While I was researching a blog on urethral manipulation I came across a paper entitled ‘Penile strangulation by a hard plastic bottle’ by Dr. Satish Jain and his colleagues published in a 2004 issue of the Indian Journal of Surgery. As the paper explains:
“Penile strangulation is a rare injury and most require only removal of the constriction and conservative management. Penile strangulating objects are usually rings, nuts, bottles, bushes, wedding rings etc. in an adult, while in children they tend to be rubber bands threads or hair coils. In adults these constricting penile bands, whether expandable or non-expandable, are placed deliberately by the person himself for masturbation or by the female counterpart to prolong erection. In children these are used to prevent enuresis and incontinence or as an innocent childish experiment. Because these bands occlude penile venous flow, most patients present to the emergency with penile edema” [an edema is a swelling caused by fluid in body tissue].
They reported the case of a 27-year old man who turned up at hospital needing emergency treatment for an extremely swollen penis and unable to urinate. This occurred as a result of placing his penis inside a hard plastic bottle as a masturbatory aid. In short, the neck of the bottle got stuck, constricting the penis base. The paper then described how the bottle was removed:
“The hospital carpenter was called to assist in cutting open that bottle. With the use of iron cutting saw…first the bottle was cut near the neck and then the bottle neck was cut open slowly and diagonally. The penis was held slightly bent downwards. Once one end of the bottle neck was cut open, the plaster spreader (used by orthopaedician) was use to hold the cut ends open and the whole bottle neck was cut opened and removed after 15 minutes of struggle…Penile edema subsided completely in a week and patient had an uneventful recovery. There was no erectile dysfunction or decreased uroflow”.
This case was relatively easy to treat and on the less serious side. Later in the paper, the authors note that more serious medical complaints can arise including ulceration (skin inflammation and/or lesion), necrosis (death of body tissue), urinary fistula (abnormal opening of the urethra) or even gangrene (death and decay of body tissue due to loss of blood supply). Unsurprisingly, these latter conditions most often occur because the patient is too shy or embarrassed to seek medical help.
It was after reading this paper that I went searching for other cases and found many papers on the topic (far too many to outline here). However, I thought I would pick out some that caught my eye. Penises stuck inside bottles seemed (somewhat predictably) to feature quite heavily. For instance, Dr. C.K. Ooi and colleagues reported two cases of “unusual” penile strangulation in a 2009 issue of the Singapore Medical Journal. One of the cases was a 77-year old man who got his penis stuck in a bottle. Although the bottle was successfully removed in the emergency ward the patient subsequently developed post-obstructive diuresis (i.e., excessive urination). The second case was a 60-year old man who got his penis stuck inside a metallic ring. An orthopaedic cutter was used to remove the ring and there were no long-term complications. Another paper by Dr. Matthias May and colleagues in a 2006 issue of the International Urology and Nephrology reported the case of a 49-year old man who got his penis stuck in a polyethylene terephthalate (PET) bottle. (Ethylene terephthalate is a light plastic material that is – according to various papers I read – “nearly indestructible”). After trying to cut the bottle off with a scalpel and then a glass saw, the bottle was finally removed by cutting it longitudinally with an oscillating saw (that was normally used for cutting off patient plaster casts).
A more recent case in a 2011 issue of the International Journal of Biological and Medical Research by Dr. Uday Shamrao Kumbhar and colleagues reported the case of a 46-year old man who got a plastic bottle neck stuck on the base of his penis following attempted masturbation. More specifically, they reported that:
“The man came after 14 [hours] with gross penile edema and impaired penile sensation distal to the constriction…The nature of the plastic bottle neck was such that an attempt at cutting the device was difficult. We retrieved the constructing device by cutting it by soldering gun (used for electrical soldering by electrician). Cuts were taken at two places – 3 and 9 o’clock positions. The only hurdle was heat generated during the soldering, which was overcome by intermittent soldering and pouring cold normal saline in between”.
The patient recovered fully and following removal had a normal erection, could masturbate and have sex without problems. The most recent case I came across was published in a 2014 issue of Case Reports in Urology. The authors (Dr. Avinash Chennamsetty, Dr. David Wenzler and Dr. Melissa Fischer) reported the case of a 49-year-old man that turned up at the Emergency Department complaining that his penis was swollen and painful. The authors reported that nine days prior to coming into hospital the man had placed a metallic constriction device over his penis for an “autoerotic motive” but then found that he couldn’t remove it. The authors noted that:
“He was able to urinate but had a decreased force of stream. Physical exam revealed a tightly encircling metallic ring with peripheral cogs placed on the mid shaft of the penis causing severe penile engorgement and edema. The metal appeared to be a very hard alloy with thickness measuring 5–7mm depending on the location. The penile skin under the ring was excoriated and necrotic. Due to the incarceration time, degree of necrosis, and significant distal edema, simple lubrication, compression, and manual removal were not an option for fear of amputation. Manual and electric ring cutters were used, but after several attempts, we were unable to do more than scratch the surface of the metal ring. The patient was given procedural sedation and a tongue depressor was placed beneath the metal ring to provide soft tissue protection. Using the pin cutter, enough force was generated in one attempt to snap the ring into two separate pieces”.
