Penile strangulation due to a metal ring: A case report

Introduction: Penile strangulation is a condition in which a foreign material compresses the penis, resulting in penile enlargement due to a circulatory disturbance. Case Report: A 68-year-old male patient was referred to our hospital in order to undergo the removal of a metal ring that had strangled his penis. The ring was successfully removed using an airtime cutter. His penis showed no ischemic lesions at one week after removal. Conclusion: We herein report a rare case of penile strangulation. (This page in not part of the published article.) International Journal of Case Reports and Images, Vol. 8 No. 7, July 2017. ISSN – [0976-3198] Int J Case Rep Images 2017;8(7):470–472. www.ijcasereportsandimages.com Matsumiya et al. 470 CASE REPORT PEER REVIEWED | OPEN ACCESS Penile strangulation due to a metal ring: A case report Kentaro Matsumiya, Takashi Kawahara, Yosuke Yamashita, Yutaro Hayashi, Kota Shimokihara, Sohgo Tsutsumi, Daiji Takamoto, Taku Mochizuki, Yusuke Hattori, Jun-ichi Teranishi, Yasuhide Miyoshi, Yasushi Yumura, Masahiro Yao, Hiroji Uemura


INTRODUCTION
Penile strangulation is a condition in which a foreign material compresses the penis, resulting in penile enlargement due to a circulatory disturbance [1]. We herein describe a case of penile strangulation due to a metal ring that the patient had worn to the reduce pain of varicocele.

CASE REPORT
A 68-year-old male was referred to our hospital with an enlargement of his penis due to a metal ring. He had been inserting his penis into a metal ring to reduce the pain associated with varicocele for ten years. Three hours before his initial visit, he could not remove this ring and experienced difficulty in urination ( Figure 1). To treat his condition, the patient was referred to our hospital at six hours after penile strangulation. We initially attempted to remove the ring using a ring cutter and wire cutter; however, this failed to cut the ring. We then asked a dental surgeon to cut the ring using an airtime cutter. The ring was successfully cut and removed from his penis (Figures 2 and 3).

DISCUSSION
Penile strangulation is caused when an object compresses the penis. In most cases, the removal of the foreign body is difficult because of priapism in the external penis. Penile strangulation represents an emergency disease, as the compression of the penis for an extended period of time interrupts the blood flow, resulting in penile ischemia [1].
In previous reports, the strangled penile body was divided by soft and hard materials. Rubber and vinyl have been reported as soft materials, while metal rings, metallic pipes, and the tops of PET bottles have been reported as hard materials. Soft materials compress the skin deeply, with ulceration occurring in severe cases. Hard materials first lead to edema rather than ulceration. The duration of strangulation in the previously reported cases has ranged from one hour to ten years [1].
In the present case, the patient had strangled his penis in order to reduce the pain associated with varicocele. Previous reports showed that the reasons for penile strangulation were divided into non-sexual and sexual  purposes. The sexual purposes have included (but are not limited to) improving energy, extending erection time, and enlarging the penis [2]. The duration of strangulation varied according to the reasons. The patients in whom penile strangulation occurred due to non-sexual reasons presented to hospital earlier than the patients in whom the purpose was sexual [3]. In this case, the patient performed penile strangulation for a therapeutic reason. The patient presented to a hospital in the early stage of penile strangulation, after experiencing difficult urination. We have to remind that inappropriate usage of foreign bodies resulting in penile strangulation.
The removal of the object strangling the penis is the most important aspect of treatment in cases of penile strangulation. A previous report suggested that the object can be removed at up to 12 hours without any complications [1]. In our case, the rapid removal might have contributed to the lack of any complications. Instruments that have been used in removal have included pincers, a plaster cutter, a hammer, and a grinder [4][5][6]. However, air turbines for dental use are most frequently used to remove such objects [5]. The top of the air turbine is coated with diamonds and spins at a rate of 400,000 times per minute, which gives it a high cutting ability. Water can be poured to reduce the frictional heat and improve the safety of the procedure-as we did in our case [7]. When standard procedures including the use of a ring cutter fail to cut the object, the use of an air turbine with the assistance of a dental surgeon is sometimes necessary [8]. Followed-up is needed to confirm no ischemia after removal of metallic ring.

CONCLUSION
We herein describe a case of penile strangulation due to a metal ring that the patient had worn to the reduce pain of varicocele. The removal of the object strangling the penis is the most important aspect of treatment in cases of penile strangulation. *********

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