Acute preputial strangulation secondary to hair tourniquet syndrome

Hair tourniquet syndrome is a rare condition in which a hair somehow becomes tightly entangled around an appendage such as a toe, finger or genitals, acting like a tourniquet.1 This can hinder venous blood flow, resulting in swelling and edema, which in turn further tightens the tourniquet. Ultimately, this may lead to tissue necrosis and severe damage to the affected area. In the penile hair tourniquet syndrome subset, the condition has been reported to occur mostly spontaneously but some have been reported to be self-inflicted or purposeful, in an attempt to manage nocturnal enuresis. Most frequent reported symptoms are edema (31%), urinary symptoms (17%), and in only 9% pain. Average age of debut is 5.1 years (5 months to 12 years).1 We report, here, a mild case of penile hair tourniquet syndrome where early proper care was taken to ensure no severe complications occurred as has otherwise been described in the literature.2, 3 A mother contacted the on-call urologist late in the evening, because of what she saw during diaper change before bedtime on her almost 3-year-old boy. A hair was tangled around the distal end of the prepuce, which was also seen to be very swollen. The boy had been in day care the whole day. Diapers were usually changed throughout the day there; however, the diaper was wet and an estimated maximum of 12 h had passed since the last diaper change. The boy was well and did not complain of pain. The parents were able to remove a single strand of black hair, but the prepuce remained very swollen. Interestingly, neither of the parents had black hair. Photo documentation was sent to the urology department to assess (Figure 1). Since the hair was already removed, a check-up visit was planned the following day. When the boy was assessed, parents reported that there was a clear regression of the edematous prepuce since hair removal. The boy was well and playing and showed no signs of pain or discomfort. On examination, no injuries to the glans, which was seen with normal color tone, nor signs of damage to the penile skin, were noted except for preputial edema. Furthermore, no suspicion or signs of abuse were noted, which has been reported in other cases.1 The boy was seen again 1 week later. The prepuce was still slightly edematous but otherwise unremarkable and no problems with voiding were recognized. No indication was therefore found for ultrasound examination and no further follow up was planned. Hair tourniquet syndrome is a subcategory of penile strangulation often seen with hair wrapped around the coronal sulcus, thereby functioning as a tourniquet. In the literature, various complications related to longstanding strangulation have been reported such as urethrocutaneous fistulae, complete urethral transection, penile gangrene, and penile amputation.1, 4-7 Prevention is easier the earlier the correct diagnosis is acknowledged because worsening edema obscures the hair and renders its removal a difficult task. Hair tourniquet syndrome is rare, and thus awareness of its existence as a differential diagnosis is important when encountering patients with penile edema and urinary symptoms, as prompt diagnosis and proper management is vital to ensure that it does not lead to severe complications. Anders Munk wrote the manuscript, and Martin Skott, Yazan F. Rawashdeh revised it critically. All three authors contributed to the design, conception, and literature review. All authors read and approved the final manuscript. The authors declare no conflict of interest. Informed consent was obtained from the parents.