|Year : 2016 | Volume
| Issue : 2 | Page : 99-101
Penile strangulation by polyvinyl chloride plastic pipe ring: Case report of sexual perversion
Prasad V Magdum1, Vikram Prabha1, Vikas Sharma1, P Srikanth1, Shridhar C Ghagane2, Ankur Agarwal1, Murigendra B Hiremath2
1 Department of Urology, KLE Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and MRC, Belagavi. Karnataka, India
2 Department of Studies in Biotechnology and Microbiology, Karnatak University, Dharwad, Karnataka, India
|Date of Web Publication||18-May-2016|
Prasad V Magdum
KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and MRC, Nehru Nagar, Belagavi - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
Penile constriction rings are either used for erotic or autoerotic purposes or to increase sexual performance. Various objects, both metallic and nonmetallic, can be used as constricting devices. Potentially, they can become irremovable, resulting in reduced blood flow, leading to edema and, sometimes, gangrene. We report an case of penile strangulation with a polyvinyl chloride (PVC) plastic pipe ring presenting as an urological emergency. It was removed with the help of a dental drill after failed attempts of the use of orthopedic instruments. Management of such cases can be challenging and removal of such objects requires the help of various orthopedic and dental instruments.
Keywords: Constriction ring, dental drill, penile strangulation
|How to cite this article:|
Magdum PV, Prabha V, Sharma V, Srikanth P, Ghagane SC, Agarwal A, Hiremath MB. Penile strangulation by polyvinyl chloride plastic pipe ring: Case report of sexual perversion. J Sci Soc 2016;43:99-101
|How to cite this URL:|
Magdum PV, Prabha V, Sharma V, Srikanth P, Ghagane SC, Agarwal A, Hiremath MB. Penile strangulation by polyvinyl chloride plastic pipe ring: Case report of sexual perversion. J Sci Soc [serial online] 2016 [cited 2020 Aug 13];43:99-101. Available from: http://www.jscisociety.com/text.asp?2016/43/2/99/182609
| Introduction|| |
Penile constriction rings are either used for erotic or autoerotic purposes or to increase sexual performance. Penile strangulation is a rare injury and most require only removal of the constriction and conservative management. The penis can be strangulated by many objects, but, usually, they are rings, nuts, bottles, bushes etc. in an adult, while in children they tend to be rubber bands or threads. In adults, these constricting penile rings, whether metallic or nonmetallic, are placed purposefully by the person himself for masturbation or by the female counterpart to enhance performance.  Many of these adults give a history of alcohol consumption or psychiatric problems. In children, these are used to prevent enuresis and incontinence or placed accidentally while experimenting with objects. These devices occlude penile venous flow; most patients present to the emergency department with penile edema. It is an uncommon emergency in urology, but prompt removal of such objects is of utmost importance; if left untreated, there are potentially dangerous consequences such as gangrene. We report a case that had polyvinyl chloride (PVC) plastic pipe ring as a constricting agent, which was managed successfully with the use of dental instruments. 
| Case report|| |
A 60-year-old male, chronic alcoholic presented with a history of application of PVC plastic pipe ring on his penis to achieve sustained erection and for pleasure enhancement. After sexual intercourse, he was unable to remove the pipe ring and gradually developed increasing penile swelling and pain. With failed attempts of self-removal, the patient came to the emergency department for further treatment. He gave a history of application of such constricting rings in the past for sustained erection. He used to apply bigger size rings, but unfortunately this time under influence, he applied a smaller size ring. This advice of application of penile ring was given by one of his multiple sexual partners. His general examination findings were normal. On abdominal examination, the bladder was not palpable. Local examination revealed a 2 inch PVC plastic pipe ring placed at the root of the penis with significant distal edema and tenderness without any gangrenous changes [Figure 1]. After an initial failed attempt of cutting with the help of stout scissors, the patient was given short general anesthesia and an attempt was made to cut the pipe with a bone cutter. With unsuccessful attempts, and considering hardness of the pipe, the decision was taken to cut it with a dental drill with a diamond burr. After placing a malleable plate between the pipe and the patient's penis to protect the skin, the pipe was slowly cut and removed from the penis [Figure 2]. Following removal, the penile edema began to resolve and no signs of necrosis or damage to the penis were noted. The patient was catheterized. Postoperatively, penile edema subsided [Figure 3]; the catheter was removed and the patient was discharged after proper psychiatric evaluation and counselling. On follow-up, penile edema subsided completely and the patient had no erectile dysfunction.
