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CASE SERIES |
https://doi.org/10.5005/njem-11015-0023 |
Penile Strangulation
1Department of Emergency Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2Department of Psychiatry, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India
3Department of Emergency Medicine, Bharati Vidyapeeth Deemed to be University and Medical College, Pune, Maharashtra, India
4,6,7,9–12Department of Emergency Medicine, King George’s Medical University, Lucknow, Uttar Pradesh, India
5Department of Emergency Medicine, Bharati Hospital, Pune, Maharashtra, India
8Department of Emergency Medicine, Bharati Hospital, Lucknow, Maharashtra, India
Corresponding Author: Utsav Anand Mani, Department of Emergency Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, Phone: +91 9920611314, e-mail: utsavanandmani.kgmu@gmail.com
How to cite this article: Mani UA, Tripathi P, Sarangan V, et al. Penile Strangulation. Natl J Emerg Med 2023;1(3):67–70.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.
Received on: 18 December 2023; Accepted on: 08 January 2024; Published on: 25 January 2024
ABSTRACT
Penile strangulation is an acute urological emergency which requires a specialised multidisciplinary approach to management of the patient. We present to you two cases managed in our ER. Through these cases, we aim to understand the underlying psychiatric implications of such patients while learning how to remove the objects in the emergency. The metallic objects from both patients were retrieved in time to prevent loss of organs and maintain the preservation of the function of penis. Psychiatric evaluation of the patients was done and both were diagnosed to be having compulsive sexual behaviour disorder (CSBD).
Keywords: Compulsive sexual behaviour disorder, Penile strangulation, Psychiatric emergency, Urological emergency.
INTRODUCTION
Penile strangulation is defined as the application of constrictive metallic or non-metallic objects which progressively cause engorgement of the penis. In medical literature, it is also known by terminologies, such as penile entrapment, penile constriction, penile incarceration, penile constrictive band injury, phallic ring entrapment, penile tourniquet syndrome, etc. It is an acute urological emergency, often a manifestation of an underlying psychosexual disorder. Delay in treatment may lead to ischaemia, gangrene, urinary retention, temporary to permanent loss of sensation over the dorsum of penis and further trauma due to frustrating attempts at self-removal. Complete necrosis, autoamputation, and urethro-cutaneous fistula have also been reported.1–3
The patient is embarrassed and may present late upon developing urinary retention and penile venous engorgement similar to as seen in fracture of the penis. The aim of the emergency physician should be to prevent end organ necrosis of the penis, establish urethral patency, abstain from iatrogenic trauma and address the underlying psychiatric disorder. The ER physician should involve a urologist early on and preferably extricate the object in their presence. The decision to remove the device either in OT or ER should be made jointly. The stepwise approach of the ER physician should be to reassure the patient, prescribe anxiolytics if needed, call for a urology consult, attempt retrieval if grades I–III (Table 1),4 observe the patient after retrieval and refer to a psychiatrist for OPD consultation. Complete recovery is indicated by the preservation of erectile function on follow-up. A useful algorithm has been made by Singh et al. and it should be used by ER physicians and urologist when in doubt.5
| Grade | Involvement |
|---|---|
| Grade I | Oedema 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 oedema with decreased penile sensation |
| Grade III | Injury to skin and urethra but no urethral fistula. Loss of distal penile sensation |
| Grade IV | Complete division of corpus spongiosum leading to urethral fistula and constriction of corpus cavernosum with loss of distal penile sensation |
| Grade V | Gangrene, necrosis or complete amputation of distal penis |
CASE DESCRIPTION
Case No. 1
The first case is of a 56-year-old University professor, known diabetic with no previous hospital admissions presented to EMD at 6 AM with pain and a metallic ring in his penis (Fig. 1). The patient gave a history of having thoughts of a sexual nature towards his daughter. He took psychiatric counselling and medication for the same but to no avail. He saw a video about how the rings applied to the penis will help eliminate sexual thoughts gradually. Vitals showed tachycardia with normal BP, saturation, and respiratory rate. The patient did not have any addictions. On examination of genital area there were three metal rings seen on the penis—one at the glans and two at the root of the penis. There was oedema of the area of the penis between the root and glans (Fig. 1). Patient says that he applied them at about 1:30 am in the morning. Patient complained of gradually worsening pain and urine retention. Lignocaine jelly was applied over the whole of the penis. The swelling near the glans was reduced by squeezing glans to reduce the swelling. The ring over the glans was removed first. For the remaining rings, the same method was used. But after getting the ring till the middle of the penis, we had to squeeze the penis more to reduce the oedema. The whole process to remove all three rings took about 120 min. A pliers or wire ring cutter could not be used due to the excess oedema. About 5 minutes after removal of all three rings, patient passed 300 mL urine and then was discharged. He was asked to follow-up in urology and psychiatry OPD after a day.
