What Is the Best Way to Wear a Penis Ring on Your Penis

• Periodical List
• Urol Ann
• five.12(one); Jan-Mar 2020
• PMC6978966

Urol Ann. 2020 Jan-Mar; 12(i): 15–18.

Penile ring entrapment – A true urologic emergency: Grading, approach, and management

Omar Dawood

Section of Urology, Southern Illinois Academy School of Medicine, Springfield, IL, United states

Seena Tabibi

Department of Urology, Southern Illinois University School of Medicine, Springfield, IL, USA

Julia Fiuk

Department of Urology, Southern Illinois University School of Medicine, Springfield, IL, USA

Neil Patel

Department of Urology, Southern Illinois University School of Medicine, Springfield, IL, The states

Ahmed El-Zawahry

Department of Urology, Southern Illinois Academy School of Medicine, Springfield, IL, USA

Received 2019 Feb 4; Accustomed 2019 Sep xxx.

Abstract

Penile rings are used to sustain erection in order to enhance sexual pleasure. They work by reducing the outflow of claret from the cavernosal tissue. However, if left for extended periods of time severe edema, urethral fistula, gangrene, and fifty-fifty consummate loss of the distal penis can ensue, this is known as penile ring entrapment (PRE). Management poses detail challenges due to its rarity. Herein, we report our experience with three patients from our institution that presented with PRE and include a review of the approaches others have taken. Nosotros too suggest a simpler and more effective grading scale to allow for easier communication between providers, as the current grading scales do not practise so.

Keywords: Ischemia, penis, scrotum, trauma, urethra

INTRODUCTION

Since ancient times, penile rings have been used to heighten sexual pleasure. They work by constricting the outflow of blood from the penis, prolonging erection.[1,two,3] Different materials such as rubber bands, wedding ceremony rings, hammerheads, bullrings, and plastic bottlenecks have been used.[3,four] Regardless of the material used, constriction should be no longer than 30 min.[v] Prolonged constriction leads to astringent ischemia and edema. If left unresolved, the penis volition get necrotic and will somewhen self-amputate. Urgent intervention is vital. Different treatment options have been elaborated. Nosotros written report our experiences, treatment methods others have taken, and propose a newer grading scheme that volition let clinicians to swiftly and efficiently communicate the severity of this condition.

METHODS AND PATIENTS

We performed a retrospective review of charts from our institution from September 2012 to September 2018, identifying patients who presented with penile ring entrapment (PRE). Nosotros looked at patient characteristics, pattern of presentation, blazon of entrapment, and treatment. We besides did a review of the literature to place other handling approaches for PRE.

RESULTS

Nosotros identified iii patients who presented at our institution with PRE.

The first patient is a 60-year-quondam Caucasian male person who presented with a ring effectually his scrotum and penis for 48 h. He had excessive scrotal and penile edema with minimal bruises at the ring location. Initial attempts to reduce scrotal and penile swelling by compression (in club to slide the ring off easier) failed. Next, we gave anesthesia for comfort and then applied olive oil around the penis and scrotum every bit lubrication to assistance with sliding. A natural language blade was inserted between the ring and penis to protect underlying tissues during sliding. Continuous compression was practical until the edema decreased enough for the ring to slide off. We were successful and all soft tissues appeared feasible.

The second patient is a 28-year-old Caucasian who presented with a thick and broad wedding ring around the base of operations of his penis for >12 h [Effigy 1]. Several attempts to remove the band in emergency department at two dissimilar hospitals failed, and finally, he was referred to our institution. He had extensive bruising and edema of the penile shaft distal to the ring. The shaft of his penis was Number on exam. Our initial attempt (with the patient under conscious sedation) to slide the ring off with compression and lubrication failed. The patient experienced such discomfort, for which general anesthesia was then induced. Nosotros and then attempted needle aspiration and a release incision to decompress the corpora and decrease the swelling; still, this was not enough. Ultimately, we used a diamond-tipped Midas drill from the hospital engineering section to split the ring in half. During this procedure, a metal ruler and cold-h2o irrigation were used to protect soft tissues and prevent thermal injury. After band removal, we performed flexible cystoscopy to dominion out urethral injury. Information technology revealed extensive urethral bruises, for which we placed sixteen French Foley catheter [Effigy ii]. The patient recovered and showed improvement at follow-up.

