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Indian Journal of Surgery
Medknow Publications on behalf of Association of Surgeons of India
ISSN: 0972-2068
Vol. 66, Num. 3, 2004, pp. 173-175

Indian Journal of Surgery, Vol. 66, No. 3, June, 2004, pp. 173-175

Case Report

Penile strangulation by a hard plastic bottle: A case report

Department of Surgery and Surgical Oncology, Mohan Dai Oswal Cancer Treatment and Research Foundation, Ludhiana
Correspondence Address:Mohan Dai Oswal Cancer Treatment and Research Foundation, G. T. Road, Sherpur Chowk, Ludhiana-141009 mdoh1@satyam.net.in

Code Number: is04043

ABSTRACT

Penile strangulation is a rare injury, but requires urgent management. Various metallic and non-metallic objects are placed over the penis to increase sexual performance or because of autoerotic intentions. We describe a case who had put a hard plastic bottle over his penis which resulted in strangulation of the penis. To remove it was a challenge as the chances of injury to the surgeon and the patient were high. Patient was successfully managed and had an uneventful recovery. There was no erectile dysfunction and uroflow was normal. The patient was lost in the follow up, so long term outcome could not be studied. The treatment of penile strangulation is decompression of the constricted penis, so as to facilitate free blood flow and micturition, which requires resourcefulness and presence of mind.

INTRODUCTION

Penile strangulation is a rare injury and most require only removal of the constriction and conservative management. Penile strangulating objects are usually rings, nuts, bottles, bushes, wedding rings etc. in an adult, while in children they tend to be rubber bands threads or hair coils. In adults these constricting penile bands, whether expandable or non-expandable, are placed deliberately by the person himself for masturbation or by the female counterpart to prolong erection.[1] In children these are used to prevent enuresis and incontinence or as an innocent childish experiment. Because these bands occlude penile venous flow, most patients present to the emergency with penile edema. We report a case, which had hard plastic bottleneck as a constricting agent, which was managed successfully.

CASE REPORT

A 27 year old male presented in the emergency with markedly swollen penis. He had placed his penis in a hard plastic bottle for masturbation. The bottleneck got stuck and constricted the base of the penis.

On Examination there was a bottleneck around the base of penis. The distal penis and glans were swollen [Figure - 1]. Patient was not able to pass urine. There was no evidence of any skin ulceration. The distal penile sensations were normal.

The hospital carpenter was called to assist in cutting open that bottle. With the use of iron cutting saw (Hexa Blade) first the bottle was cut near the neck and then the bottle neck was cut open slowly and diagonally. The penis was held slightly bent downwards. Once one end of the bottle neck was cut open, the plaster spreader (used by orthopaedician) was use to hold the cut ends open and the whole bottle neck was cut opened and removed after 15 minutes of struggle.

There was ecchymosis of the skin. Patient was catheterized. Penile edema subsided completely in a week and patient had an uneventful recovery. There was no erectile dysfunction or decreased uroflow till one month of follow up. Long-term outcome could not be studied because patient did not come for further follow up.

DISCUSSION

Penile strangulation injuries range from simple penile engorgement to ulceration, necrosis, urinary fistula or even gangrene. As the patient is shy of telling this problem or patient is mentally abnormal they may present late and have severe injury. Metallic Rings cause less injury than nonmetallic rings.[1] As the corpus spongiosum and urethra are covered by a thin layer of fibrous tissue they are most susceptible to injury.

AL Bhat et al (1999) graded these injuries as follows.[1]

Grade I Edema of distal penis. No evidence of skin ulceration or urethral injury
Grade II Injury to skin and constriction of corpus spongiosum but no evidence of urethral injury. Distal penile edema with decreased penile sensation.
Grade III Injury to skin and urethra but no urethral fistula. Loss of distal penile sensations.
Grade IV Complete division of Corpus spongiosum leading to urethral fistula and constriction of corpus cavernosa with loss of distal penile sensations.
Grade V Gangrene, necrosis, or complete amputation of distal penis

The present case had a grade I injury and required only the removal of constricting device. But more severe cases may require Supra Pubic Cystostomy (SPC), urethral reconstruction, degloving and Skin Grafting or some times amputation.

The evaluation of penile strangulation can be done by local temperature, sensation, color, ability to void, distal pulsations and local tissue injury at the site of constriction. In case of absent pulsations the distal blood flow can be checked by Doppler flow meter or wood lamp examination after IV Fluroscein.[2]

The choice of method for removal depends upon type, size, and time since strangulation and availability of the equipment. These methods may be aspiration of corpora, saws, grinders, and dental drills etc.[3],[4],[5] After the removal of the object the urethra should be evaluated radiologically. If grade III-V injuries are found, SPC should done. In grade I and II injuries, simple emptying of the bladder by urethral catheterization may be required. Our case had only grade I injury and patient improved after removal of the constricting agent. Catheterization was done.

CONCLUSION

Penile strangulation is a serious injury requiring urgent attention and intervention to prevent the complications. Aim should be restoration of blood supply and micturition with least discomfort to the patient. Long term follow up with Micturating Cysto-Uretherogram (MCU), Uroflowmetery etc. is necessary. These patients should also undergo a psychosexual assessment to prevent further episodes of such genital auto-mutilation.

REFERENCES

1.Bhat AL, Kumar A, Mathur SC, Gangwal K. Penile strangulation. Br J Urology 1991;68:618-21.  Back to cited text no. 1    
2.McGraw JB, Myers B, Shanklin KD. The value of fluorescein in predicting the viability of arterial flaps. Plast Reconstr Surg 1977;60:710-9.   Back to cited text no. 2    
3.Browning WH. Reed DC. A method of treatment for incarceration of the penis. J Urol 1969;101:189-90.  Back to cited text no. 3    
4.Sony FJ, Wagner SA, Woosside JR, Orgel MG, Borden TA. Management of Penile incarceration. Urology 1984;24:18-20.  Back to cited text no. 4    
5.Tiwari VS, Razdan RL, Yadav VNS. Strangulation of penis by a metallic nut. Int Surg 1977;62:558-60.   Back to cited text no. 5    

Copyright 2004 - Indian Journal of Surgery


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