Successful removal of a penile constriction wedding ring in a rural area.
We report a case of a strangulating penile ring and the challenges faced during attempts at removing it. [1-3]
A 28-year-old man presented to the casualty department of Van Velden Hospital, which is in a rural part of Limpopo Province, South Africa, accompanied by his mother. His penis was severely swollen and blue, and constricted with a ring (wedding ring) at the middle section. The patient reported that he had applied the ring 4 hours previously for erotic reasons, on the recommendation of friends. His wife had delivered 2 weeks ago by caesarean section.
The penis was erect and blue (Fig. 1) and the patient was in severe pain. His vital signs were normal.
The patient was immediately taken to the casualty theatre. We first attempted to use the string method  to remove the ring, with the patient under sedation with ketamine. However, this failed because of excessive swelling. A second attempt at removal was made using an orthopaedic oscillating saw. The ring proved too wide and strong, with limited space due to swelling.
An attempt was then made using an aspiration method.  Multiple puncture aspirations were applied with a 20 mL syringe and a pink needle. The oedema subsided and the ring was successfully removed (Figs 2 and 3). The patient was admitted and treated with broad-spectrum antibiotics and analgesia. Within 3 days he had recovered completely and was discharged (Figs 4 and 5).
[FIGURE 1 OMITTED]
[FIGURE 2 OMITTED]
One month later, the patient was reviewed as an outpatient. He reported full recovery.
Penile strangulation is a rare emergency, but occasionally occurs on a worldwide basis. [4,5]
[FIGURE 3 OMITTED]
[FIGURE 4 OMITTED]
[FIGURE 5 OMITTED]
Bhat et al.  presented an original classification for penile strangulation, as follows:
I. Distal oedema only
II. Distal oedema, skin and urethral trauma, corpus spongiosum compression, decreased penile sensation
III. Separation of corpus spongiosum, urethral fistula, corpus cavernosum compression, no distal sensation
IV. Gangrene, necrosis, or distal penile amputation.
A variety of techniques are available to deal with this emergency:
* String technique
* Cutting technique (may involve nonmedical equipment and personnel) [3,4]
* Aspiration technique
* Surgical techniques (including amputation). 
Aspiration of blood was an effective method for the removal of a wedding ring strangulating a penis that had been applied for erotic purposes. Should it be considered as the method of choice? The doctor should decide on the removal method depending on the case, the settings and available equipment.
[1.] Silberstein J, Grabowski J, Lakin C, Goldstein I. Penile constriction devices: Case report, review of the literature, and recommendations for extrication. J Sex Med 2008;5(7):17471757. DOI: 10.1111/j.1743-6109.2008.00848.x
[2.] Noh J, Kang TW, Heo T, Kwon DD, Park K, Ryu SB. Penile strangulation treated with the modified string method. Urology 2004;64(3)3:591. D0I:10.1016/j.urology.2004.04.058
[3.] Bhat AL, Kumar A, Mathur SC, Gangwal KC. Penile strangulation. Br J Urol 1991;68(6):618-621. D0I:10.1111/ j.1464-410x.1991.tb15426.x
[4.] Snoy FJ, Wagner SA, Woodside JR, Orgel MG, Bordem TA. Management of penile incarceration. Urology 1984;24(1):18-20. DOI:10.1016/0090-4295(84)90379-0
[5.] Detweiler M. Penile incarceration with metal objects. Scand J Urol Nephrol 2001;35(3):212-217. D0I:10.1080/003655901750291980
Accepted 2 June 2016.
A Fhima, (1) MD; N Lahouel, (2) MD, FEBOPRAS, FFCPRAS
(1) Casualty Department, Van Velden Hospital, Tzaneen, Limpopo, South Africa
(2) Department of Plastic, Reconstructive and Aesthetic Surgery, Chris Hani Baragwanath Hospital and University of the Witwatersrand, Johannesburg, South Africa
Corresponding author: A Fhima (firstname.lastname@example.org)
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|Title Annotation:||CASE REPORT|
|Author:||Fhima, A.; Lahouel, N.|
|Publication:||South African Medical Journal|
|Article Type:||Case study|
|Date:||Nov 1, 2016|
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