Patient 2 earlier treatment

Patient 2 after treatment

The tertiary patient is a 42-year-sometime Caucasian male person who presented with a metallic washer pushed to the base of the penis. There were extensive bruises and edema distal to the washer. Attempts at twisting the ring off with lubrication were unsuccessful. Next, a vice clamp and Dremel tool were obtained from hospital maintenance. The ring was meticulously sawed in half every bit wet gauze and a tongue depressor were used as a barrier to protect the peel. Vice clamps were used to stabilize the ring. There was not any evidence of nother tissue injuries.

DISCUSSION

A penile ring is typically used to restrict the outflow of claret from the penis to prolonged erection and raise sexual pleasure.[1,ii,3] Wearing the ring for extended periods of time volition atomic number 82 to penile ischemia and strangulation. Somewhen, the patient volition experience severe edema, necrosis, urethral fistula, gangrene, penile amputation, and even expiry.[6,seven]

Patients tend to nowadays late in their status due to embarrassment.[6] Our feel was similar; unfortunately, delaying clinical intervention results in increased risk of the same complications of PRE.[eight]

The primary goal of management in these cases is to restore claret supply to the penis while preserving the integrity of penile and urethral tissue. Success depends on what method is used to remove the ring. There are multiple treatment approaches (sliding, cutting, and surgery) that take been reported in the literature; surgeons take used different tools depending on what is at their disposal and their experience [Table 1]. Cystoscopy may exist performed afterwards the intervention to assess the level or urethral injury.

Table 1

Summary of case reports on penile band entrapment

Reference	Age	Description of penis	Duration, ring material	Treatment method
Our patient-1	threescore	Penis and scrotum, with edema	2 days, metal	Olive oil was applied and ring was slid off
Our patient-two	28	Penis, marked edema with bruise	12 h, metal	Band was cut past diamond tip Midas drill
Our patient-3	42	Penis, edema	Metal	Ring was cut via dermal tool using
Sawant et al.[3]	70	Penile edema without gangrene	two months, condom	Rubber band was cutting
Sawant et al.[3]	23	Penis, with distal edema and circumferential ulcer	24 h, rubber	Band was cut
Sawant et al.[3]	42	Mid penile shaft band with distal edema	18 h, metal	Band was cut using stout pair of scissors
Sawant et al.[iii]	35	Base of penis, with marked penile edema	4 days, metallic	Ring was cutting by K-wire cutter
Alkhureeb[one]	30	Base of penis, penile edema, urinary retention	viii h, metallic	Os cutter- fail Lateral corporotomy (surgery) to reduce edema, then ring was slid distally to the glans, then using proline 0 on glans, ring was removed
Nuhu et al.[ii]	60	Penis, consummate penile gangrene	1 day, metal nut	Cystotomy and penile amputation with perineal urethrostomy (surgery)
Paonam et al.[9]	47	Penis, marked edema	2 days, metal	Band was cut by micrometer bicycle-shaped bur
Nason et al.[ten]	Not specified	Penoscrotal edema	7 h titanium	Bone cutter - neglect Fire brigade department used an electric axel driver to cut the ring
Liu et al.[eleven]	Non specified	Preputial edema	Unknown time, PET bottle	Bottle removed with persistent suture traction and lubrication (sliding)
Sharma et al.[4]	37	Edema, areas of discoloration almost base of penis	5 days, metal	Ring was slid over penis by applying gentle traction over pare
Patel et al.[12]	43	Edema of penis and scrotum	one mean solar day, metal	Industrial commodities cutters to cut the ring
Agu et al.[6]	26	Penile shaft edematous, mildly tender, cold, sensate, and engorged	23 h, stainless steal ring	Penile shaft made slippery with salvon and advanced forward via sliding
Wu et al.[13]	45	Ring placed at base of genetalia, all-encompassing penoscrotal edeam	48 h, metal ring	Ring slide off with vascular slings
Sathesh-kumar et al.[14]	50	Root of scrotum, penoscrotal edema	ii days, metal band	Ring cutting with pedal cutter from fire department
Patel et al.[15]	45	Not mentioned	6 months, ii metal-ringed hose clamps	Wire cutters from the orthopedic set were used to cut the metal clamps
Baruah et al.[16]	17	Gross penile edema with impaired penile sensation distal to ring	17 h, metallic ring made of blend	Ring was slide off
Geraniotis[17]	45	Penis was incarcerated at base of penis	1 week, Barbell retaining (steel) band	Gas driven nonsurgical drill used to cut the ring

