Strangulation of the penis with foreign body’s dates back to the year 1755 in spite of that very little was reported in literature (61 cases) [1]. The majority of these cases were self-inflicted. Psychosexual or psychiatric disorders (small penis syndrome) were the main causes of the injury in adults. In children foreign bodies were applied by illiterate parents because they believed that it prevents enuresis [2].

Case 1

A 23-year-old patient presented to the causality department of Khartoum Teaching Hospital, because of inability to pass urine and severe pain around the area of the external genitalia.

The patient gave no history indicative of any serious chronic disease. He claimed that his genitalia were small in size, so he consulted three urologists and a dermatologist who reassured him but was not yet convinced; therefore he sought the advice of a native healer, who advised him to intermittently wrap the root of the penis.

He kept doing this for a couple of weeks before coming up with the idea of introducing a Spur gear around the genitalia.

On examination the patient looked ill, irritable and was in severe pain. He was not cyanosed or jaundiced. No lymphadenopathy. With the exception of the bladder no abdominal masses were palpable.

The penis and scrotum were oedematous, in some parts gangrenous. A heavy spur gear was seen strangulating the external genitalia (Figure 1).

Figure 1: Heavy metallic gear.

The liver and kidney function tests were within normal range, CBC: WBCs were elevated (13,800), rest was normal.

The bladder was drained by a cystofix. The patient was then given Intravenous normal saline and IV Ceftriazone 1 g combined with 500 mg of IV metronidazole.

He was taken to the operating theatre. An electric saw was used to divide the foreign body but has failed.

Lateral incisions were made on the scrotum and penis. The testicles were delivered outside the scrotal sac. They looked normal.

The gear could then be removed, the testicles were put in place and the incisions were closed (Figures 2-4).

Figure 2: Gear removed.

Figure 3: The Gear.

Figure 4: Final step.

A 33-year-old patient presented with severe pain and swelling of the genitalia due to entrapment with a metallic ring which has been put by the patient two days prior to presentation. Patient claimed to be “mislead by the devil” (Figure 5).

Figure 5: Second case.

On admission, he was found to be quite stable. His vitals were normal. Abdominal examination revealed no masses. Examination of the genitalia showed oedematous swelling of the genitals. Under general anesthesia the ring could be divided into two pieces using an electric saw (Figure 6).

Figure 6: Ring divided.

Case 3

The last case was a 38-year-old male who presented with swelling of the genitalia and bleeding due to entrapment with a double ring which has been put by the patient one day prior to admission (Figure 7). After doing the necessary investigations, the ring was cut by an electric saw.

Figure 7: Double Ring and bleeding.

Metallic objects, eg., bolts, washers, hammer heads etc. were generally used, as well as plastic and other less solid materials [2-4], metallic rings were the most commonly used tools [5]. This falls in line with the cases encountered in our department.

The presenting symptoms were pain, swelling of the external genitalia. One patient retained urine and another one had bleeding, this matches what has been reported in the literature [6-8].

Two of the patients had the scrotum and penis entrapped. One patient only had involvement of the penis. The average time of strangulation was 48 hours but it seems to have affected only the venous drainage, therefore the organs could be saved.

The lack of knowledge and awareness was reflected in the claims made by two of the patients who accused devils and native healers. This highlights the magnitude of such problems in developing countries.

In two of the patients the procedure was very easy, and in one patient a lengthy operation was needed.

Self-inflicted genital injuries are very serious and may lead to serious complications ranging from gangrene of the genitalia to complete loss.

There are no standard techniques or equipment for removal of these objects, but the time factor is crucial to preserve the organs.