1. Penile Gangrene as complication of penile rings
Faraj Alkizim, Daniel Kanyata
Moderators Dr J Githaiga, Prof. J Oliech
Good afternoon, I am Dr Kanyata. I will attempt to discuss penile incarceration after that excellent case presentation by Dr Alkhazim

2. Incidence An urological emergencies
About 60 cases reported to date of penile incarceration
Concurrent penile scrotal incarceration has been described
Darby J. Cassidy, Genital incarceration: an unusual case report. Can Urol Assoc J. Jun 2010; 4(3): E76–E78.
Penile incarceration is a rare urological emergency, and there are about 60 documented cases in literature today. Penile scrotal incarceration is an even more rare diagnosis with only three documented cases. It is a problem that has plagued even earlier civilisations with the first documented case being in the 17th century.

3. Age 14 yrs.- 54 yrs. (largest case series Darkin 1948)
Case reports on 64 yr. old and 70 yr. old reported.
Paediatric cases youngest being 3 yrs.
Has been described in all geographic regions
Bhatt AL, Kumar A, Mathura SC, Gangwal KC. Penile Strangulation. Br J Urol 1991;68:618-21
Ivanovski et al. Penile Strangulation: Two Case Reports and Review of the Literature. J Sex Med 2007;4:1775–1780
Singh B, Kim H, Sander H. Strangulation of penis by hair. Urology 1978;11:170–2
The largest case series to date was by Darkin in the USA where he found the age spread of his patients was However cases in the geriatric age group have been described and also a child as young as 3 years by Singh in India.

4. Predisposition Populations that use penile rings including
Novelty seekers(Erotic reasons)
Erectile dysfunction
Psychiatric illness especially schizophrenic
Paediatric population, enuresis
penile enlargement kit.
By far novelty seeking for erotic and autoerotic purposes is by far the most prevalent predisposing factor. This is so especially is used concurrently with recreational drugs.
Patient s with erectile dysfunction and psychiatric illness, physical handicap, also are a propped predisposing factors
In paediatric population enuresis was a predisposing factor. In fact firm 1 is currently following a patient who developed a fistula after advice from his teachers that he should tie a string around his penis to prevent bed wetting. Name and Ip number of the patient
Our patient was unusual in that he was originally using it for penile enlargement purposes.

5. Pathophysiology Normal Physiology of the tumescent Penis
Divided into two zones
High pressure
Low pressure
Literature on the physiology of the male penis mostly dwells with how it achieves an erection, however there is little literature on how it functions while tumescent. While tumescent the penis is divided into two zones and high pressure zone and a low pressure zone.

6. Pathophysiology-2 High pressure zone Tumescent function
Bound by tunica albuginea
Bulbourethral artery and deep/cavernosal artery
Compression of sub-albugineal venous plexus reduces venous drainage of the corporas
Suprasystolic pressures by bulbospongiosum and ischiocavernosus
The high pressure zone serves the tumescent function and is bound by the tunica albuginea. It consists of a pair of corpora cavernosa fused in the midline intercavernous septum, a consequence of embryologic fusion of the genital bud and a single ventrally placed corpus spongiosum.(development?) This bound by the tunica albuginea a tough fibrous sheath are served by the deep/cavernosal artery and the bulbourethral artery respectively.
Relaxation of the sinusoids gradual increases the volume of the penis and as the penis increases the compression of the sub-albugineal venous plexus resulting in venous congestion
At the full erection stage as this is called the ischiocavernosus muscles and bulbospongiosum muscles contract reflexively and suprasytolic pressures

7. Arterial Blood supply

8. Crossection of the penis
This shows the blood supply to the corpus cavernosus and the corpus spongiosum fro the penile artery. The crossection illustrates how the tunica albuginea surround these bodies. The tensile strength of caderevic tunic albuginea is about 1500 mmHg when measured by a tensionmenter or half that if saline is infiltrated from the inside. It requires about 1kg/cm2 to stretch it. Thus it is a strong tunic around the corporas.
The ischiocavernosus muscle and bulbospongiosum arise from the perineal body and perineal membrane they attach around and onto the tunica albuginea on the outer surface. When they contract they constrict the corporas increasing the pressure beyond systolic.

9. Veno-occlusive mechanism
Central and peripheral parasympathetic impulses induce acetylcholine release at the nerve ends, the endothelial capillary cell secrete nitrous oxide, 2nd messenger using calcium to induce the relaxation.

