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Try out PMC Labs and tell us what you think. Learn More. Penile strangulation is a challenging clinical situation and usually requires prompt treatment. Here, we report four cases of penile strangulation by different objects which were successfully removed by aspiration and string method. We found that instead of using heavy cutting instruments and other surgical methods, string and aspiration technique is much better. Penile strangulation is an unusual clinical condition that was first reported in by Gauthier.

Metallic or nonmetallic objects are the most common cause of penile strangulation. Urgent treatment is required, as potential delays may lead to permanent and severe damage, including penile amputation, sepsis, and even death. Herein, we report four cases of penile strangulation due to different objects and their removal by modified string technique, i.

A year-old unmarried man presented to our emergency outpatient department with a strangulated penis of 6-h duration. After placing a piece of metallic plumbing pipe, he was unable to remove it from his engorged penile shaft after autostimulation. He was having severe pain in the penis and was unable to void. Physical examination showed a thick metallic ring, 4 cm in length stuck at the base of the penis.

The whole of the penis distal to metallic object was grossly swollen and congested [ Figure 1 ]. In the emergency room, removal of the ring was initially attempted using lubricants but was unsuccessful due to the long pipe and grossly engorged penis.

The patient was admitted and immediately taken to emergency operation theater. Under spinal anesthesia, we used modified string and aspiration method and were able to remove the metallic pipe within 20 min of time [ Figure 2 ]. Following removal of the ring, it was noticed that there was loss of epidermis at the site of impaction. He was discharged on postoperative day 2 with an advice of regular dressing, oral anti-inflammatory drug, and antibiotics. Ten-day follow-up showed a partial-thickness skin loss at the site of impaction [ Figure 3 ].

There was no loss of distal penile sensation and no voiding difficulty, and he could attain a normal erection. He is waiting for a split-thickness skin grafting by the plastic surgeons. Steps of modified string method. With the help of two wide-bore gauge needles, distal corpora cavernosa was punctured and blood aspirated [ Figure 2a ]. After proper lubrication, a 10 Fr Foley catheter could be negotiated between the metallic pipe and the penis and passed from the root of the penis toward the glans [ Figure 2b ]. Distal glanular end of the catheter was circumferentially coiled over the penile shaft, in clockwise direction, compressing the shaft to a diameter just lesser than the inner diameter of the ring [ Figure 2c ].

The metallic pipe was glided over the catheter-covered compressed penis, distally toward the glans for approximately 4 cm. The proximal end of the Foley catheter was unwinded, which helped pushing the pipe distally [ Figure 2d ]. The same procedure was repeated three times before the pipe could be glided past the glans completely [ Figure 2e ].

Normally, this procedure is best done with the help of a vessel loop, but due to its unavailability in the emergency, we had to use a Foley catheter. Penile strangulation is a rare clinical entity which may lead to serious complications if not treated promptly and judiciously. The reasons for applying foreign bodies to the external genitals are varied and depend on the patient's age group. In middle-aged and elderly men, the leading cause of application of foreign bodies is to increase sexual performance or because of autoerotic intentions, while masturbation and sexual curiosity are the leading causes in male adolescents.

Although usually acute, cases of chronic strangulation and acute cases lasting up to 1 month have been reported. They attend the emergency room once all the home remedies to remove the foreign body fail, and local pain starts appearing. This delay has clinical implications in the form of long-term outcome. Because the vasculature of the penis is compressed, a variety of complications can result from strangulation injuries, depending on whether the veins, arteries, or both are compressed.

Grade II: Distal edema, skin and urethral trauma, corpus spongiosum compression, decreased penile sensation. Grade IV: Separation of corpus spongiosum, urethral fistula, corpus cavernosum compression, no distal sensation. In one of the largest studies on penile strangulation by hair, Harouchi et al.