Fig. 1: Presentation of the first patient with three rings
Case No. 2
The second patient is a 63-year-old male who presented with the complaint of a bolt stuck at the root of his penis since 4 days (Fig. 2). The patient is a farmer by profession, he has two sons and a daughter, and he has been a widower for the past 30 years. The sons and daughters are married and he lives alone. The patient is an occasional drinker. On examination, the penis was swollen, and the patient complained of pain and decreased micturition for the past 2 days. On further enquiry, the patient admitted that he inflicted this onto himself out of ‘’playful curiosity’’ (patient used the word chakallas with loosely translates to this) 4 days back, and for the first 3 days, did not inform anyone about the stuck bolt out of shame. Only after the patient started feeling difficulty in micturition, he told his elder son about his condition.
Fig. 2: Presentation of the second patient with a bolt
The patient was immediately taken to emergency OT and after 40–50 needle pricks under regional anaesthesia to allay the venous engorgement the bolt was successfully unscrewed and the entire procedure was without any complications. After due local care, patient was managed on antibiotics and anti-inflammatory drugs (Fig. 3). Daily dressing was also done with aseptic precautions. Once swelling subsided, patient started to micturate normally and was then discharged. A psychiatric counselling was done for the patient and he was not asked to follow-up further.
Fig. 3: After removal of the bolt, postoperatively
DISCUSSION
Metallic and non-metallic objects can be removed by any of the four methods. (a) String technique—involving the use of a string or umbilical tape that can be passed through the object and with help of lignocaine jelly to slide the object out.6 (b) Aspiration technique—a technique which involves multiple punctures over the swollen part to drain the lymph and venous blood out, thus reducing the size and sliding out the object.6,7 (c) Cutting—various instruments have been used, such as Hammer and Chisel, Dremel Moto tool, dental hand piece, orthopaedic straw, and ring cutter.4,6,8–11 Despite being the most commonly used method for removal, the procurement of these tools in an ER may be difficult and risk of iatrogenic physical and thermal injury is high.5 (d) Surgery—surgical degloving upto Buck’s Fascia or the Corpus cavernosum to remove the object followed by skin grafting is done mostly for grades IV and V patients.6,12 Total amputation of penis with perineal urethrostomy has also been done.13
Grades I–III patients can be treated without surgery. Choice of anaesthesia (regionally/general) or periprocedural sedations on along with the decision to remove the objects in OT or ER should be based on individual patient, object incarcerating and the circumstances they arrive in. It has been suggested that urine retention is a preliminary step in the treatment. However, we recommend that it should be attempted after object has been removed. Foleys catheterisation is recommended for grades I–II of penile strangulation and suprapubic catheterisation for grades III–V.4,6,14–16
Wood lamp examination after intravenous fluorescein dye injection is to be done after decompression of grades I–III injuries to exclude any devitalised tissue underneath the object. However, it is necessary for all grades IV–V patients.5,6,17 Doppler ultrasound of penis can be done bedside prior to remove the object to evaluate penile vascularity. It is important to note that an ER physician should not consider metallic objects to be more harmful than non-metallic as a constriction band, thread, or hair may be buried in the oedema and thus difficult to retrieve especially in children.18,19
Regarding underlying psychiatric implications, studies have shown that eroticism and erectile dysfunctions are known inducements for using penile rings to sustain erection.20 However, in our first case, rather than using penile rings for increasing pleasure and sustaining erections, it was done in order to decrease sexual compulsions which were probably caused by intrusive unacceptable or taboo thoughts. Several terms have been used to describe excessive sexual behaviours, including compulsive sexual behaviour, hypersexuality, sexual addiction, sexual impulsivity, and impulsive–compulsive sexual behaviour, therefore, there has not been any universal consensus for a standardised terminology. Some substantial efforts have been made for the formulation of a term which can encapsulate such variations amongst the sea of ambiguous terminologies, one such impactful term being compulsive sexual behaviour disorder (CSBD) which can be described as a condition characterised by a “persistent pattern of failure to control intense, repetitive sexual impulses or urges, leading to repetitive sexual behaviour over an extended period that causes marked distress or impairment in personal, family, social, educational, occupational, or other important areas of functioning.”21 Patients with CSBD commonly report compulsive behaviours, impulse-control difficulties, and