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Case 14-1: Penoscrotal entrapment

Patient Presentation

A young male presented to the emergency department (ED) complaining of scrotal and penile pain. He had placed his penis and scrotum through a thick metallic ring approximately 48 hours before presentation.

Figure 14-1.

WA = thick metallic ring at base of scrotum and penis

Clinical Features

The patient’s penis and scrotum were markedly swollen and edematous with a thick metallic ring around the base of his penis and scrotum. There were no external signs of vascular insufficiency or necrosis and no open wounds or ulcers. Abdominal examination was unremarkable, and the bladder was not distended.

Differential Dx

  • Several concerns were extant, including vascular insufficiency of either scrotal contents or of the penis.

  • Urinary retention was not present per patient history and not evident on examination.

Emergency Care

The patient was in moderate painful distress. The patient received 1 mg of intravenous hydromorphone for pain. Deliberations as to how to remove this metallic ring ensued. The initial thought was to place the patient into Trendelenberg position, apply ice to the genitalia, and manually compress the scrotum and penis slowly to reduce the edema and slip the scrotum backwards through the ring. This did not seem like a viable plan given the degree of swelling and concern for vascular injury. The decision was made to cut the metal ring under conscious sedation. Ketamine 1 mg/kg was administered IV. A hand-held rotary tool with a metal cutting disk was utilized for ring removal. The flat blade of an army/navy surgical retractor was slipped between the metal ring and the skin to prevent the cutting disk from causing injury as it cut through the metal ring. Cold water was continuously poured over the metal ring and flat blade of the retractor to prevent the metal from heating and causing burns. Two separate cuts on opposite sides of the metal ring were required for removal. It should be noted that our ED has both a battery powered and 120 V hand-held rotary cutting tool for such a case.

Outcome

The ketamine sedation abated, and the patient had a significant reduction in his pain level. He was observed over several hours, with the edema rapidly resolving. He was able to urinate with no signs of any other complication, and he was discharged home.

Key Learning Points

  • Management of uncommon and novel clinical scenarios often require utilization of novel and innovative procedures. A high-speed, hand-held, rotary tool is one of the nonstandard pieces of equipment emergency physicians will find useful.

  • When using a powered rotary cutter, continuous application of cooling fluid (generally water) to prevent heating of the metal ...

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