Penile strangulation caused by a thread or human hair is an uncommon cause of urethral injury described in paediatric piactice. Five children presented with this entity to the Aga Khan University Hospital, Karachi between August, 1991 and August, 1992. Three children had uneventful recoveries after removal of the contricting agent. Two patients developed urethrocutaneaus fistulae and partial amputation of the penis because of late presentation Early recognition and removal of the constricting agent is necessary to prevent serious complication

Moazam, Farhat

Nazir, Zafar

Rasheed, Khalid

English

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eCommons@AKUSection of Paediatric Surgery Department of SurgeryJanuary 1993Penile constrictive band injuryZafar NazirAga Khan University, zafar.nazir@aku.eduKhalid RasheedAga Khan UniversityFarhat MoazamAga Khan UniversityFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_paediatrPart of the Surgery CommonsRecommended CitationNazir, Z., Rasheed, K., Moazam, F. (1993). Penile constrictive band injury. Journal of the Pakistan Medical Association, 43(7), 135-137.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_paediatr/19Penile Constrictive Band InjuryPages with reference to book, From 137 To 139 Zafar Nazir, Khalid Rasheed, Farhat Moazam ( Department of Surgery, The Aga Khan University Hospital, Karachi. ) Abstract Penile strangulation caused by a thread or human hair is an uncommon cause of urethral injurydescribed in paediatric piactice. Five children presented with this entity to the Aga Khan UniversityHospital, Karachi between August, 1991 and August, 1992. Three children had uneventful recoveriesafter removal of the contricting agent. Two patients developed urethrocutaneaus fistulae and partialamputation of the penis because of late presentation Early recognition and removal of the constrictingagent is necessary to prevent serious complications (JPMA 43: 135, 1993).Introduction Penile tourniquet or constrictive band injury caused by an encircling object has been describedperiodically in all ages1,2. The constricting bands are placed on the penis for a variety of reasons andthe objects used have been diverse3,4. In children rubber bands, threads and human hair have beenreportedly used to prevent nocturnal enuresis or incontinence and sometimes as childhoodexperimentatioon5-7. Severe damage to the erectile tissue and urethra can result, requiring majorreconstructive procedures. The purpose of this report is to call attention to this injury in young childrenand to stress the importance of early recognition and management.Patients and Methods Between August, 1991 and August, 1992 five ‘children presented to the paediatric surgery service atThe Aga than University Hospital, Karachi, with penile constrictive band injury. The medical recordswere reviewed retrospectively for age at presentation, circumcision, history of nocturnal enuresis,nature of constricting agent, duration before diagnosis, presenting symptoms and signs, treatment andthe outcome. The injuries were graded ‘as described by Bashir and El-Barbary8 (Table I).Illustrative Case ReportS.I.U., a seven year old circumcised boy (patient 4 in Table II)with a history of nocturnal enuresis, tied a thread around his penis to control bed wetting and avoidpaternal punishment. Fle concealed the swelling of the glans until one week later, when he was seen bya local physician for progressive penile swelling and circumferential inflammation at the coronalsulcus. The child was placed on systemic antibiotics with no response. In the third week following theepisode, the physician discovered an encircling thread, buried in the coronal sulcus. Following itsremoval, the patient developed an urethrocutaneous fistula and was referred to The Aga than UniversityHospital. Examination under anaesthesia revealed complete division of the corpus spongiosum, leadingto a urethral fistula and partial amputation of the corpus cavernosum (Grade 2 injury). The glans wasmarkedly swollen (Figure la and ib).After wound debridement, the glans was sutured to the corpora cavernosum. The youngster is awaitingelective repair of the fistula.Results The salient features of the patients are summarized in Table II. The average age of the patients was 5.2years, with a range of 6 months to 9 years. All children had been circumcised at birth. Two patientsadmitted to tying polyester thread around the penis to control nocturnal enuresis. In one patient thecotton thread was tied by an elder sibling. The mean time interval between occurrence of the event andrecognition of the constricting agent was 2.6 weeks (range 2 to 4 weeks). The physical and mentaldevelopment in all children was normal for age.Discussion If unrecognized, penile constrictive band injury can result in serious sequelae. The first case of such aninjury secondary to human hair was reported by Morgenstern in 1888g. Since then occasional reportshave jtppeared in medical literature describing mostly adult patients, some of whom were mentallydisabled1-3. In children, penile strangulation may occur accidentally by the hair of the caretaker or maybe an intentional act by the patient, a sibling, or family members. This injury has been occasionallyreported as a form of child abuse5. As in previous reports, all the patients in our series werecircumcised. Circumcision makes the coronal sulcus more accessible to the constricting agent and maybe a reason why this injury has never been reported in uncircumcised children6. The extent of thedamage is related to the duration of constriction and the nature of the constricting agent The corpusspongiosum and the penile urethra are covered by a thin layer of fibrous tissue, and therefore, are moresusceptible to injury than the corpus cayernosum which is enveloped by the dense tunica albuginea2,6.Progressive compression of the penile vessels is responsible for distal oedema and gangrene. Theneural bundle may be injured effecting the sensation of the glans. If the constricting agent cuts throughthe ventral aspect of the penis, the urethra is transected resulting in a urethrocutaneous fistula. Humanhair and thread can be easily over-looked once the swelling of the glans ensues, resulting in extensiveinjury. Two patients in the present series had a delay in diagnosis of 3 and 4 weeks and developedurethral fistulae. Unexplained edema of the glans with a marked erosion of the coronal sulcus andsurrounding inflammation in a young child should be viewed with a high index of suspicion. Anunderlying circular constricting agent should be included in the differential diagnosis of penile swellingbeside local infection (balanitis) paraphimosis, trauma, contact dermatitis and insect bites.Confirmation of the diagnosis may require a thorough examination under general anaesthesia. Ifdiagnosed early, removal of the constricting agent and local care of the wound is all that is necessary(Figure 2).Reconstruction of the transected urethra should be delayed until the inflammation has resolved and thetissues have healed. Long term follow-up may be necessary to detect urethral strictures and possiblesexual dysfunctions.References 1. Boat, AL, Kumar, A., Mathur, S.C. et aL Penile strangulation. Br.J. Urol., 1991;68:618-21.2. Stoller, M.L., Lue, T.F. and McAninch, 1W. Constricting penile band injüty:anatomical andreconstructive considerations.). UroL, 1987;137:740-42.3. Sinha, B.B. Penile incarceration by a metallic object. Br.). Surg, 1988;75:33.4. Fiumara, NJ. Annular constriction of penis; the tourniquet syndrome. JAMA., 1978;240:2353-54.5. Snyder, N.M. and Caldamone, A.A. Genitourinary injuries, In. K.J. Welch, J.G. Rondoiph and M.M.Ravitch et al eds. Pediatric surgery, Chicago, Year Book Medical Publisher Inc., 1986, pp. 174-85.6. Sheinfeld, J., Cot, L.R., Erturk, B. et aL Penile tourniquet injury due to coil of hair. 1 UroL,1985;133:1042-43.7. Alpert, J.J., Filler, Rand Glaser, H.H. Strangulation of an appendage by hairwrapping, N. EngI. 3.Med., 1965;273:866-67.8. Bashir, A.Y. and El-Barbary, M. Hair coil strangulation of the penis. 3. Roy. Coil. Surg. Edin.,1980;25:47-51.9. Morgenstern, 3. Retention of urine and edema of penis from constriction by hair. Pediatrics,1888;5:248.

Penile constrictive band injury

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Penile constrictive band injury

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