substance use.22 3.3% of patients with obsessive-compulsive disorder (OCD) had current CSBD and 5.6% had lifetime CSBD, with a significantly higher prevalence in men than in women.23 Obsessive-compulsive disorder is characterised by obsessions (intrusive thoughts, images, or impulses) which are ego-dystonic as the patient knows they are irrational and its futile to entertain them but despite multiple efforts to curb them, patients give in and that results in compulsions (repetitive thoughts or actions that act to neutralise the obsessions) in order to alleviate the anxiety produced by those thoughts. To summarise, obsessions increase anxiety, while compulsions decrease anxiety. Repetitiveness is a major characteristic of these compulsions, with an increase in tension/anxiety before the behaviour, and a sense of release/relaxation at the time of their implementation.24
In our first case, the 56-year-old patient had those intrusive taboo thoughts of a sexual nature towards his daughter which he initially tried to ward off, but later succumbed, leading to unacceptable compulsions and to physically restrain him to perform those compulsions he took this drastic step of using penile rings in order to inhibit erections and/or acts of masturbation.
On the contrary, our second case, 63-year-old patient, used penile rings out of playful curiosity, which is in accordance with several studies where patients stated that they used the rings to enhance pleasure and to prolong their erection during sexual intercourse.25 Though, certain attributions can be made to hypersexuality but comprehensive psychiatric evaluation and assessment is deemed optimal after emergency management. Around 100 years ago, German psychiatrist Krafft-Ebbing described “pathological sexuality” as a condition similar to that of today’s compulsive sexual behaviour in which a person’s “sexual appetite is abnormally increased and permeates all his thoughts and feelings, allowing of no other aims in life, tumultuously, and in a rut-like fashion demanding gratification without granting the possibility of moral and righteous counter-presentations, and resolving itself into an impulsive, insatiable succession of sexual enjoyments.”26 While Goodman defined “sexual addiction” as a form of behaviour that can function both to provide pleasure and as an escape route from internal discomfort/distress. He characterised it as a failure to control one’s sexual behaviour and the continuation of sexual behaviour despite significant harmful consequences, which is evident here as penile ring entrapment leading to critical injury.27,28 Paraphilia-related disorders associated with help-seeking behaviours included compulsive masturbation (sample prevalence, 69%).29
Hypersexuality is quite misunderstood and misinterpreted, somewhat because of its ambiguous descriptions and varied presentations. Usually, in nascent stages, patients have certain needs and/or wants which gradually snowball into persistent urges and actions of sexual nature, leading to certain risk-taking behaviours, which was the case here, in dire need of emergency management. The disease burden is difficult to estimate as most of these cases go unreported mostly due to shame, embarrassment, and profound stigma associated with them.30 Not just physical and mental health, sexual health is also an integral component of overall health. Due to lack of adequate sex education and awareness, sexual activities become technically and emotionally overwhelming with derogatory perceptions, and hence, it is not uncommon for critical injuries to occur resulting in patients ending up in emergency department for immediate aid. Usually, sexual emergencies comprise only a small percentage of the emergencies in any casualty department, regardless, these emergencies need proper attention and care from teams having doctors from varied branches in order to have a holistic management and a psychiatrist can also be considered as a valuable contribution, but this is a bit far from reality as of now, since India has dearth of both, specialised psychiatrists, and emergency physicians. Sensitisation and training is required for prompt diagnosis and subsequent management, where data collection and sharing is pivotal for certain strategy formulations.31,32
Mindfulness can be considered as an impactful component of successful therapy for patients seeking help for hypersexual behaviour as it will help in devaluating hypersexuality, improving emotional regulation, developing healthier stress coping mechanisms, increasing threshold to act upon desires, maladaptive sexual urges, and impulses.33
CONCLUSION
Penile strangulation is an acute urological emergency that has good outcome if managed early. This injury has been reported across many journals in the form of case reports. Through this article, we aim to stress on the importance of involving a psychiatrist in early consultation, while the patient is still in the hospital. This article should raise the awareness of emergency physicians to understand the psychiatric perspective of this injury and treat it as an Acute Urological – Psychiatric Emergency.