Treatment options

1. Sliding: Sliding should be used equally an initial approach. This is the safest fashion to preserve underlying tissue. Diverse lubricants have been reported such every bit Salvon and even olive oil. If the band is slid, the surgeon must beginning compress the edematous tissue and then provide traction. This method was reported to be successful past other authors.[4,6,11,xiii,16] We performed this method and were successful with one of our patients. However, we were unsuccessful in two of our patients. This method is safest and quickest but clearly is not suitable for all cases

2. Cutting: Cut seems to exist the next suitable selection later on sliding has been attempted. Cutting appears to be a highly sought out method past many surgeons.[3,9,10,12,14,15,17] Diverse tools have been used to cutting the ring such as a micrometer wheel-shaped bur, stout scissors, M-wire cutter, DerMel, bone-cutting clamp, and an electrical axel driver.[3,9,10] Nosotros successfully used a diamond-tipped Midas Drill and Dremel tool. However, if cut is sought out, it is very important to protect the underlying tissue from mechanical and thermal injury. Nosotros used cold saline irrigation to forbid thermal injury and a natural language depressor to protect the pare and underlying tissue

3. Surgery: With failure of other approaches, surgical options may be needed. Lateral corporotomy to release edema and facilitate subsequent removal with lubrication, as performed by Alkhureeb et al., is one surgical approach.[i] We resorted to a limited surgical approach in society to drain fluid from the corpora and pare, our thinking was this would permit the penis to go more compressible. All the same, we plant this to be of picayune help. Nuhu et al. experienced and extreme case of penile gangrene and preformed a cystotomy and perennial urethrosotomy.[2] Fortunately, nosotros did not experience such an intense and rare case.

Grading of penile entrapment

There are different classifications of penile entrapment that have been reported [Table 2]. Sawant et al. embrace a grading system originally described by Bashir and El-Barbary, which focuses on the consequences of penile strangulation and urethral injury non easily visible past exam.[3,xix] Another grading arrangement published past Bhat et al. utilizes penile sensation in its nomenclature. This, however, could exist misconstrued by patient feet and delivery of anesthesia by other providers prior to urologic assessment.[18] Regardless, both require detailed data that would be obtained accurately subsequently the intervention.

Tabular array ii

Summary of grading system

System	Grade 0	Grade 1	Form 2	Grade three	Grade 4	Grade five
Sawant et al.[3]	No urethral injury	Partial division of corpus spongiosum + urethrocutaneous fistula	Complete division of corpus spongiosum + constriction of corpus cavernosum	Gangrene and amputation
Bhat et al.[eighteen]		Edema distal to penis	Grade i + decreased distal penile sensation	Grade 1 + loss of distal penile sensation	Class 3 + complete separation of corpus cavernosa	Gangrene or amputation
Ours		Superficial injury with distal edema	Injury to corpora or urethra	Gangrene, amputation, fistula, or separation of corpora

We are proposing a revised grading system that is simpler to communicate, effective, and more pertinent to the problems surrounding PRE. Course 1 is superficial tissue injury with distal edema. Form ii is whatever deep tissue injury involving the corpora or urethra assessed by examination, and Course iii is tissue loss, gangrene, separation of the corpora, or fistula. This grading scale is uncomplicated, depends mainly on clinical examination, and is easy to adopt by any emergency doctor or urologist.

Conclusion

PRE is a rare, truthful urologic emergency that can lead to penile amputation. Management should be urgent and directed toward removing the ring while protecting underlying tissue. Handling is based on the severity of the presentation and the tools at the physician's disposal. A grading system is helpful in communicating the caste of injury betwixt health-care providers, but it is necessary that it is unproblematic, quick, and easy to communicate. We feel we accept achieved this goal.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/accept given his/her/their consent for his/her/their images and other clinical data to be reported in the journal. The patients empathize that their names and initials volition not exist published and due efforts will be fabricated to muffle their identity, just anonymity cannot be guaranteed.

Fiscal support and sponsorship

Zippo.

Conflicts of interest

There are no conflicts of interest.

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