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Table of Contents
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 15-18  

Penile ring entrapment – A true urologic emergency: Grading, approach, and management

Department of Urology, Southern Illinois University School of Medicine, Springfield, IL, USA

Date of Submission04-Feb-2019
Date of Acceptance30-Sep-2019
Date of Web Publication07-Nov-2019

Correspondence Address:
Mr Omar Dawood
718 Stevens Creek Blvd., Forsyth, IL 62535
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DOI: 10.4103/UA.UA_16_19

PMID: 32015611

Rights and Permissions

Penile rings are used to sustain erection in order to enhance sexual pleasure. They work by reducing the outflow of blood from the cavernosal tissue. However, if left for extended periods of time severe edema, urethral fistula, gangrene, and even complete loss of the distal penis can ensue, this is known as penile ring entrapment (PRE). Management poses particular challenges due to its rarity. Herein, we report our experience with three patients from our institution that presented with PRE and include a review of the approaches others have taken. We also propose a simpler and more effective grading scale to allow for easier communication between providers, as the current grading scales do not do so.

Keywords: Ischemia, penis, scrotum, trauma, urethra

How to cite this article:
Dawood O, Tabibi S, Fiuk J, Patel N, El-Zawahry A. Penile ring entrapment – A true urologic emergency: Grading, approach, and management. Urol Ann 2020;12:15-8

How to cite this URL:
Dawood O, Tabibi S, Fiuk J, Patel N, El-Zawahry A. Penile ring entrapment – A true urologic emergency: Grading, approach, and management. Urol Ann [serial online] 2020 [cited 2020 Mar 29];12:15-8. Available from: http://www.urologyannals.com/text.asp?2020/12/1/15/270538

   Introduction Top

Since ancient times, penile rings have been used to enhance sexual pleasure. They work by constricting the outflow of blood from the penis, prolonging erection.[1],[2],[3] Different materials such as rubber bands, wedding rings, hammerheads, bullrings, and plastic bottlenecks have been used.[3],[4] Regardless of the material used, constriction should be no longer than 30 min.[5] Prolonged constriction leads to severe ischemia and edema. If left unresolved, the penis will become necrotic and will eventually self-amputate. Urgent intervention is vital. Different treatment options have been elaborated. We report our experiences, treatment methods others have taken, and propose a newer grading scheme that will allow clinicians to swiftly and efficiently communicate the severity of this condition.

   Methods And Patients Top

We performed a retrospective review of charts from our institution from September 2012 to September 2018, identifying patients who presented with penile ring entrapment (PRE). We looked at patient characteristics, pattern of presentation, type of entrapment, and treatment. We also did a review of the literature to identify other treatment approaches for PRE.

   Results Top

We identified three patients who presented at our institution with PRE.

The first patient is a 60-year-old Caucasian male who presented with a ring around his scrotum and penis for 48 h. He had excessive scrotal and penile edema with minimal bruises at the ring location. Initial attempts to reduce scrotal and penile swelling by compression (in order to slide the ring off easier) failed. Next, we gave anesthesia for comfort and then applied olive oil around the penis and scrotum as lubrication to help with sliding. A tongue blade was inserted between the ring and penis to protect underlying tissues during sliding. Continuous compression was applied until the edema decreased enough for the ring to slide off. We were successful and all soft tissues appeared viable.

The second patient is a 28-year-old Caucasian who presented with a thick and wide wedding ring around the base of his penis for >12 h [Figure 1]. Several attempts to remove the ring in emergency department at two different hospitals failed, and finally, he was referred to our institution. He had extensive bruising and edema of the penile shaft distal to the ring. The shaft of his penis was Number on examination. Our initial attempt (with the patient under conscious sedation) to slide the ring off with compression and lubrication failed. The patient experienced such discomfort, for which general anesthesia was then induced. We then attempted needle aspiration and a release incision to decompress the corpora and decrease the swelling; however, this was not enough. Ultimately, we used a diamond-tipped Midas drill from the hospital engineering department to split the ring in half. During this procedure, a metal ruler and cold-water irrigation were used to protect soft tissues and prevent thermal injury. After ring removal, we performed flexible cystoscopy to rule out urethral injury. It revealed extensive urethral bruises, for which we placed 16 French Foley catheter [Figure 2]. The patient recovered and showed improvement at follow-up.
Figure 1: Patient 2 before treatment