10. Suprasystolic pressure

11. Pathophysiology-3 Low pressure zone Lies outside the tunica albuginea
Arterial supply by Dorsal artery.
Nutritive branches to all entities of the penis
All the drainage venous channels lie in this zone
The low pressure zone includes all the layers outside the tunica albuginea.
Skandalaskis reckons that the deep dorsal vein is also compressed by the fact that it lies in the space between bucks fascia and the tunica albuginea on to which it is tightly adherent and the main nutritive drainage is by the posterior inferior system comprising the bulbar (BV), cavernous (CaV), and crural (CrV) is the main nutritive drainage.

12. The dorsal artery is shown as the terminal artery of the penile artery
The dorsal artery is shown as the terminal artery of the penile artery. It does not penetrate the tunica albuginea and it lies in a cave formed by the splitting of bucks fascia, the deep layer of the penis, which is a continuation of the outer sheath of ischiocavernosus and is intimately attached to the tunica albuginea.
It provides nutritive branches to all entities of the penis including the corporas, urethra and then supplies the bulb. Skandalaskis reckons it provides most of the supply to the glans. It also has no anastomosis with the deep and bulbourethral arteries thus the integrity of the high pressure zone is maintained during erection.

13. Venous channels
The venous drainage is mostly by what is described by the poster inferior system of veins all lying in this area. This low pressure zone therefore serves nutritive and drainage functions

14. Pathophysiology-4 Placed at base of the penis.
Penis rings , man’s best friend/enemy
Ring functions as a incomplete tourniquet
Convert low pressure zone to a high pressure zone
Trapped blood-depleted of oxygen/nutrients.
Penile rings therefore turn the low pressure zone into a high pressure zone by functioning as an incomplete tourniquet.
There is a gradual extravasation of fluid into the intestinal space however most of this increase is in the tissue beyond the bucks fascia
This is due to the high tensile strength of the tunica albuginea.
The nutritive function of the dorsal artery and the drainage function of the poster inferior complex of veins is interfered with and this causes pathology.

15. Pathophysiology-5 Impairs nutritive and drainage functions.
Penile cells –hypoxic/anoxic –death
Oedema of the tissues superficial to tunica albuginea
Tunica albuginea has high tensile strength resisting stretch

16. Macroscopic Penile Vs Scrotal Type of constrictor, metallic vs plastic
Classified by Bhatt et al.
Revised by Silberstein(2008)
Macroscopically you have to determine whether the ring is penile or penile scrotal because that affects management.
The type of constrictor metallic vs plastic. Plastic constrictors were associated with more high grade injuries compared to metallic rings postulated that because of their elastic properties they had a higher propensity to compress the penis.
A combination of tightness and duration of constriction will present with an increasing degree of pathology and this was classified by Bhatt et al and revised by Silberstein in 2008
One patient described by Stuppler et al had been incarcerated for 25 yrs. This was a patient who was cognitively impaired with a grade 4 injury according to bhat

17. Assessment of penile strangulation
Temperature
Pain/paraesthesia- penile sensation
Pulsation- by Doppler ultrasound
Pallor /colour- dark hue, gangrene, IV fluorescein
To aid in classification According to Bhatt et al 1991 initial assessment should include a mention on temperature, colour, sensation ability to void and pulsation by Doppler ultrasound
Wood lamp red free light, fluorescein is fluorescent material and it differentially binds to healthy and necrotic tissue thus when exposed to red free light it emits light at different colours. It aids in determination of assessing blood flow to distal segment. The ophthalmologist use it routinely

18. Bhatt et al. classification1
Distal oedema only 2
Distal oedema, skin and urethral trauma, corpus spongiosum compression, decreased penile sensation 3
Skin and urethral trauma, no distal sensation; 4
Separation of corpus spongiosum, urethral fistula, corpus cavernosum compression, no distal sensation; 5
Gangrene, necrosis, or distal penile amputation.
Bhatt et al had 5 grades of increasing pathology. In grade 4 separation of corpus spongiosum occurs first due to the thinner tunica albuginea around the bulbospongiosum.

19. Silberstein revised classification
Low grade injury – to require no further intervention once the constricting object has been extricated.
High grade injury-likely to require surgical intervention. Incl. urethral fistulae , necrosis of the penis
Silberstein J, Grabowski J, Lakin C, and Goldstein I. Penile constriction devices: Case report, review of the literature, and recommendations for extrication. J Sex Med 2008;5:1747–1757
Silberstein further characterised them into low grade and high grade injuries corresponding to bhat grade 1-3 and 4-5 respectively

20. Management General Measures
Divert the urine- suprapubic vs urethral catheterisation?
About 20% presented with acute urinary presentation. Opinion is divided as to whether suprapubic catheterisation is necessary to prevent further damage.

