Penile Gangrene by Non Metallic Objects: A Rare Aetiology in Adults

A 43 year old male presented to our OPD with complaint of lose of distal part of penis. 20 days back patient applied a perfume to his genitals, and in to the meatus followed which he developed irritation and pain in the penis. To decrease that pain he applied 10 rubber band to his penis. He removed all rubber bands after some time forgot to remove the one on corona. He was having obstructive voiding symptoms but still he ignored and was consuming analgesics for pain. After ten days he found that his glans is flabby and not having any sensation over that. Then he found to have a rubber band almost transecting the corona. While removing that rubber band glans also came out. At the time of presentation patient was having fever, pus discharge from the distal stump and leucocytosis. He was treated with antibiotics and debridement Psychiatric evaluation was normal. During debridement was found to have multiple small abscesses inside the corpus cavernosum which was drained and partial amputation was done [1,2] (Figures 1 and 2).

A 43 year old male presented to our OPD with complaint of lose of distal part of penis. 20 days back patient applied a perfume to his genitals, and in to the meatus followed which he developed irritation and pain in the penis. To decrease that pain he applied 10 rubber band to his penis. He removed all rubber bands after some time forgot to remove the one on corona. He was having obstructive voiding symptoms but still he ignored and was consuming analgesics for pain. After ten days he found that his glans is flabby and not having any sensation over that. Then he found to have a rubber band almost transecting the corona. While removing that rubber band glans also came out. At the time of presentation patient was having fever, pus discharge from the distal stump and leucocytosis. He was treated with antibiotics and debridement Psychiatric evaluation was normal. During debridement was found to have multiple small abscesses inside the corpus cavernosum which was drained and partial amputation was done [1,2] (Figures 1 and 2).

Case 2
A 63 year old diabetic and hypertensive male patient admitted in

Abstract
Penile strangulation from metallic and non-metallic objects has been reported since 1755. The largest series of such cases was reported by Dakin in 1948, with the presenting age between 15 to 56 years. 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. Although condom catheters are more comfortable and less painful than indwelling catheters, they are not completely without risk. Various complications have been described in the literature, including skin irritation, maceration, ulceration, allergic reactions, urinary tract infections, fistula formation, penile edema, localized ischemia, and gangrene. We describe two cases of penile glans strangulation leading to auto amputation caused by a rubber band and another case of distal penile gangrene due to strangulation by tight condom catheter.  cardiology ward for angiography complained brown colored urine since one day. He was having right hemiperesis, and on condom catheter since 5 days. On removing the catheter found to have gangrene of the distal 2/3rd of the penis. Dorsal slit of prepuce was done for per urethral catheterisation. The gangrene got demarked in 3 days. Then partial amputation of the penis done and wound healed without any infection (Figure 3).

Discussion
Penile strangulation is a rare urological emergency. Gangrene of the penis is still rare. The progressive vaso-occlusive changes that result in penile gangrene are usually caused by diabetes mellitus, Grade IV: Complete division of corpus spongiosum leading to urethral fistula and constriction of corpora carvernosa with loss of distal penile sensations.
Grade V: Gangrene, necrosis, or complete amputation of distal penis. Grade V injury requires partial amputation as was done in both our cases. Delaying intervention usually requires more extensive surgery and increased the risk of wound complications. Thus, an aggressive surgical treatment initially is advocated. Simply observing these patients usually leads to subsequent liquefaction, infection, and urinary obstruction, which might require intervention with percutaneous supra-pubic tube drainage and debridement [8].
The second case also highlights an important aspect, that use of condom catheter should be judicious as it can be counterproductive if not properly taken care.

Conclusion
Partial penile auto amputation is very rare. Even non metallic elastic rubber band can also cause strangulation, gangrene and auto amputation of penis. Early debridement and partial amputation is important to preserve the penile stump as well as to achieve good cosmetic and functional results. Proper application and routine care of condom catheters is important in preventing this complication.