What is Penile Zipper and Ring Injuries?
Zipper-related injuries to the penis are actually the most common type of injury to the penis in adults, with a reported 2,000 cases each year. Many men who experience this type of injury end up going to the emergency department after attempts to fix the issue at home fail. The injury often results in swelling, pain, bruising and build-up of fluid in the tissue. It’s important to note that many adult patients may delay seeking medical help due to embarrassment, which can impact the speed and effectiveness of treatment. This type of injury is most common in children.
For those who aren’t aware, the condition of penis skin or foreskin caught in a zipper is technically referred to as a “zipper-related penile injury” (ZIRPI) and has been recognized since 1936. Zippers, which were invented about 100 years ago by a Swedish-American engineer named Gideon Sundback, originally raised concerns about “possible genital mishaps.”
Penile rings, on the other hand, are typically used for enhancing erections and are often used for sexual gratification. Although it’s rare, the ring can sometimes get trapped at the base of the penis or behind the area where the penis connects to the scrotum. In such instances, the ring can restrict blood flow, causing the penis to become extremely swollen, starved of blood (ischemic), and painful. Without prompt treatment, this can lead to a serious condition where tissues die (necrosis) or even develop gangrene. Because of this, emergencies involving penile ring entrapments are considered serious situations in urology (the branch of medicine that deals with the urinary tract in men and women, and the reproductive system in men) and must be dealt with promptly.
What Causes Penile Zipper and Ring Injuries?
Zipper injuries often happen to young children who are dressing and zipping up while their attention is elsewhere. It’s not uncommon for young kids to get easily distracted. Adults can also experience zipper injuries, but it’s less frequent. This typically happens when a caregiver or relative is zipping up the clothing, as seen with patients with dementia or individuals with disabilities that limit their ability to dress themselves fully. For boys, only injuries from toilet seats are more common than zipper injuries. It’s uncertain if not wearing underwear plays a role in this. Some factors known to increase the risk of zipper injuries include being under the age of 18, not being circumcised, and needing help with dressing.
A penile ring entrapment happens when a ring is put around the penis, typically for erotic reasons, and the wearer can’t remove it. As a result, blood accumulates in the veins leading to swelling, decreased blood and lymph fluid flow, bruising, a bluish color, poor tissue oxygen supply, tissue death, and can even progress to gangrene (dead tissue due to lack of blood flow). Usually, it’s adults who experience this issue and they often delay seeking emergency medical help because they feel embarrassed. This delay often results in more severe injuries by the time they seek medical care.
Risk Factors and Frequency for Penile Zipper and Ring Injuries
Zipper injuries mostly happen in children and teens, but they’re pretty rare. They make up less than 0.5% of all emergency visits for kids. Most often, it happens when the foreskin gets caught in the zipper because of distraction or inattention. This can also happen to adults who can’t dress themselves due to conditions like dementia, traumatic brain injury, cerebral palsy, or spinal cord injuries. Other people have to help them with dressing.
Since zipper injuries to the penis are so rare in adults, people who provide care often don’t see it as a risk. However, it can be a serious injury if the patient can’t feel anything in their genital area or can’t communicate that they’re hurt.
Penile ring entrapments are also really rare, with less than 100 cases reported in medical literature. It mostly happens in adults between the ages of 15 and 56 years, and can last from 3 hours to a month. In young children, hair can unintentionally cause a similar issue, known as penile hair strangulation. This can make it look like another condition called paraphimosis. This usually happens at around three years of age, but it’s been reported in boys from newborns up to five years old.
Signs and Symptoms of Penile Zipper and Ring Injuries
Patients experiencing complications from a zipper injury or a ring entrapped around the penis or scrotum often feel significant pain and embarrassment when discussing the situation. It’s important for medical professionals to handle these cases with discretion and respect. Zipper injuries often partially involve the head of the penis, but some might result in skin tears and extensive tissue damage.
Injury from ring entrapment around the penis or scrotum is usually clear upon physical examination. However, sometimes, there may be so much swelling that the ring is not immediately seen. The complication becomes trickier if the ring is entrapped around the base of the scrotum, making removal more complex.
The majority of patients or caregivers might have already tried to remove the entrapping object manually. Unfortunately, these attempts often lead to further tissue damage and delay the patient’s arrival at the Emergency Department, resulting in more pain, swelling, bruising, and tissue destruction.
A grading system for assessing the severity of ring entrapment injuries has been suggested. According to Dawood et al.,
- Grade 1 involves swelling at the end of the penis with only minor skin damage.
- Grade 2 covers injuries with significant damage to deep tissues, affecting the urine tube (urethra) and/or erectile tissues (corpora).
- Grade 3 includes formation of abnormal connections (fistulas), extensive tissue loss, death of tissues (necrosis), or decay (gangrene).