|Figure 1: (a) Clinical photograph showing 2 inch PVC plastic pipe ring being placed at the root of the penis with signifi cant distal penile edema without ischemic changes (b) Ventral view showing the constricting ring with multiple marks of cutting the ring|
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|Figure 2: (a) Photograph showing attempts being made to cut the PVC plastic pipe ring with the help of a bone cutter (b) Photograph showing the constricting ring being cut with the help of a dental drill with a diamond burr with a malleable plate being placed between the pipe and the penis (c) Visible constricting marks after removal of the constricting ring|
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|Figure 3: (a) Postoperative clinical photograph showing subsiding penile edema without any obvious skin injury (b) Follow-up image with completely subsided edema|
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| Discussion|| |
Various metallic and nonmetallic devices, including finger rings, metallic nuts, and plastic bottles, retaining rings, hammerheads, and rubber bands have all been described to have caused strangulation to the male external genitalia in medical literature. ,, These constricting devices may impede the venous and lymphatic return causing distal edema of the external genital that eventually leads to ischemia. There are numerous reports of penile strangulation in medical literature. ,,,,,,, In most cases, the act is performed to initiate and sustain erotic stimulation.  The constricting effect of the foreign body increases the engorgement of the penis. The subjects' inability to realize that the resulting edema of the penis will prevent normal removal of the ring, often leads to hospitalization with great discomfort. In reported cases of penile strangulation, many required special equipment and heavy armamentarium for the offending object to be extricated. ,,,, Equipment used included an iron cutter, orthopedic, and dental drills equipped with diamond tips. In a few cases, the corpus cavernosum had to be aspirated so that the tumescence could be reduced to allow for the easy removal of the foreign body. , Another ingenious method has been described, where the constricting object is removed by manual decompression of the penis. , In the report by Gupta et al., the penis was compressed by an intravenous drip set tube applied circumferentially, starting from the tip of the penis to its base in order to act as an even, compressive tourniquet, eventually allowing for the removal of the strangulating object. Local and systemic complications can occur in penile strangulation. Local complications can be minor; they include venous engorgement due to impaired venous backflow, and prolonged pressure leading to necrosis of penile skin that may require skin grafting. More significant local complications include penile gangrene from prolonged vascular ischemia that may require amputation, and the formation of urethrocutaneous fistula.  Systemic complications are less well-documented in medical literature. Renal impairment as one of the complications has been noted by Huang et al.  As the patient might be shy of telling this problem or the patient might be mentally abnormal, they may present late and have severe injury.
Bhat et al. (1999) graded these injuries as follows: 
Grade I: Edema of the distal penis. No evidence of skin ulceration or urethral injury.
Grade II: Injury to the skin and constriction of corpus spongiosum but no evidence of urethral injury. Distal penile edema with decreased penile sensation.
Grade III: Injury to the 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 cavernosa with the loss of distal penile sensation.
Grade V: Gangrene, necrosis, or complete amputation of the distal penis.
Our case had a grade I injury and required only the removal of constricting device. But more severe cases may require diversion of urine by placing suprapubic cathether (SPC), urethral reconstruction, degloving, and skin grafting, or sometimes, amputation. With the help of dental instruments, we could remove the constricting ring, preventing further complications.
| Conclusion|| |
Penile constriction rings are used for erotic or autoerotic purposes or to increase sexual performance. Potentially, they can become irremovable, resulting in injury to the penis. If treated early, consequences such as penile gangrene and erectile dysfunction can be prevented. Removal of these devices can be challenging and often requires resourcefulness and multidisciplinary approach. Proper psychological evaluation and counselling is required.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bhat AL, Kumar A, Mathur SC, Gangwal KC. Penile strangulation. Br J Urol 1991;68:618-21.
Ehikhamenor E, Ibhawoh L, Oboro H, Umanah A, Osaigbovo E, Chiedozi U. Unusual dental practice: An encounter with penile strangulation: A case report. J Med Medical Sci 2011;2:832-5.
Perabo FG, Steiner G, Albers P, Müller SC. Treatment of penile strangulation caused by constricting devices. Urology 2002;59:137.
Gupta SP, Raiger LK, Sharma V, Maheshwari R. Penile strangulation by metallic rings. Bombay Hosp J [serial online]. 2005; 47.
Huang JK, Holt D, Philip T. Penile constriction by foreign bodies: The use of a dental drill. Br J Urol 1997;79:801.
Jain S, Gupta A, Singh T, Aggarwal N, Sharma S, Jain S. Penile strangulation by a hard plastic bottle: A case report. Indian J Surg 2004;66:173-5.
Kimber RM, Mellon JK. The role of special cutting equipment and corporeal aspiration in the treatment of penile incarceration with a barbell retaining collar. J Urol 2004;172:975.
Kore RN, Blacklock AR. Ring the fire brigade. Br J Urol 1996;78:948.
McGain F, Freedman D. Penile entrapment in a bottle: The case for using a diamond-tipped portable glass saw. BJU Int 1999;83:1071-2.
Noh J, Kang TW, Heo T, Kwon DD, Park K, Ryu SB. Penile strangulation treated with the modified string method. Urology 2004;64:591.
[Figure 1], [Figure 2], [Figure 3]