Cutting of Entrapped Metal Penile Ring With Diamond Cutting Disk

{"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_1g0jdjaq"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Introduction A penile ring, or cock ring, is a mechanical device used by men to help maintain an erection. Penile rings are commercially available in a wide variety of different materials, shapes, and sizes. Once a man obtains an erection, the ring is positioned at the base of the penis. As such, it is important for men to choose a ring that is adjustable and fits comfortably. Penile rings work by occluding venous outflow from the penis.1 Rings should be removed as soon as possible after sexual activity to avoid ischemic damage to the corpora cavernosa.2 Rings left in place for extended periods of time cause progressive penile swelling, edema, and, ultimately, entrapment. Entrapped rings made of stretchable materials can often be slide over the penis or cut and removed. Rings made from metal, however, can be very challenging to remove. As a result, urologists are often called on to help manage these challenging cases. Methods A 72-year-old man with a medical history significant for hypertension developed increasing difficulty obtaining and maintaining an erection. His symptoms were refractory to phosphodiesterase-5 inhibitors. Prior to attempted intercourse, patient placed a 0.7-cm thick, stainless steel ring at the base of his penis. The patient had previously never tried penile occlusive therapy. He did not use any form of intracavernosal injection therapy in conjunction with the ring. After intercourse, he was unable to remove the ring. He presented to the emergency room 12 hours later with penile pain and swelling (Figure 1).Figure 1.: Penile entrapment with metal ring.The emergency room staff made multiple attempts to relieve the phimosis and remove the ring including lubrication and sliding, manual compression of the circumcised penis, wrapping the penis with gauze, and aspiration. An unsuccessful attempt was also made to cut the ring with a standard emergency room ring cutter. The patient went on to develop urinary retention, and a Foley catheter was placed. Options for management were discussed, and after obtaining informed consent, the patient was taken to the operating room. A general anesthetic was administered, and the Foley catheter was removed. The penis was prepped, and a cystoscopy drape was placed over the patient. The cystoscopy drape made it possible to contain and drain irrigation used during the procedure. A surgical time out was performed. Both corpora were then aspirated with 18 gauge needles. A total of 10 cc of dark blood was drained. The penis was then wrapped with gauze and manual compression was applied for 20 minutes in an attempt to reduce soft-tissue edema. After these maneuvers, the penis continued to be markedly swollen, and the ring remained entrapped at the base of the penis. These interventions did, however, reduce penile soft-tissue swelling enough to allow placement of a narrow metal malleable retractor between the ring and the dorsal side of the penis. At this time, it became evident that, to be safely removed, the ring would need to be cut. We discussed the surgical instrument options available for metal cutting at our institution with our orthopedic and neurosurgery colleagues. A Stryker Maestro Air Motor with PD Series Straight attachment and 25.4 mm × 0.8 mm metal cutting diamond disk were obtained. Following a tutorial from a neurosurgeon on how to safely operate the device, a full-thickness cut was made through the ring (Figure 2). The ring was then rotated, and another full-thickness cut was made on the opposite side (Figure 3). Cystoscopy tubing was used to provide continuous sterile water irrigation onto the operative field to prevent sparking and thermal injury from friction during cutting. Five metal cutting disks were used during the case as individual disks dulled from cutting overtime. The ring was subsequently removed without difficulty. A cystoscopy was then performed, and there was no evidence of urethral injury. A penile block was subsequently performed for postoperative pain control. The Foley catheter was left overnight, and the penile was covered with a mildly compressive dressing.Figure 2.: Use of malleable retractor, water irrigation, and metal cutting diamond disk.Figure 3.: Entrapped metal penile ring after being cut into 2 pieces and removed.Results The total operative time was 112 minutes. There were no surgical complications. The total time from ring placement to removal was 17 hours. The patient stayed overnight for observation. Ten days later, the patient reported only mild symptoms of penile pain. On examination, he was found to have small remaining skin abrasions and mild penile ecchymosis. He had not attempted any further sexual activity and denied any voiding complaints. The patient has since been lost to follow-up. Discussion A penile ring, also known as a cock ring, is a ring worn around the base of the penis. The ring is used to produce or maintain an erection and enhance sexual pleasure. The device works by reducing the outflow of blood from the corporal bodies of the penis. The penis ring may become stuck around the penis or scrotum and cannot be removed by the user, a situation referred to as penile ring entrapment. The first case of penile strangulation from such a ring was described by Gauthier in 1755.1 Since that time, a wide variety of penile ring injuries have been reported. A simple grading system was proposed by Dawood et al3 to help communicate and document degree of injury: Grade 1 is superficial tissue injury with distal edema, grade 2 is any deep tissue injury involving the corpora or urethra assessed by examination, and grade 3 is tissue loss, gangrene, separation of the corpora, or fistula. Management options for an entrapped ring include sliding and cutting. Sliding refers to using manual compression to reduce penile edema, placing lubrication on the penis to reduce friction and removing the ring with steady traction. Cutting can be done by various techniques including the use of an orthopedic cutter, plumber's hacksaw, electric saw, wire cutter, and diamond cutting disk. A recent review of cutting instruments and associated patient outcomes was performed by Laik and colleagues.4 Even after long periods of penile strangulation, outcomes are often good. In 1 series, only 13% of patients had lasting complications.5 There are several important safety issues to consider before cutting an entrapped metal penile ring. Urologist often have limited familiarity with the surgical instruments need to perform metal cutting in the operating room. As a result, consultation with orthopedic and neurosurgery colleagues can be helpful in not only finding the necessary cutting tools but also in the safe operating of these tools. Aspiration of corporeal blood and penile compression and wrapping may allow a protective barrier, such as a thin malleable retractor, to be placed between the ring and the penis to help protect the penis during cutting. Manual or continuous irrigation helps reduce the risk of fire from sparks and to help prevent thermal injury to the penis during cutting of the ring. Protective eyewear, on the patient and surgical team, can help prevent injury from flying debris and splash contact from irrigation. Finally, when cutting with the air powered drill and diamond disk, caution should be taken to avoid injury to the patient, surgeon, and operating room staff. Conclusion Entrapped penile rings made of metal can be challenging to remove. Urologists often lack familiarity with the tools and techniques necessary to cut and remove these devices. Preoperative consultation with orthopedics and neurosurgery can help the urologist obtain the necessary equipment to safely cut these types of rings. This case presentation and video is intended to demonstrate one technique for safely cutting and removing a tight metal ring around the penis.