Another different kind of penile strangulation – with more serious consequences – was reported by Dr. A. Nuhu and his colleagues in a 2009 issue of the West African Journal of Medicine. In this instance, a middle-aged Nigerian managed to get a round metallic nut stuck on his penis. For five days the man had delayed coming into hospital for treatment even though he was unable to urinate properly (in fact he had trouble urinating at all). By the time he went for medical help, his penis had developed gangrene. Unfortunately, the only treatment option available was a complete amputation of his penis.
It is also worth mentioning that a number of papers I came across purely describe the methods that can be used in the “extrication of penile entrapment” such as a detailed report by Dr. Guang-Ming Liu and colleagues in a 2012 issue of the International Urology and Nephrology that described the “technique of suture traction in conjunction with Dundee…performed for the management of penile entrapment in polyethylene terephthalate bottle neck” that they claim can be performed “without any special tools required in the management of penile entrapment involving PET bottles [and can] be applied safely for the low-grade penile injury”.
Within two weeks of removal, the man’s penis had fully recovered and he was able to resume sexual activity. Another earlier 2001 paper by Dr. Mark Detweiler in the Scandinavian Journal of Urology and Nephrology outlined treatment guidelines “according to level of penile trauma for penile incarceration by metal devices”. Detweiler analysed all previous cases of penile strangulation (aka penile incarceration) and divided treatment interventions into four groups going from the safest to the most dangerous to perform: (i) string techniques with and without aspiration [removal] of blood from the glans; (ii) pure aspiration techniques; (iii) cutting devices; and (iv) surgical techniques.
Finally, the most tragic case of penile strangulation I came across was one published in 2011 by Dr. Benito Morentin and colleagues in the American Journal of Forensic Medicine and Pathology. They reported that a 58-year old man was found dead at a guesthouse by a flatmate living in the house. The paper reported:
“According to the flatmate, the deceased had not been out of his room in the last 2 weeks. Two days before the death the flatmate phoned the emergency services asking for help due to the strange behavior of the subject. When the emergency staff arrived the man refused any kind of help claiming that he did not have any medical problems at all. Clinical antecedents included paresis of the left leg due to stroke, smoking, alcoholism, and social behavior disorder. At autopsy, physical examination showed that the penis was engorged and swollen, with dark black color and evident gangrene. A plastic bottle neck was found over the base of the penis. Between the bottle neck and the penis there was a piece of condom…Histologic examination of the penis revealed severe necrosis, intense hemorrhage of the tissue due to stagnated blood, and thrombosis… Death was attributed to multi-organ failure secondary to septic shock”.
This last case is clearly an extreme and tragic case. The authors speculated that the man was simply too ashamed to seek treatment. They also believed that this is the only ever death recorded as arising from penile strangulation.
Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK
Chennamsetty, A., Wenzler, D. & Fischer, M. (2014). Removal of a penile constriction device with a large orthopedic pin cutter. Case Reports in Urology, Volume 2014, http://dx.doi.org/10.1155/2014/347285
Detweiler, M. B. (2001). Penile incarceration with Metal objects a review of procedure choice based on penile trauma grade. Scandinavian Journal of Urology and Nephrology, 35(3), 212-217.
Ivanovski, O., Stankov, O., Kuzmanoski, M., Saidi, S., Banev, S., Filipovski, V., Lekovski, L. & Popov, Z. (2007). Penile strangulation: two case reports and review of the literature. Journal of Sexual Medicine, 4(6), 1775-1780.
Jain S., Gupta A., Singh T., Aggarwal N., Sharma, S. & Jain S. (2004). Penile strangulation by a hard plastic bottle: A case report, Indian Journal of Surgery, 66(3), 173-175.
Liu, G. M., Sun, G., & Ma, H. S. (2012). Extrication of penile entrapment in a polyethylene terephthalate (PET) bottle: A technique of suture traction and Dundee and literature review. International Urology and Nephrology, 44(5), 1335-1340.
May, M., Gunia, S., Helke, C., Kheyri, R., & Hoschke, B. (2006). Penile entrapment in a plastic bottle – A case for using an oscillating splint saw. International Urology and Nephrology, 38(1), 93-95.
Morentin B., Biritxinaga B. & Crespo L. (2011). Penile strangulation: Report of a fatal case. American Journal of Forensic Medicine and Pathology, 32, 344-346.
Nuhu, A., Edino, S. T., Agbese, G. O., & Kallamu, M. (2009). Penile gangrene due to strangulation by a metallic nut: a case report. West African Journal of Medicine, 28(5), 340-242.
Ooi, C. K., Goh, H. K., Chong, K. T., & Lim, G. H. (2009). Penile strangulation: report of two unusual cases. Singapore Medical Journal, 50(2), e50-52.
Shamrao Kumbhar U., Dasharathimurumu, D. & Bhargavpak, D. (2011). Acute penile incarceration injury caused by a plastic bottle neck. International Journal of Biological and Medical Research, 2(4), 1184-1185.