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Figure 2: Patient 2 after treatment

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The third patient is a 42-year-old Caucasian male who presented with a metal washer pushed to the base of the penis. There were extensive bruises and edema distal to the washer. Attempts at twisting the ring off with lubrication were unsuccessful. Next, a vice clamp and Dremel tool were obtained from hospital maintenance. The ring was meticulously sawed in half as wet gauze and a tongue depressor were used as a barrier to protect the skin. Vice clamps were used to stabilize the ring. There was not any evidence of nother tissue injuries.

   Discussion Top

A penile ring is typically used to restrict the outflow of blood from the penis to prolonged erection and enhance sexual pleasure.[1],[2],[3] Wearing the ring for extended periods of time will lead to penile ischemia and strangulation. Eventually, the patient will experience severe edema, necrosis, urethral fistula, gangrene, penile amputation, and even death.[6],[7]

Patients tend to present late in their condition due to embarrassment.[6] Our experience was similar; unfortunately, delaying clinical intervention results in increased risk of the aforementioned complications of PRE.[8]

The primary goal of management in these cases is to restore blood supply to the penis while preserving the integrity of penile and urethral tissue. Success depends on what method is used to remove the ring. There are multiple treatment approaches (sliding, cutting, and surgery) that have been reported in the literature; surgeons have used different tools depending on what is at their disposal and their experience [Table 1]. Cystoscopy may be performed after the intervention to assess the level or urethral injury.
Table 1: Summary of case reports on penile ring entrapment

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Treatment options

  1. Sliding: Sliding should be used as an initial approach. This is the safest way to preserve underlying tissue. Various lubricants have been reported such as Salvon and even olive oil. If the ring is slid, the surgeon must first compress the edematous tissue and then provide traction. This method was reported to be successful by other authors.[4],[6],[11],[13],[16] We performed this method and were successful with one of our patients. However, we were unsuccessful in two of our patients. This method is safest and quickest but clearly is not suitable for all cases
  2. Cutting: Cutting seems to be the next suitable option after sliding has been attempted. Cutting appears to be a highly sought out method by many surgeons.[3],[9],[10],[12],[14],[15],[17] Various tools have been used to cut the ring such as a micrometer wheel-shaped bur, stout scissors, K-wire cutter, DerMel, bone-cutting clamp, and an electric axel driver.[3],[9],[10] We successfully used a diamond-tipped Midas Drill and Dremel tool. However, if cutting is sought out, it is very important to protect the underlying tissue from mechanical and thermal injury. We used cold saline irrigation to prevent thermal injury and a tongue depressor to protect the skin and underlying tissue
  3. Surgery: With failure of other approaches, surgical options may be needed. Lateral corporotomy to release edema and facilitate subsequent removal with lubrication, as performed by Alkhureeb et al., is one surgical approach.[1] We resorted to a limited surgical approach in order to drain fluid from the corpora and skin, our thinking was this would allow the penis to become more compressible. However, we found this to be of little help. Nuhu et al. experienced and extreme case of penile gangrene and preformed a cystotomy and perennial urethrosotomy.[2] Fortunately, we did not experience such an intense and rare case.

Grading of penile entrapment

There are different classifications of penile entrapment that have been reported [Table 2]. Sawant et al. embrace a grading system originally described by Bashir and El-Barbary, which focuses on the consequences of penile strangulation and urethral injury not easily visible by examination.[3],[19] Another grading system published by Bhat et al. utilizes penile sensation in its classification. This, however, could be misconstrued by patient anxiety and delivery of anesthesia by other providers prior to urologic assessment.[18] Regardless, both require detailed information that would be obtained accurately after the intervention.
Table 2: Summary of grading system

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We are proposing a revised grading system that is simpler to communicate, effective, and more pertinent to the problems surrounding PRE. 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. This grading scale is simple, depends mainly on clinical examination, and is easy to adopt by any emergency physician or urologist.

