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Thread embedded into penile tissue over time as an unusual hair thread tourniquet injury to the penis: a case report
© Okeke; licensee BioMed Central Ltd. 2008
Received: 02 January 2008
Accepted: 16 July 2008
Published: 16 July 2008
Hair thread tourniquet syndrome has been recognized since the 1960s. Since then, sporadic reports have appeared in the literature describing different degrees of strangulation and/or amputation of the penis caused by a hair thread being inadvertently tied around the penis.
A 9-year-old boy presented with a 3-year history of hair thread tourniquet injury to his penis. Instead of the usual strangulation or amputation, the tourniquet had become embedded into the penile tissue, manifesting with exuberant granulation tissue and a tight urethral stricture. At surgery, the intact tourniquet was still in place, embedded in dense fibrous tissue and associated with a dense urethral fibrosis which measured about 2 cm long. The tourniquet was divided and removed, the fibrotic urethra excised and a distal penile pedicled skin flap used to perform a single-stage substitution urethroplasty. The patient has been voiding well for 28 months.
This case is unusual and is the first report of its kind. It is also the first report of a hair thread tourniquet as the cause of pediatric penile injury in Nigeria.
Hair thread tourniquet syndrome has been recognized since the 1960s when a strangulating strand of hair was reported around the penis . The patient usually presents acutely and responds well to removal of the tourniquet . When there is a delay in presentation, partial amputation of the penis is often seen, with varying degrees of urethral transection .
We report the case of a 9-year-old boy who had a hair thread tourniquet on his penis for 3 years, but presented with only urethral stricture and granulation tissue and no strangulation or amputation of the penis.
Hair thread tourniquet syndrome usually occurs in infants and is presumed to be accidental [2, 5]. However, Barton et al., in 1988, reported a case of hair thread tourniquet syndrome due to child abuse . In the case reported here, a 9-year-old boy presented with a 3-year history, placing the incident most probably at age 6 years. He could not recollect the circumstances surrounding the tourniquet application, who had applied it and why it had been applied. He had not even been aware that there was a tourniquet on his penis.
The mechanism of injury in hair thread tourniquet is ischemia in the parts distal to the site of tourniquet application. Presentation in the acute state is usual, with swelling, erythema, circumferential constriction and distal edema  with little discomfort to the child . This aspect of there being minimal discomfort to the child as well as his living with an aged grandmother whose initial recourse had been to native medication for 3 years may have contributed to his late presentation. If the tourniquet is not removed early, there may be progression to skin infection and ulceration, but removal of the constriction at this stage prevents long-term complications. In cases that are not recognized early, the dorsal neurovascular bundle may be transected, leading to the loss of sensation over the glans penis. The corpus spongiosum may become transected, leading to urethrocutaneous fistulation. The corpora carvanosa may also become transected, leading to partial or total amputation of the penis distal to the tourniquet [7–9].
It is worthy of note that even though the patient in the case presented here had his hair thread tourniquet for more than 3 years, there were no ischemic skin changes, no loss of sensation over the glans penis, and no urethrocutaneous fistulae. It is particularly unusual in that there was no degree of amputation of the part distal to the tourniquet. There was not even a discernible depression along the site of the tourniquet. The ultimate location of the hair thread was immediately subcutaneous, as if the tourniquet had 'sunk in' through the skin, embedded in fibrous tissue, with the intact dorsal neurovascular bundle running deeply in this. The granulation tissue associated with the ring scar reached only as far as the dense fibrous tissue surrounding the hair thread and did not seem to be related to the urethra.
The reason why this patient presented in this manner is not immediately apparent. It could be postulated that the hair thread tourniquet was not too tightly applied in the first place. The degree of ischemia was therefore not extreme and the associated tissue damage was minimal. Over the years, as the patient's penis grew, the intact tourniquet was gradually incorporated into the substance of the penis.
This case is peculiar and is the first report of its kind. It is also the first report from Nigeria of a hair thread tourniquet being the cause of pediatric penile injury.
Written informed consent was obtained from the patient's next-of-kin for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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