Emergency department management for an unusual case of penile entrapment and strangulation

Abstract

A 11-year-old boy was seen at our pediatric emergency department (PED) for evaluation of a swollen and painful penis. He had placed a glass ring over his penis fourteen days prior.  This resulted in straining with micturition and a fleshy circumferential non healing wound at the base of the penis with serosanguinous discharge. The glass ring eroded into the deep subcutaneous layer of the skin at the base of the penis. The distal penis was swollen and tender with no changes in skin color, texture or blurring of sensation. The glans was viable with appropriate capillary refill. Urine stream was unaffected, and the amount of serosanguinous discharge was not related to the act of voiding. Emergency measures were conducted including administration of analgesia, antiemetics, active immunization against tetanus, systemic antibiotic therapy (cefazolin), and urology consultation. Due to extensive damage, urology deferred ring removal in the PED and recommended removal in the operating room to control the probable damages better, post removal of ring. The patient was transferred as our facility did not have an inpatient unit for post operative management. The ring was successfully removed using a bone cutter under general anesthesia. Surgical exploration revealed minimal erosion into the cavernosal bodies without any injuries to the dorsal veins, dorsal and deep artery, and nerves. Intra-op cystoscopy showed no injuries to the urethra. Primary closure was done circumferentially in two layers (Buck’s fascia and skin) with an absorbable vicryl 5-0 interrupted suture, followed by pressure bandage. The case was presented to a social worker considering the clinical features of the case. The social service experts and providing physicians were reassured there was no concerns for child abuse, sexual abuse, neglect, behavioral or psychiatric disorders. The patient was discharged with Bactrim and analgesics for one week after he was able to void independently. One month follow up at the urology clinic revealed that the patient had good skin preservation, wound healing, and micturition. The patient had no difficulties with anxiety, depression, or post-traumatic stress at his follow up appointments with a behavioral health therapist.