Article

A novel, nonoperative treatment for delayed penile zipper injury

Correspondence 419

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  • A novel, nonoperative treatment for delayed penile zipper injuryB,BB

    To the Editor,

    Penile injuries are relatively uncommon but nonetheless challenging to treat when they occur. Penile zipper trauma occurs most commonly in uncircumcised boys who accidentally entrap the foreskin during hastened dressing or undressing and present for medical evaluation shortly thereafter. Delayed presentation and comorbidities may complicate treatment in the adult patient who sustains this injury. We report the case of an adult patient on Antiplatelet therapy who sustained significant penile zipper entrapment and its management.

    A 64-year-old circumcised gentleman presented to the emergency department (ED) after accidentally trapping the ventral skin of his penile shaft in the zipper of his jeans. The episode occurred shortly before anticipated sexual inter- course with the penis in a semierect state while quickly zipping up his “lucky pants” in the absence of underwear. Exhaustive attempts to free himself were unsuccessful, but embarrassment delayed his presentation for over 24 hours.

    ? Sources of support: None.

    ?? Presentation(s): Abstract presented at the 86th annual meeting of the North Central Section of the American Urological Association on October 13, 2012, in Chicago, IL.

    Of note, the patient was on clopidogrel for secondary Stroke prevention at the time of the incident.

    On examination, the patient had entrapped approximate- ly 1 cm of skin from the middle third of the ventral penile shaft between the anterior and posterior faceplates of the zipper’s fastener (Fig. 1A). Before his arrival, he already had cut away the attached zipper from his pants, leaving only the fastener and a small segment of metal teeth on either side of the median bar. The entrapped penile skin was edematous and mildly erythematous without necrosis or active bleeding.

    local anesthesia was performed by dorsal penile nerve and circumferential ring block with 2% lidocaine without epinephrine. Given the patient’s pharmacologic platelet dysfunction, we were careful not to cause bleeding. Multiple attempts to free the zipper with lubricant failed. Attempts at prying open the faceplates with hemostats also were fruitless given the strength of the zipper mechanism. Consideration was given to cutting the median bar of the fastener with bone cutters; however, significant edema of the entrapped skin precluded access to the median bar.

    A stainless steel ring cutter with a plier-like design, which was available in the ED, was used to longitudinally saw through the anterior faceplate of the zipper mechanism just lateral to the median bar (Fig. 2). After coming through the faceplate, the entire zipper assembly fell apart, freeing the entrapped skin. Surprisingly, examination of the underlying skin revealed only a minor abrasion and a healthy bleeding skin edge (Fig. 1B). The wound was irrigated, and hemostasis was achieved with gentle pressure. The cutting procedure was well tolerated and lasted approximately 5 minutes. The patient was dis- charged home the same day with twice-daily bacitracin application to the wound and a short course of oral antibiotics. On follow-up, the wound had healed well without permanent scarring, impaired erectile function, or penile curvature.

    Penile zipper entrapment is a challenging management problem, especially when complicated by delayed presen- tation and medical comorbidities. Entrapment of skin within the fastener itself, as in this case, is the most problematic scenario [1]. Various methods of zipper removal have been described previously, both surgical and nonsurgical, including manual disengagement of the zipper with lubrication [2], cutting the median bar with bone cutter or hacksaw [1,3], prying open the fastener [4- 6], or surgical excision of the involved skin [7,8]. In this case, all of the aforementioned nonsurgical techniques proved unsuccessful, a problem commonly encountered in the literature [9], possibly owing to the edema of the entrapped skin. Immediate surgical intervention was less desirable given the patient’s platelet dysfunction and interest in preserving the involved skin. To our knowledge, this is the first report of using a ring cutter for this indication. When other techniques have failed or are

    420 Correspondence

    Fig. 1 Penile skin entrapped in zipper fastener before (A) and after (B) extrication.

    contraindicated, division of the posterior faceplate with a ring cutter is a readily available, effective, atraumatic option for nonoperative zipper removal with good cosmetic and functional outcomes.

    Special thanks to Matthew Fabec, PA-C for his assistance with photography.

    Matthew J. Maurice MD Edward E. Cherullo MD

    Urology Institute university hospitals Case Medical Center

    Case Western Reserve University School of Medicine

    Cleveland, OH 44106, USA E-mail address: [email protected]

    http://dx.doi.org/10.1016/j.ajem.2012.08.034

    Fig. 2 Stainless steel ring cutter (A) and metal zipper fastener following division of the anterior faceplate (B).

    References

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    2. Kanegaye JT, Schonfeld N. Penile zipper entrapment: a simple and less threatening approach using mineral oil. Pediatr Emerg Care 1993;9: 90-1.
    3. Flowerdew R, Fishman IJ, Churchill BM. Management of penile zipper injury. J Urol 1977;117:671.
    4. McCann PA. Case report: a novel solution to penile zipper injury–the needle holder. ScientificWorldJournal 2005;5:298-9.
    5. Mishra SC. Safe and painless manipulation of penile zipper entrapment.

      Indian Pediatr 2006;43:252-4.

      Raveenthiran V. Releasing of zipper-entrapped foreskin: a novel nonsurgical technique. Pediatr Emerg Care 2007;23:463-4.

    6. Ezell WW, Smith EI, McCarthy RP, et al. Mechanical traumatic injury to the genitalia in children. J Urol 1969;102:788-92.
    7. Mydlo JH. Treatment of a delayed zipper injury. Urol Int 2000;64:45-6.
    8. Mellick LB. Wire cutters and penis skin entrapped by zipper sliders. Pediatr Emerg Care 2011;27:451-2.

      Clinical, laboratory, and educational challenges of diuretic dopingB,BB

      To the Editor,

      We read the article by Mayr et al [1] with great interest. Since antiquity, unethical athletes have attempted to gain an iniquitous competitive advantage by using one or other doping substances. A list of doping substances banned in sports is published yearly by the World Anti-Doping

      ? Financial support – Nil.

      ?? Conftict of interest – Nil.

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