AUTHORS’ CONTRIBUTION
UAM, VS, and PT wrote the original draft and final draft. MK, PG, SA, and HA were involved in data collection and validation. HA contributed to the original draft, conceptualisation and supervision. UK, SHR, and MS contributed to the original draft and editing.
REFERENCES
1. Nelius T, Filleur S. Self-inflicted penile strangulation. Aktuelle Urologie 2010;41(1):64–66.DOI: 0.1055/s-0029-1224690.
2. Hussain HM. A hair tourniquet resulting in strangulation and amputation of penis: Case report and literature review. J Paediatr Child Health 2008;44(10):606–607.DOI: 0.1111/j.1440-1754.2008.01394.x.
3. Singh I, Ansari MS, Nabi G, et al. Chronic progressive penile strangulation with urethrocutaneous fistula—Report of a case. Indian J Surg 2003;65:191–192.
4. Bhat AL, Kumar A, Mathur SC, et al. Penile strangulation. Br J Urol 1991;68(6):618–621.DOI: 0.1111/j.1464-410x.1991.tb15426.x.
5. Singh I, Joshi MK, Jaura MS. Strangulation of penis by a ball bearing device. The J Sexual Med 2010;7(11):3793–3797.DOI: 0.1111/j.1743-6109.2010.01929.x.
6. Detweiler MB. Penile incarceration with metal objects a review of procedure choice based on penile trauma grade. Scand J Urol Nephrol 2001;35(3):212–217.DOI: 0.1080/003655901750291980.
7. Tundidor Bermudez AM. Incarceracion del pene por objeto metalico pesado. Archivos españoles de urología 1998;51(5):483–484.PMID: 9675947.
8. Etetafia MO, Nwajei CO. Successful removal of strangulating metal penile ring using a dental handpiece. BMJ Case Rep 2014;2014:bcr2014205030.DOI: 0.1136/bcr-2014-205030.
9. Greenspan L. Tourniquet syndrome caused by metallic bands: A new tool for removal. Ann Emerg Med 1982;11(7):375–378DOI: 0.1016/s0196-0644(82)80368-5.
10. Schuster G, Stockmal P. Genital incarceration with metal rings: Their safe removal. Techniques in urology 1999;5(2):116–118.PMID: 10458669.
11. McLaughlin T, Coyner W. Removal of a strangulating metal bearing from the penis. J Urol 1989;141(3):617.DOI: 0.1016/s0022-5347(17)40915-3.
12. Schellhammer P, Donnelly J. A mode of treatment for incarceration of the penis. J Trauma Acute Care Surg 1973;13(2):171–173.DOI: 0.1097/00005373-197302000-00013.
13. Nuhu A, Edino ST, Agbese GO, et al. Penile gangrene due to strangulation by a metallic nut: A case report. West African Journal of medicine 2009;28(5):340–342.DOI: 0.4314/wajm.v28i5.55018.
14. Punekar SV, Shroff PR, Vaze ML. An unusual case of strangulation of penis by metal hammer head-(a case report). J Postgrad Med 1978;24(1):58.PMID: 731615.
