Strangulation of the penis is a rare condition that requires emergency management. Several objects, metallic or not, can be placed on the penis to increase sexual performance or for self-erotic intentions especially in psychotic patients with unusual sexual impulses. The problem of removing the foreign body and repairing the damage is a real challenge for the practitioner and a great stress for the patient. We report a case of a 42-year-old schizophrenic patient who presented to the emergency department for a strangulation of the penis secondary to a metal ring placed at the base of the penis 10 days before the consultation without urinary disorder. A review of the literature allowed us to highlight the different clinical pictures of penis strangulation and the therapeutic methods and to highlight the importance of psychiatric care of sexual behaviour in chronic psychotics.
Schizophrenic patients frequently have very poor interpersonal relationships. Disability comes from the association of different psychic symptoms that disrupt interactions with others and inevitably influence their sexual life. The erroneous perception of the external genital organs, decreased libido, and erectile dysfunction due mainly to neuroleptics can lead these subjects to unusual sexual practices such as self-mutilations or, as in our case, putting a ring at the base of the penis.
We report a case of strangulation of the penis by a metallic ring. The therapeutic circumstances and approach are given in detail in this work.
A man, aged 42, who is single, schizophrenic, and under neuroleptic and anticholinergic therapy (chlorpromazine, haloperidol, and trihexyphenidyl), presented to the emergency department with his brother to consult for strangulation of the penis by a metallic ring placed at the base of the penis 10 days before for self-erotic stimulation.
The clinical examination found a bluish edema with blisters and ulcers on both sides. The glans was engorged and cyanosed, with a total loss of sensitivity. There was neither urethral fistula nor urinary disorders associated. The patient was calm without any signs of anxiety.
Attempts to remove the ring by lubrication, clamping, and then a manual saw were unsuccessful. We have made a section of the metallic ring by an angle grinder. A wooden tongue depressor was inserted between the penis and the ring and permanent cooling with physiological serum was performed (Figure
Different materials used for cutting the metal ring incarcerated in the root of the penis.
The sequences were marked by suppuration of the cutaneous lesions (24 hours after removal of the metal ring) (Figure
Condition of the penis before and after removing the ring.
The diagnosis was made of wet gangrene and the patient was given piperacillin, metronidazole, and amikacin with local care.
After the end of the antibiotic treatment and drying of the lesions, the patient was addressed to psychiatry. The penis was swollen, blackish, and insensible. The patient was not seen again.
Incarceration of genital organs is a rare clinical fact, which poses little diagnostic problem. However, the objective is to find the best method for the ablation of the metal and to appreciate the importance of the damage caused. It is a rare global phenomenon and a circumstantial pathology that most urologists encounter not more than once in their practice.
According to many authors, the incarceration of genital organs in adults is the result of self-erotic acts whose goal is to prolong the erection and delay ejaculation and sometimes to increase manhood (supernatural effect) [
The principle of the treatment is simple: it is the rapid decompression of the penis to allow a good vascularization of the tissues. On the other hand, the choice of the therapeutic method is a real challenge for the urologist given the great number of ring types used and the variability of the lesions [
To facilitate the therapeutic decision, Bhat et al. have developed a simple classification of trauma by strangulation of the penis [
Several therapeutic varieties are proposed to take care of this type of lesions but the choice remains difficult given the unusual nature of this trauma. This choice can be directed by the grade of the lesions [
The first step is relief of urinary retention by transurethral catheterisation for grades I and II [
The main therapeutic techniques are grouped into 4 categories [
After the urgent removal of the obstacle, a psychiatric care is necessary [
Strangulation of the penis is a rare trauma that requires management in the first few hours. We think that this type of accident in psychotic patients has a bad prognosis in consequence of the delay of the consultation and the high risk of recurrence for lack of psychiatric care of their sexual disorders. We believe that the prevention of this accident by a more cautious psychiatric care is better than curing such a dangerous trauma.
The authors declare that they have no conflicts of interest.