21. Management-2 Specific Measures Divided into Cutting techniques
String technique and its variants
Purely aspiration techniques
Surgical techniques

22. Cutting techniques Most desirable?
Protect underlying skin by use of malleable and cool water irrigation
Cutting tools may be unavailable or inadequate
The diversity of cutting tools used is a s varied as physician imagination and also include help fro firefighters. The most recent case of penile incarceration in recent memory in KNH had to involve the kilimani police station to borrow the cutters used to cut containers however the patient got infected later and succumbed to sepsis.

23. Massoud et al. External Genitalia Entrapment. Urol J. 2010;7:136-7
Silberstein J, Grabowski J, Lakin C, and Goldstein I. Penile constriction devices: Case report, review of the literature, and recommendations for extrication. J Sex Med 2008;5:1747–1757
Massoud et al. External Genitalia Entrapment. Urol J. 2010;7:136-7
Silberstein J, Grabowski J, Lakin C, and Goldstein I. Penile constriction devices: Case report, review of the literature, and recommendations for extrication. J Sex Med 2008;5:1747–1757

24. String technique and its variants
Originally used in traumatised fingers
String, cord or umbilical tape slipped under the ring
distal part wrapped tightly.
Proximal part pulled progressively slipping the ring towards the glans
Drain the glans before starting the procedure
The string technique was devised by Flatt (28) for removing rings from traumatized fingers. Bucy first
utilized it in 1968 (14). Some authors have chosen to aspirate blood from the glans before starting
(4, 5) or during (14, 15) the string procedure. Instead of cord, Browning & Reed employed umbilical tape
with glans drainage accomplished by injecting 150 units of hyaluronidase (15). The wrapping technique
employs the latex band from a urinary leg bag as the compressive element (22).

25. String technique and its variants-2
String traumatic to oedematous and friable skin
Nylon tape was fairly atraumatic
Most cases General anaesthesia used
Ring block effective and safe alternative
Time limit seems to be 72 hrs.
The width and elasticity of the latex band were atraumatic to the edematous tissue and compressed the
From Table I, it can be seen that the string-technique (string, cord, umbilical tape) with glans drainage has been successfully employed for grades one to three (4, 5, 14).
General anesthesia was used all except one grade 3 case with glans drainage where 15 mg i.m. morphine was utilized (15). The wrapping technique without glans drainage was employed for a grade 1 injury and required no anesthesia (22). A string technique variant failed for a grade 5 trauma with the . nal resolution being excision to Buck’s fascia (20). The longest site time for the metal objects in the stringtechnique and variant group was only 72 h. Reported recovery times ranged from 1 to 24 h (15, 22). Both average site time (23 h) and recovery time (12.5 h) were relatively short.

26. Aspiration techniques
Only 3 described cases
multiple puncture wounds with gauge 18(pink in blood transfusion sets)
Multiple stabs to drain fluid
One aspirated blood from glans and corpora
Time limit about 12 hrs.

27. Surgical techniques Failure of preceding techniques.
Bhatt grade 4 and 5 injury but cases should be individualised

28. Blood supply to the penile skin
Its dependent on the blood supply to the skin by the external pudendal vessels. I would like you to note the position of the vessels on the dorsal side of the penis.

29. Most utilise the concept that most of the oedema is in the tissue superficial to the tunica albuginea. Any longitudinal cut developed at the layer superficial to bucks fascia will allow the interstitial fluid to egress from the cut edges and the ring can be easily slipped through and the then skin repaired. Blood supply by the external pudendal vessel and is on the dorsal surface therefore the skin flaps should be raised from the ventral surface centered around the bulbospongiosum and this will ensure the skin remains viable
Olajide et al. Novel surgical extrication of penile constricting metal ring. IJCRI 2013;4(9):511–514.
Olajide et al. Novel surgical extrication of penile constricting metal ring. IJCRI 2013;4(9):511–514.

30. Prognosis Grade 1-3- Recovery good, full recovery by 15 days
Grade 4 and 5- Aggressive removal of devitalised tissue to prevent morbidity or infection, urethral Ž fistulas, tissue resection, prolonged recovery time and penile amputation.
Mark B. Detweiler. Penile Incarceration with Metal Objects, A review. Scand J Urol Nephrol 35: 212–217, 2001
Mark B. Detweiler. Penile Incarceration with Metal Objects, A review. Scand J Urol Nephrol 35: 212–217, 2001

32. The End