of penile incarcerationand the availability of equipment. Nonmetallicthin objects are easy to remove butobjects like thread or hair may erode deepinside the skin and may cause severe urethralinjury. Thin metallic rings, at times, can beremoved easily by means of metal cuttersbut a variety of tools has been used for thispurpose when the constricting object iscomposed of hard metal and is difficult tocut. These include saw, cutting tongs, highspeed drills, hammer and chisel, and DremelMoto-Tool etc. [1,4,5]. When a drill is usedto cut the object, a lot of heat is producedwhich can cause thermal injury tounderlying penile tissue. To prevent this,continuous irrigation with copious amount ofice water is required [1,5]. Suchsophisticated tools are not easily available inemergency wards and this lack of adequateresources often warrants an attempt atmanual removal of the constricting object.The choices of methods for removingthe object intact include the String Methodwhich was originally described by Flatt forremoving strangulating ring from a finger[6]. Vahasarja et al. [7] reported two casessuccessfully managed by this method.Detweiler and Perkins [8] used latex band ina similar fashion calling it the WrappingTechnique. We used the AspirationTechnique in this patient. Aspiration ofblood was done from the shaft and glans ofpenis to achieve detumescence followed bymanual expression of fluid and successfulremoval of the constricting agent. The penileskin edema was overcome by wrapping thepenis tightly in a tape-gauze and thusproviding sustained compression over alength of penis. So this combination ofmaneuvers made it possible to remove thetwo rings intact without the use ofsophisticated tools, leading to the desiredresult and an uneventful recovery. Therehave been few previous case reports ofsuccessful use of this technique [9-11].Surgery in the form of degloving ofpenis to reduce its effective diameter may berequired in some patients. Coverage withskin graft or flap is required. Surgery is alsoindicated in case there is ulceration ornecrosis of skin, debridement of devitalizedtissue is done followed by skinreplacement [3]. Urethra should be evaluatedradiologically soon after removal of theconstricting object if injury is contemplated.
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