Penile Constriction Injuries: Single-Centre Series Details Removal Techniques and Outcomes

Penile constriction injury is a rare urological emergency in which a circumferentially compressing object — most often a metallic ring — traps venous and lymphatic outflow from the penis. Progressive distal swelling follows, and if the device is not removed promptly, arterial inflow is eventually compromised, producing ischemia, skin ulceration, urethral injury, tissue necrosis, gangrene and, in the most severe cases, loss of the distal penis. Because the condition is uncommon, the published evidence consists almost entirely of isolated case reports and small case series, which has so far prevented the development of standardized management guidelines.

A new retrospective observational study, published in the African Journal of Urology, reports the experience of a tertiary referral centre that treated twelve consecutive adult men with penile constriction injuries between January 2020 and December 2025. The researchers, based at the Sher-i-Kashmir Institute of Medical Sciences in Srinagar, analysed demographic data, the type of constricting device, the duration of incarceration, injury severity graded on the Bhat classification, removal techniques, complications and functional outcomes. The study received institutional ethics committee approval, and informed consent was waived because of its retrospective design, although written consent was obtained for publication of clinical photographs.

The twelve patients had a mean age of 42.0 years, with a median age of 38 years and a range spanning 25 to 83 years. Half were married. Sexual gratification was the most common reason for applying the constricting device, cited by 91.7 percent of patients, and eleven of the twelve men had applied the device themselves. The twelfth injury was iatrogenic: an elderly bedridden patient sustained penile constriction from prolonged condom catheter application by caregivers, an uncommon mechanism the authors highlight as preventable and deserving of greater awareness among caregivers and healthcare workers. Pre-existing psychiatric illness, documented in previous medical records and confirmed by psychiatric consultation after treatment, was present in seven patients, or 58.3 percent. No patient had documented substance abuse or cognitive impairment, and no new psychiatric diagnoses were identified during admission.

Metallic rings were the most frequent constricting devices, accounting for 58.3 percent of cases, followed by metallic bearings at 25.0 percent. The device was most often located at the base of the penis. The median interval from application to hospital presentation was 72 hours, but the range was strikingly wide, extending from nine hours to a full month. Injury severity covered the entire Bhat spectrum, from grade I distal edema without urethral injury to grade V gangrene or complete distal penile amputation, with grade II and grade V injuries the most common in the series. Four patients presented with urinary retention, while none had urethral bleeding at presentation.

Management was individualized according to the material and thickness of the constricting object, the severity of edema, tissue viability and the equipment available. All patients received immediate resuscitation and analgesia, broad-spectrum intravenous antibiotics when skin ulceration, infection or necrosis was suspected, and tetanus prophylaxis per institutional protocol. Removal was performed under penile block in five patients and spinal anaesthesia in seven. The string, or winding, technique was the commonest removal method, used in 41.7 percent of cases, followed by mechanical and electric metallic cutters for thick rigid devices. The mean procedure duration, defined as the time from initiation of removal to complete device removal, was 37.7 minutes with a standard deviation of 22.7 minutes.

Urinary drainage was required in seven patients: four received urethral Foley catheterization where urethral integrity was preserved, and three underwent suprapubic cystostomy, reserved for complete retention, suspected urethral injury, extensive edema precluding urethral catheterization, or gangrene requiring debridement. The mean hospital stay was 7.4 days, with a median of three days and a range of one to thirty days. Non-viable tissue was debrided where necessary, and patients with extensive skin loss underwent reconstructive procedures including split-thickness skin grafting.

Complications were recorded in eight of the twelve patients and were not mutually exclusive. These included partial penile skin necrosis in two patients, skin necrosis with gangrene in one, penile and scrotal gangrene with abscess in one, Fournier’s gangrene in one, urethral stricture in two, penile fracture in one, painful erections in one and testicular atrophy in one. Secondary management included debridement with or without skin grafting in four patients, optical internal urethrotomy for urethral stricture in two, penile fracture repair in one, and partial penectomy with abscess drainage and scrotal debridement in one patient with established gangrene. The penile fracture was diagnosed clinically and confirmed by ultrasonography showing a breach in the tunica albuginea, and the testicular atrophy, identified at six-month follow-up in a patient whose metallic bearing also encircled the scrotum, was confirmed clinically and by ultrasound documenting reduced testicular size and volume.

Functional outcomes were assessed at follow-up with a median duration of 24 months and a range of six to 36 months; one patient was lost to follow-up. Erectile function, evaluated with the five-item International Index of Erectile Function questionnaire, was assessable in ten patients: five had erectile dysfunction, defined as a score of 21 or below, and five had preserved function. Among eleven patients available for urinary follow-up, ten were voiding adequately, two of them after previous urethrotomy for stricture, while one remained on suprapubic catheter drainage. The authors caution that pre-injury erectile function was not systematically documented and individual IIEF-5 scores were unavailable retrospectively, so post-injury erectile dysfunction could not be definitively attributed to the constriction injury itself.

The study’s discussion emphasizes that delayed presentation appeared to be associated with more severe injuries and adverse outcomes in this series, consistent with previous reports. Progressive venous obstruction, worsening edema and eventual arterial compromise explain the high proportion of advanced injuries among men presenting late, and fear, embarrassment and repeated unsuccessful attempts at self-removal probably contributed to the delays. The authors also frame their contribution not as a novel extraction technique but as an integrated clinical description: detailed patient-level functional outcomes, representation of the complete Bhat grade spectrum, inclusion of an uncommon condom catheter-associated injury, routine psychiatric assessment and a retrospectively developed, experience-based stepwise algorithm for device removal. They note that familiarity with multiple extraction techniques is essential because no single method is universally successful, and that cutting techniques require careful protection of underlying penile tissue.

The investigators acknowledge the limitations of their work: a retrospective design, a small sample of twelve patients, a single-centre experience, loss to follow-up in one patient and the absence of systematically documented pre-injury erectile function. No inferential statistical analyses were performed, and missing outcome data were not imputed. Even so, they argue that institutional experiences of rare conditions continue to add valuable evidence, and they call for larger multicentre studies with standardized functional assessment to better define predictors of long-term outcome. Their conclusion distils the practical message of the series: early recognition, prompt decompression, individualized selection of the removal technique based on device characteristics, edema, tissue viability and available expertise, and structured follow-up to detect delayed urethral and sexual sequelae remain the cornerstones of successful management of this potentially organ-threatening emergency.

Subject of Research: Retrospective single-centre case series of penile constriction injuries describing device removal techniques, complications and functional outcomes

Article Title: The trapped penis: contemporary management and outcomes of penile constriction injuries

Article References: Maulik, D., Kannan, G., Mondal, A., Mandal, D., Kumar, K. A., Quadir, U., Jana, A., Halder, I., Nandi, D., & Nayak, J. J. (2026). The trapped penis: contemporary management and outcomes of penile constriction injuries. African Journal of Urology, 32(1), Article 79. https://doi.org/10.1186/s12301-026-00628-9

Image Credits: AI Generated

DOI: 10.1186/s12301-026-00628-9

Keywords: penile constriction injury, urological emergency, Bhat classification, metallic penile rings, condom catheter injury, string technique, retrospective case series, erectile dysfunction, urethral stricture, tertiary referral centre, trapped, penis