In 1755 the first case of penile strangulation has been reported in literature. Adults use foreign bodies on the penis for sexual gratification [1] . They mostly use rings, nuts, plastic bottles, wedding rings etc. for sexual gratification which may result in penile strangulation. Children may use rubber bands, threads or hair coils out of curiosity [2] - [4] . Metallic or non-metallic objects like beverage bottle are usually put on the penis by the patient himself for masturbation or by his female partner to prolong erection [5] - [8] . Constricting object compresses veins and lymphatic and results in penile edema and necrosis. As these patients cannot remove such constricting objects themselves, so they always seek medical advice. Due to a fear of social stigma, usually these patients seek medical advice quiet late and present with complications. Varieties of objects, cause of strangulation, degree of injury and treatment modalities are different for each patient [7] - [10] . Removal of these constricting articles is usually demanding for treating surgeons. Depending on the type of constricting material, special equipment is essential for successful removal of the foreign bodies. We share our experience of managing penile strangulation in two patients: one with nozzle of a cut plastic bottle and another with metallic ring.

Metallic or non-metallic objects like beverage bottle are usually put on the penis by the patient himself for masturbation or by his female partner to prolong erection [5] - [8] . These abnormal articles around penis may cause penile strangulation injuries. These injuries range from simple penile engorgement to ulceration, necrosis, urinary fistula or even gangrene.

Different causes of penile injuries are like strangulation injuries, zipper injuries, due to use of erection- inducing devices, sexual abuse, and torture. In some social culture, penis is wrapped deliberately with strangulating objects in an effort to protect against evil spirits or to treat urinary incontinence or nocturnal emissions [11] . Penile strangulation by metallic rings is most difficult to manage, as it may stop arterial supply, lymphatic flow and thus causes gangrene. Sometime it may result in amputation [12] .

AL Bhat et al. (1999) graded these injuries as follows [6] .

Grade I Edema of distal penis. No evidence of skin ulceration or urethral injury.

Grade II Injury to skin and constriction of corpus spongiosum but no evidence of urethral injury. Distal penile edema with decreased penile sensation.

Grade III Injury to skin and urethra but no urethral fistula. Loss of distal penile sensations.

Grade IV Complete division of corpus spongiosum leading to urethral fistula and constriction of corpus cavernosa with loss of distal penile sensations.

Grade V Gangrene, necrosis, or complete amputation of distal penis.

As these patients cannot remove such constricting objects themselves so, they always seek medical advice. Mostly these patients come with complications due to late presentation. The evaluation of penile strangulation can be done by local temperature, sensation, color, ability to void, distal pulsations and local tissue injury at the site of constriction. In case of absent pulsations the distal blood flow can be checked by Doppler flow meter or wood lamp examination after IV Fluroscein [13] .

The choice of method for removal depends upon type, size, incarceration time, trauma grade, and availability of the equipment to remove the constricting object. Prompt diagnosis and early treatment are essential to avoid the potential complications of ischemic necrosis and auto amputation. Removal of such devices is usually challenging and often requires imagination and a multidisciplinary approach [14] .

Treatment techniques for penile incarceration can generally be divided into four groups: the string technique and its variants, with and without aspiration of blood from the glans; aspiration techniques; cutting devices; and surgery [15] . In our first case, cutting device, bone cutter was used and in second case, the string technique was used.

After the removal of the object the urethra should be evaluated radiologically. If grade III-V injuries are found, urinary diversion should be done via suprapubic puncture. In grade I and II injuries, simple emptying of the bladder by urethral catheterization maybe required. But more severe cases may require suprapubic cystostomy, urethral reconstruction, degloving and skin grafting or sometimes amputation.

To our knowledge, our first case is the second report of a penile trap in a PET bottle nozzle and 3^rd case of penile strangulation with bottle nozzle. Rigidity of the material is extremely high, especially as these bottles are manufactured for recycling purpose.

Our 1^st case had grade I injury and 2^nd case had grade II injury. In both the cases constricting article were removed. In 2^nd case skin grafting was done. Both patients improved without any complication like impotence or stricture urethra.

Use of various abnormal articles around the penis for sexual gratification or due to perverted behavior may be sometime due to paraphilia. These patients should always undergo a psychosexual assessment. Hypersexuality can change sexual behaviors. The etiology of hypersexuality is multifaceted and engages a variety of physiological and psychological mechanisms. Malfunctioning of Frontal lobe can result in bizarre and hypersexual behavior [16] . The psychosexual assessment is essential to prevent such episodes of bizarre behavior in future.

Penile strangulation is a serious injury requiring urgent attention and intervention to prevent the complications. Aim should be restoration of blood supply and micturition with least discomfort to the patient. Removal of these constricting articles is usually demanding for treating surgeons as there are chances of injury to the penis of patient. Depending on the type of constricting material, special equipment is essential for successful removal of the foreign bodies. Long-term follow-up with micturating cysto-uretherogram (MCU) and uroflowmetery is necessary. Such patient should always undergo a psychosexual assessment to prevent such incident in the future. These days sex toys are available in the market and can be utilized for sexual gratification.

Snigdha Goyal,Isha Saini,Sunder Goyal, (2015) Strangulation of Penis: Two Cases Report & Review. Open Access Library Journal,02,1-5. doi: 10.4236/oalib.1101594