Strangulation Induced Penile Gangrene in a Mentally Challenged Person

INTRODUCTION

Penile strangulation is an uncommon surgical emergency that arises from self-injury, mistakes involving circumcision, attacks, or interactions with animals. Various materials are utilised in penoscrotal constriction devices, which are used for autoeroticism or prolonged erections. On the other hand, penile strangulation is an uncommon urological emergency that requires immediate attention to avoid permanent damage. The main objective is the timely removal of foreign objects, which is frequently difficult and calls for creativity and a multidisciplinary approach.^[1]

A rare urological emergency called penile strangling is caused by the trapping of a foreign item, which can limit blood flow and possibly cause necrosis. In order to avoid serious consequences such as sepsis or gangrene, prompt care is essential.^[2] Age-group-specific incidents range from hair tourniquets in paediatric instances to self-applied objects, such as metallic items or plastic bottles, in adult cases, which are frequently connected to wishes for sexual enhancement or curiosity.^[3] Most of the time, imaging is not necessary while performing penile amputation as a surgical emergency.^[4] The goal of treatment is timely removal, which is complicated and calls for a multidisciplinary approach.^[5,6] This paper provides an overview of our urethral reconstruction experience following a singular instance of penile gangrene brought on by self-strangulation.

CASE REPORT

A mentally challenged 25-year-old boy was admitted to our hospital with a possible case of penile gangrene. Several rubber bands with adhesions in the base of the penis were discovered during an inspection of the external genitalia, which resulted in the constriction ring and strangulation of the penis [Figure 1]. The penis was chilly, sensitive, and oedematous in the area distal to the band. The area around the constriction band was flowing with urine [Figure 2]. In the emergency department, the rubber bands were removed right away. A neglected youngster had a persistent case of strangulated penile gangrene, and the boy was unable to cooperate with his parents. No blood flow with gangrenous alterations was seen in the entire penis on imaging. He underwent a total penectomy, bilateral orchidectomy, and urethroplasty. Postoperatively, we kept him on a silicone catheter for 4 weeks, and on follow-up, no complications were noted.

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Figure 1:

Rubber band piece at the base of the penis.

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Figure 2:

Gangrenous penis with constriction band around it.

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DISCUSSION

The most popular strangulation in the paediatric population, with a mean age of 7.5 years, was listed in the first publication on this ailment. Penile amputation is an uncommon and difficult injury; it is treated as an emergency, much like other severe penile injuries such as penile fractures, penetrating penile injuries, and penile soft tissue injuries.^[7] Penile strangulation or incarceration is frequently caused by applying constricting objects, such as iron rings or rubber bands, to the penis. This can result in severe swelling, skin ulcerations, and necrosis.^[6] The first course of treatment usually is removing the object and then fixing any damage.

Based on their treatment of eight patients, Bhat et al. developed a five-point grading system for penile strangulation injuries.^[5] The distal penis could have oedema ranging from grade 1 (no urethral damage or skin ulceration) to grade 5 (gangrene, necrosis, or total amputation of the distal penis).^[5] The limited sample size may have contributed to the lack of widespread adoption of this grading system.

Placements of strangulation agents made accidentally or out of curiosity were restricted to the paediatric population. The elderly group was the only demographic to receive strangulation agents for incontinence. In this instance, a urethral tear and non-viable corpora spongiosum muscles necessitated a penectomy along with bilateral orchidectomy and urethroplasty.^[8]