   Conclusion Top

PRE is a rare, true urologic emergency that can lead to penile amputation. Management should be urgent and directed toward removing the ring while protecting underlying tissue. Treatment is based on the severity of the presentation and the tools at the physician's disposal. A grading system is helpful in communicating the degree of injury between health-care providers, but it is necessary that it is simple, quick, and easy to communicate. We feel we have achieved this goal.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Alkhureeb M. Case report of early release of penile strangulation by metallic rings. Int J Sci Res 2016;5:1442-4.  Back to cited text no. 1
Nuhu A, Edino ST, Agbese GO, Kallamu M. Penile gangrene due to strangulation by a metallic nut: A case report. West Afr J Med 2009;28:340-2.  Back to cited text no. 2
Sawant AS, Patil SR, Kumar V, Kasat GV. Penile constriction injury: An experience of four cases. Urol Ann 2016;8:512-5.  Back to cited text no. 3
[PUBMED]  [Full text]  
Sharma PK, Vijay MK, Das RK, Tiwari P, Goel A, Kundu AK. Metallic ring used for autoerotic purpose leading to serious strangulating penile injury and its management. UroToday Int J 2011;4:1.  Back to cited text no. 4
How Do Erectile Dysfunction Rings Work? [03 43 13 3B 9F 56 66 A7 A4 29 2C DE 2B 13 7E 2A 25 CD]; 2013. Available from: https://prostate.net/articles/how-do-erectile-dysfunction-rings-work. [Last accessed on 2019 Feb 04].  Back to cited text no. 5
Agu TC, Obiechina N. Post coital penile ring entrapment: A report of a non-surgical extrication method. Int J Surg Case Rep 2016;18:15-7.  Back to cited text no. 6
Morentin B, Biritxinaga B, Crespo L. Penile strangulation: Report of a fatal case. Am J Forensic Med Pathol 2011;32:344-6.  Back to cited text no. 7
Xu T, Gu M, Wang H. Emergency management of penile strangulation: A case report and review of the Chinese literature. Emerg Med J 2009;26:73-4.  Back to cited text no. 8
Paonam S, Kshetrimayum N, Rana I. Penile strangulation by iron metal ring: A novel and effective method of management. Urol Ann 2017;9:74-6.  Back to cited text no. 9
[PUBMED]  [Full text]  
Nason GJ, Abdelsadek AH, Foran AT, O'Malley KJ. Multidisciplinary emergent removal of a metal penoscrotal constriction device. Ir Med J 2017;110:536.  Back to cited text no. 10
Liu GM, Sun G, Ma HS. Extrication of penile entrapment in a polyethylene terephthalate (PET) bottle: A technique of suture traction and Dundee and literature review. Int Urol Nephrol 2012;44:1335-40.  Back to cited text no. 11
Patel NH, Schulman A, Bloom J, Uppaluri N, Iorga M, Parikh S, et al. Penile and scrotal strangulation due to metal rings: Case reports and a review of the literature. Case Rep Surg 2018;2018:4.  Back to cited text no. 12
Wu X, Batra R, Al-Akraa M, Seneviratne LN. Penoscrotal entrapment: A safe, innovative technique for removing metal constricting devices. BMJ Case Rep 2012;2012. pii: bcr2012006466.  Back to cited text no. 13
Sathesh-Kumar T, Hanna-Jumma S, De Zoysa N, Saleemi A. Genitalia strangulation – Fireman to the rescue! Ann R Coll Surg Engl 2009;91:W15-6.  Back to cited text no. 14
Patel C, Kim R, Delterzo M, Wang R. Prolonged penile strangulation with metal clamps. Asian J Androl 2006;8:105-6.  Back to cited text no. 15
Baruah SJ, Bagchi PK, Barua SK, Deka PM. An innovative surgical technique for treating penile incarceration injury caused by heavy metallic ring. Indian J Urol 2009;25:267-8.  Back to cited text no. 16
[PUBMED]  [Full text]  
Geraniotis EG. Re: Penile incarceration with barbell retaining ring. J Urol 2002;167:2531.  Back to cited text no. 17
Bhat AL, Kumar A, Mathur SC, Gangwal KC. Penile strangulation. Br J Urol 1991;68:618-21.  Back to cited text no. 18
Bashir AY, El-Barbary M. Hair coil strangulation of the penis. J R Coll Surg Edinb 1980;25:47-51.  Back to cited text no. 19


  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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