15. Snoy FJ, Wagner SA, Woodside JR, et al. Management of penile incarceration. Urology 1984;24:18–20.DOI: 0.1016/0090-4295 (84)90379-0.
16. Klein FA, Smith MV. Treatment of incarceration of the penis by tempered steel bushings. J Emerg Med 1987;5(1):5–8.DOI: 0.1016/0736-4679(87)90003-5.
17. McCraw JB, Myers B, Shanklin KD. The value of fluorescein in predicting the viability of arterialized flaps. Plastic Reconstr Surg 1977;60(5):710–719.DOI: 0.1097/00006534-197711000-00006.
18. Bashir AY, El-Barbary M. Hair coil strangulation of the penis. J Roy Coll Surg Edinburgh 1980;25(1):47–51.DOI: 0.1016/S0090-4295(97) 00078-2.
19. Sheinfeld J, Cos LR, Erturk E, et al. Penile tourniquet injury due to a coil of hair. J Urol 1985;133(6):1043–1044.PMID: 3999207.
20. Kyomukama LA, Ssebuufu R, Wani SA, et al. Penile ring entrapment and strangulation: A case report at Kampala International University Teaching Hospital in Western Uganda. Int J Surg Case Rep 2021;80:104982.DOI: 0.1016/j.ijscr.2020.09.080.
21. Kraus SW, Krueger RB, Briken P, et al. Compulsive sexual behaviour disorder in the ICD‐11. World Psychiat 2018;17(1):109–110.DOI: 0.1002/wps.20499.
22. Snagowski J, Brand M. OR-82: Approach and avoidance tendencies in cybersex addiction: Adaption of an Approach-Avoidance-Task with pornographic stimuli. J Behav Addict 2015;4(S1):37–39.
23. Fuss J, Briken P, Stein DJ, et al. Compulsive sexual behavior disorder in obsessive–Compulsive disorder: Prevalence and associated comorbidity. J Behav Addict 2019;8(2):242–248.DOI: 0.1556/2006.8.2019.23.
24. Stein DJ. Classifying hypersexual disorders: Compulsive, impulsive, and addictive models. Psychiatr Clin North Am 2008;31(4):587–591.DOI: 0.1016/j.psc.2008.06.007.
25. Purnell S, Lam P, Lipscombe C, et al. Successful removal of metal rings causing penile strangulation. IOSR J Dental Med Sci 2016;15: 110–113.
26. Krafft-Ebbing R. Psychopathia Sexualis (1886). Translated by Rebman FJ. New York, Physicians and Surgeons Book Co, 1927.
27. Goodman A. Diagnosis and treatment of sexual addiction. J Sex and Marital Ther 1993;19(3):225–251.DOI: 0.1080/00926239308 404908.
28. Black DW, Kehrberg LL, Flumerfelt DL, et al. Characteristics of 36 subjects reporting compulsive sexual behavior. Am J Psychiat 1997 Feb;154(2):243–249.DOI: 0.1176/ajp.154.2.243.
29. Kafka MP, Hennen J. The paraphilia-related disorders: An empirical investigation of nonparaphilic hypersexuality disorders in outpatient males. J Sex Marital Ther 1999;25(4):305–319.DOI: 0.1080/00926239908404008.
30. Dutta E, Naphade NM. Hypersexuality – A cause of concern: A case report highlighting the need for psychodermatology liaison. Indian J Sex Transm Dis AIDS 2017;38(2):180–182.DOI: 0.4103/ijstd.IJSTD_27_16.
31. Rao TS, Kalra G. Sexual emergencies: A psychiatrist’s perspective. In: Emergencies in Psychiatry in Low-and Middle-Income Countries 2017 Jun 13. CRC Press. pp. 124–134.
32. Gaspar SS, Dias JS, Martins F, et al. Sexual urological emergencies. Sexual Med Rev 2015;3(2):93–100.DOI: https://doi.org/10.1002/smrj.44.
33. Reid RC, Bramen JE, Anderson A, et al. Mindfulness, emotional dysregulation, impulsivity, and stress proneness among hypersexual patients. J Clin Psychol 2014;70(4):313–321.DOI: https://doi.org/10.1002/jclp.22027.
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