Keywords
penile ring - impacted - pliers - metallic rings
Introduction
A penile ring stuck in the penis is a medical emergency uncommonly seen in an emergency department. These rings are inserted, by especially psychiatric patients, for self-stimulation and masturbation. Prompt management is crucial to prevent penile gangrene. We present a rare case report with a penile ring stuck in the penis that was timely managed.
Case Summary
A 39-year-old married male presented to emergency services with complaints of penile swelling, penile pain, and impacted ring for 1 day. He had no significant past psychiatric history. He was under the influence of alcohol, when for sexual gratification he had inserted a ring from a chain to his penis. He got an erection but started having pain and engorged penis. He tried to remove the ring but failed to do so. He waited for the resolution of penile engorgement for 6 hours, but did not get relief from swelling. He came to the hospital emergency department with a tense and turgid penis. A gentle attempt was made to remove the ring; however, all efforts were in vain. An intravenous line was set up, and the patient was given analgesics, sedatives, and antibiotics. The ring was made of steel, with a thickness of 3 mm, and the internal diameter of the ring was 2.5 cm. Ring ends were overlapping and were tightly fitting at the coronal sulcus leading to pain and swelling of the glans ([Fig. 1]).
Fig. 1 (A) Impacted penile ring, (B) penile ring loosened, and (C–D). removed penile ring.
With the help of two metallic household pliers, ends of metallic rings were separated and the ring was removed. The swelling subsided after the removal of the ring. Psychiatry consultation was taken. The patient was placed on antibiotics and analgesics and was discharged home after 36 hours with no adverse effects. He followed for 12 months with no short- and long-term complications.
Discussion
Articles made of plastic, metal, and rubber bands are used by some people to achieve erection and orgasm by constricting penis. Strangulation of the penis can be caused by materials such as thread, hair, a rubber band, wedding ring, engine bearing, hammerhead, bull ring, plastic bottle, or metal plumbing cuff, with each requiring a different type of cutting device. Intentional use of articles or devices including metallic rings to enhance sexual performance and orgasm is not uncommon. These articles cause constriction of the penis leading to decreased venous flow and helping to achieve a penile erection and maintain it. Patients having erectile dysfunction use these devices to attain and sustain the penile erection. Young males as well as psychiatric patients use these to achieve sexual pleasure. Sometimes these devices could not be removed after insertion. If left untreated, it may lead to ischemia, necrosis, and sometimes autoamputation of the penis. Complications reported are urinary retention, distal hypoesthesia, ulceration, desquamating epithelium, urethral stricture, urethral fistulas, priapism, gangrene, and amputation. These patients usually present late due to shame and regret, especially in India.[1]
[2]
Cutting is the most common method described for the removal of these rings. Nonmetallic and thin objects are easy to remove. Metal objects are difficult to remove. Appropriate cutting tools may be difficult to obtain, especially in emergencies. The process of removal of these rings is time-consuming with the possibility of iatrogenic penile injury. Several techniques have been described to remove these rings: ring cutters, plumber Hackshaw, pliers, string method, dental cutter, etc. However, if the penis is gangrenous, necrotic, or other modalities have failed, degloving or amputation of the penis may be indicated contingent on the extent of devitalized tissue.[3]
[4]
Our patient, a middle-aged male with no history of psychiatric illness having an erectile disorder, placed a metallic penile ring to achieve sexual stimulation. The ring got stuck, and he developed penile swelling and pain. We removed the penile ring with household pliers ([Fig. 2]).
Fig. 2 Management of impacted penile ring.
Conclusion
Penile constriction devices impacted in the penis is a true emergency. Removal of these constriction devices is tricky. Timely removal prevents penile complications. Follow-up of the patients and treatment of the associated disorder, erectile disorder or psychiatric disorder, is a must. The counseling of these patients to prevent further use of constriction devices is crucial and foremost.
