A 12 year old boy developed difficulty in passing urine and history of intermittent retention of urine, due to penile strangulation by a thread applied one year previously.

Corresponding Author: Shah, Safdar. Department of Urology and Haemodialysis, Sheikh Zayed Medical College, Rahimyar Khan. E.mail uro2010@hotmail.com, abeer15@msn.com

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Penile strangulation is a rare injury that leads to a wide range of vascular and mechanical injuries1,2. penile strangulaton was first time reported in literature in 1755 3. The various objects are used for strangulation are metallic, non metallic objects, (strong rubber band, condom ring) which are placed around the penis to enhance sexual performance or for some auto erotic intention 4. Any age can be affected 6, the penile strangulation by a thread or hair is also called penile tourniquet syndrome. The usual presentation of this constriction syndrome is in the form of penile swelling, phimosis, stricture at the base of penis, lymphedema and sign of vascular insufficiency, necrosis (urethocutaneous fistula), to a gangrene (partial or complete amputation of the penis) 5, 6 most of the injuries are either incidental , accidental or intentional in nature 5.
Below is presented a case of long standing chronic penile constriction by a thread leading to urethral constriction and penile swelling and thickening of penile tissue and skin over it.
Case report: A twelve year old boy was admitted in the Urology Department, Sheikh Zayed Medical College/ Hospital, Rahim Yar Khan in March 2009 with complaint of difficult in urine, history of intermittent retention of urine and constant dribbling of urine. There was no other complaint regarding other system. On thorough interrogation the father of boy told that the son had an accident where he applied a thread ligature around the penile shaft a year ago which according to him had disappeared after giving rise to swelling of the penile shaft. On examination vitals were normal, patient was circumcised. The glans penis was normal with normal external urethral meatal opening. There was swelling, thickening and hardening of the mid of the penile shaft and the skin over it was not mobile (Figure 1). Rest of the penile shaft was normal with normal mobile skin. The urinary bladder was palpable and percussable.
All routine investigations were within normal limits. A Foley catheter (10Fr) and a feeding tube (12Fr) was tried but could not be negotiated. At cystourethroscopy there was an annular ring-like constriction of the penile urethra. The scope was passed with some force and dilatation of the annular ring was done by a dilator and a Foley catheter No. 12FR was passed. 200ml of urine was evacuated from the urinary bladder. The penile shaft was operated for the exploration of thread (string) a circular incision was given just over the strangulated band. Skin and fascia was explored, a thick band of fibrous tissue was excised with a string of thread found incorporated and embedded into deep fascia. It was explored and pulled out by a artery forceps (Figure 2). The whole of the fibrous band was excised and corpora cavernosa and spongiosa were inspected which were found to be normal. The cut tunica albuginea was closed with absorbable sutures (Vicryl 3/0). The skin and fascia were closed in layers, the compression bandage was applied over the wound and dressing was reopened after 48 hours. The wound was found to be normal. The patient remained five days in a hospital with uneventful postoperative recovery. Patient was followed in OPD after one week and the Foley catheter was removed on the 12th day postoperatively. The patient had a normal urinary stream and slight penile swelling after two week of follow up.
Discussion: Entrapment syndrome or strangulation of the penis is a well known but uncommon clinical emergency which presents with progressive painless disfigurement of the penis caused by a strand of ligature and thread coiled around the penile shaft 7. Different types of constricting objects
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like wedding ring, metal plumbing with bull ring, hammer and plastic bottle neck have been described 7. Instead of the routine strangulation or amputation the tourniquet sometimes had become embedded into penile tissue leading to growth of exuberant granulation tissue and fibrosis 8. Constriction penile band injury can be managed by either conservative approach or by surgical technique 8, 9. Various surgical techniques are used to approach the defect by either giving a circular incision or by degloving of the penis10. If the condition in acute the treatment is by decompression of the constricted penis. But if the penile constriction is longstanding and chronic, there are chances of incorporation of a tourniquet into penile tissue with granulation and fibrosis development at the initial site of injury 8. In this case, a circular incision was used to explore the site of constriction and removed the thread with preservation of normal penile anatomy.
Figure 1 Showing thickening and swelling at the base of penile shaft
Figure 2 Thread in situ (left) and after removal (above)
References
1. Bhat AL, Kumar A, Mathur SC, Gangwal KC.“Penile Strangulation. Br J Urol.1991 Dec: 68 (6):618-21.
2. XU T, Gu M, Wang H. Emergency management of penile strangulation: case report and review of Chinese literature. Emerg Med J; 2009 Jan; (1): 73-4
3. IvanovskI O, Stankov O, Kuzmanoski M, Saidi S, Banev S, Filipovski V, Lekovski L, Popov Z. Penile strangulation: two case reports and review of literature. J Sex Med 2007 Nov; 4 (6): 1775-80
4. Perabo FG, SteinerG, Albers P. MA1/4ller SC Treatment of penile strangulation caused by constricting devices. Urology. 2002 Jan; 59 (1): 137.
5. Haddad FS. Penile strangulation by human hair , Report of three cases and review of the literature. Urol Int 1982; 37 (6): 375-88.
6. Lopes RI, Lopes SI, Lopes RN. Chronic Penile Strangulation. Int. Braz J Urol. 2003 jul-Aug; 29 (4): 327-9.
7. Shamim M. Progressive Hair Coil Strangulation of Penis. J Coll physicians Surg Pak: 2004. Oct; 14 (10): 636-7
8. Okeke LI. Thread embedded into penile tissue overtimes as an unusual hair thread tourniquet injury to the penis: a case report. Pediat Emerg car,. 2007 Mar,23(3);169-70 .
9. Stoller Ml, Lue TF, Mc Aninch JW. Constrictive penile band injury; anatomical and reconstructive considerations J Urol. 1987 Apr; 137 (4): 740-2
10. Detweiler MB. Penile incarceration with Metal objects a review of procedure choice based on penile trauma grade. Scand J Urol Nephrol, 2001 Jun; 35 (3): 212-7



Date added to bjui.org: 24/10/2009 (publication information)
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CASE REPORTS: Long-standing penile strangulation by a thread leading to urethral constriction

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