Testing for Penile Zipper and Ring Injuries
Diagnosing the condition is usually straightforward and can often be determined based on your description of symptoms and a physical examination by a doctor. There’s typically no need for any special lab tests or imaging procedures like X-rays or scans.
Treatment Options for Penile Zipper and Ring Injuries
If a zipper catches and injures skin, the preferred solution is to try and remove or dismantle the zipper gently without needing surgery. This should be done with great care to avoid causing any extra damage to the area.
If the zipper has trapped some skin, there are various steps that can be taken in the Emergency department, usually without needing any sedation or anesthetics. One method is to use a narrow elastic wrap to compress the swelling around the area which has been injured. This can help to reduce the swelling, making it easier to handle the zipper and remove it. Usually, doing this for around 20 minutes is enough.
Once the swelling has been reduced, a mineral oil can be applied to the area to help soften the skin that has been caught by the zipper. However, if this process isn’t successful, it can make the skin and zipper slippery, making other attempts to remove the zipper more difficult.
The next step is to try and take apart the zipper to free the skin that has become trapped. Scissors or wire cutters can be used to cut the cloth part of the zipper which should make the individual teeth of the zipper fall out, therefore freeing the skin. It’s possible to do this without needing any sedation or local anesthetic.
Various tools can be used to cut the zipper, including a small hacksaw, scissors, bone cutter or wire cutters. Alternatively, needle-nosed pliers can be used to press the central bar on the zipper from both sides. This can loosen the zip and free the skin. Cutting the cloth around the zipper may be needed if pliers can’t easily reach the central bar. Another option is to use the flat end of a screwdriver to force the zipper open.
If these methods aren’t successful, a local anesthetic may be applied, particularly for children. In adults and older children, a “penile block” can be applied to immediately relieve pain and allow for more manipulation of the area.
In some extreme cases, part or all of the skin around the penis may need to be removed, or even the whole foreskin, in which case a urology consultation is generally recommended. Circumcision is only considered as a last resort when other methods have proven unsuccessful. Any attempts to forcefully manipulate the area without adequate pain relief should be avoided as this can be very uncomfortable for the patient.
In cases where a ring has become trapped around the penis, there are two main ways it can be removed: sliding it off or cutting it off. Initially, the sliding technique is recommended as it’s usually the easiest and quickest method. Some sort of lubrication such as mineral oil, machine oil or even olive oil can be used to aid the process. For slippery rings, thin elastic tape can be used to provide traction to the ring.
If the sliding technique isn’t successful, the ring will need to be cut off. This is often easier with non-metallic rings but can still be achieved with metallic rings using tools such as scissors, a ring cutter, orthopedic pin cutters or a Gigli saw. If these tools aren’t successful, stronger, electrical saws might be needed, but this should be done while the patient is under general anesthetic to ensure safety.
What else can Penile Zipper and Ring Injuries be?
Generally, the diagnosis is clear and evident from a direct examination. However, there are some conditions that could potentially lead to confusion. These include:
- Balanoposthitis (caused by an infection or contact)
- Contact dermatitis (skin rash caused by contact with certain substances)
- Insect bites
- Paraphimosis (an inability to move the foreskin back to its usual position)
- Penile amputation
- Penile contusion (bruise)
- Penile fracture
- Penile hair strangulation
- Penile laceration (cut)
- Penile paraphimosis (a condition where the foreskin can’t be retracted)
- Penile trauma
- Postinstrumentation complications, such as those from indwelling catheter insertion
- Sexual assault
- Traumatic epididymitis (inflammation of the tube at the back of the testicle)
- Urethritis (inflammation of the urethra)
What to expect with Penile Zipper and Ring Injuries
The outcome is usually positive, even for those with serious soft tissue damage. Patients with urethral injuries may develop narrow areas called strictures. More serious injuries may need specific treatments like grafting or other repair techniques.
Possible Complications When Diagnosed with Penile Zipper and Ring Injuries
Some of the possible complications after this type of surgery include the narrowing of body passage (stricture formation), partial or entire removal of the penis (self-amputation), abnormal connection between organs (fistula formation), cell death (necrosis), tissue death (gangrene), and even death.
Possible complications:
- Formation of stricture
- Partial or total self-amputation of penis
- Fistula formation
- Necrosis
- Gangrene
- Death
Recovery from Penile Zipper and Ring Injuries
Normal wound care is typically enough for the wound to heal properly. Topical or pill-form antibiotics are not commonly needed. However, for patients with more serious injuries, they might be recommended.
Preventing Penile Zipper and Ring Injuries
To prevent future incidents of zipper injuries, patients are advised to wear protective undergarments. For cases where a penile ring gets trapped, patients are advised to explore other methods for personal satisfaction. These precautions can help avoid any unpleasant or painful incidents in the future.