High-grade injuries are defined as injuries that are likely to require second surgical intervention after removal of the strangulating agent. Based on these classifications, it is possible to evaluate the severity of complications that occurred after incarceration as well as to determine the treatment strategy. Three patients presented here had low-grade injuries, and no surgical intervention was performed after removal of the rings. One patient had high-grade injury with partial-thickness skin loss who was referred to plastic surgeon for skin grafting.

One patient had persistent distal penile numbness with less sexual satisfaction, but none of them had any erectile dysfunction. All the patients underwent a uroflowmetry at 3- and 6-month postintervention irrespective of any voiding difficulty. None of these patients had any delayed development of urethral stricture disease or erectile dysfunction at mean follow-up of 16 months range: 4—24 months.

Table 1 is showing details of patients who presented with penile strangulation and their management and outcome. Patients of penile strangulation with different objects, their management, and the outcome. The treatment of penile strangulation is prompt decompression of the constricted penis to facilitate free blood flow and micturition. Various techniques have been described in the literature: aspiration, string method, combination of aspiration and string method string,[ 2 ] cutting devices,[ 9 , 10 ] and deglove operation.

Cutting tools used included an iron saw, orthopedic equipment, and a high-speed diamond-tipped dental drill. However, metallic constricting rings placed around the penis present a challenge to urologists, especially when they are long and thick. Availability of gadgets, sometimes at odd hours, and the unavoidable delay of its arrangement in a case which has already presented late is a major issue in management and ultimately may worsen prognosis.

Even when available, the use of various cutting instruments took long time, and unfortunate reports of iatrogenic injury are also high. Regarding techniques which use string, the resource needed is very minimal. Vahasarja et al. However, if there is not only congestion of the corpus spongiosum and the glans penis but also the edema of the foreskin, foreskin puncture and glandular puncture should be performed at the same time.

If there is only edema of the foreskin without blood stasis in the penis glans, foreskin puncture is enough. In our experience, string method with aspiration of blood from corpora is better than the use of various cutting devices. These two methods are particularly useful together, as the string technique provides sequential compression and aspiration allows the congested blood a method of exit. Instead of glanular puncture described ly, we did bilateral corporal aspiration, preventing the possibility of formation of a corporoglanular shunt leading to erectile dysfunction in the future.

We successfully removed various objects by this method. With rapid intervention and removal of the foreign body, most patients do extremely well and need no further intervention. The outcome, even after long periods of penile strangulation, is often good. Penile strangulation by a constricting device is a urologic emergency with potentially severe clinical consequences.

Removal of such devices can be challenging and often requires resourcefulness and a multidisciplinary approach. Clinicians should use the least traumatic technique to remove a constriction device from the genitals as soon as possible after incarceration. String method along with aspiration of blood from the penis is an easy yet very effective method for the treatment of penile strangulation. In comparison to other methods of object removal, it needs least resources and appears to be safer than other methods.

The authors certify that they have obtained all appropriate patient consent forms. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. National Center for Biotechnology Information , U. Journal List Urol Ann v. Urol Ann. Author information Article notes Copyright and information Disclaimer. Address for correspondence: Dr. E-mail: ni. Received Dec 9; Accepted Sep This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.

This article has been cited by other articles in PMC. Abstract Penile strangulation is a challenging clinical situation and usually requires prompt treatment. Keywords: Foreign body, penile ischemia, penile strangulation, string method. Open in a separate window. Figure 1. Figure 2. Figure 3. Procedure With the help of two wide-bore gauge needles, distal corpora cavernosa was punctured and blood aspirated [ Figure 2a ].

Table 1 Patients of penile strangulation with different objects, their management, and the outcome. Persistent distal penile numbness [Figure 5]. Figure 6. Figure 4. Figure 5. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Gauthier M. Observation of strangulation of the testicles and yard, caused by the passage of a lighter. J Med Chir Pharmacol. Penile strangulation treated with the modified string method.

Penile strangulation: Two case reports and review of the literature. J Sex Med. Penile strangulation by a hard plastic bottle: A case report.

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