A25-year-old man presented to the ED complaining of pain, swelling, and erythema of his glans penis. The patient reported that this developed after having a new bar penile piercing five days earlier.
He had increased penile pain in his glans and swelling with painful bilateral inguinal lymphadenopathy for three days. The pain made it difficult for him to walk, and he was concerned because he felt his urine stream was obstructed and spraying. The patient reported that each night he was wrapping his penis in toilet paper and then placing a condom over the toilet paper as directed by his piercing studio.
Vital signs were within normal limits. Examination revealed erythema of the glans penis. Two piercings are present on the ventral surface near the base. A Prince Albert piercing with a ring was coming out of the urethral meatus on the ventral side. The new bar piercing travels transversely through the glans penis.
Body piercing dates back to at least 3000 B.C. It is documented in wall carvings, paintings, and sculptures of the body. Some sources state body piercing may have originated with the Hindu religion, but it has been documented in tribal societies on all continents, especially in Africa, Asia, and South America. These piercings have represented rites of passage from adolescence to adulthood in some cultures.
The Prince Albert, a penile ring through the urethral meatus that exits on the ventral surface, dates back to the Victorian age. The piercing is named after Queen Victoria's husband, who is rumored to have worn the ring to secure his genitals to his leg while wearing a tight uniform. Little documentation was made about piercings in western society until World War II, but it is believed that tattooing and piercings of the labia and nipple were performed before the war.
The punk movement in 1970s Europe reignited an interest in body piercing. This started with the use of safety pins, but allergic reactions prompted piercers to use different alloys to reduce undesirable reactions.
Body piercing has increased in all age and socioeconomic groups in western society. Several studies cited a range 33 percent to 51 percent in the number of Americans getting at least one piercing in their lifetime.
Complications depend on the experience of the piercer, sterility of the piercing technique, and wound care by the customer. The most common complications associated with piercings are local infection and bleeding. Local infection was reported in 10 percent to 30 percent of piercings. The most commonly isolated species are Staphylococcus aureus, group A streptococci, and Pseudomonas.
Case reports also have documented the transmission of hepatitis B and C through piercings, but several other methods of transmission are possible for these cases. Additional research is needed to evaluate body piercing as a risk factor for viral hepatitis. Risks of acquiring hepatitis and other sexually transmitted diseases also depend on the hygiene practices of the individuals with piercings.
Case reports stemming from body piercings include sepsis, endocarditis, toxic shock syndrome, and pneumonia. Those with pre-existing cardiac disease are at substantial risk of developing endocarditis after a piercing. These patients should refrain from piercings or be pretreated with prophylactic antibiotics prior to the procedure.
Over the past decade, metal allergies associated with piercings have increased. The most frequent contact allergen is nickel sulfate at 13 percent. Gold also has been on the rise recently with rates of 0.78 percent to 13 percent. The European Nickel Directive set threshold values for nickel content, but limits are often ignored. These restrictions do not exist in the United States. Piercing also can be the cause of sensitization to an allergen. One study found metal sensitization of four percent in men without piercings, 11.1 percent in men with one piercing, and 14.6 percent in men with two or more piercings.
Genital piercings may show pronounced delay in wound healing, which may take up to one year. This can be delayed further by sexual intercourse and bike riding. Local and systemic infection can arise; episodes of Fournier gangrene have been reported. Genital piercings also have been documented to initiate paraphimosis.
Hemorrhage is another complication of penile piercing. Where the piercing crosses through the glans (known as a Palang), the spongy body of the penis can be damaged, leading to massive hemorrhage. One young man developed a case of traumatic hypospadias after a piercing was torn out during sexual intercourse. This injury required surgical repair for a glandular hypospadias.
Skin traumatized by piercing may increase the susceptibility of papillomavirus infection. One 22-year-old man presented with a 5 mm exophytic growth on his penis. The patient had a previously healed piercing over the area; he was treated with liquid nitrogen and podophyllin.
Another incident involved an uncircumcised man who presented with paraphimosis three days after he had the ventral portion of the glans of his penis pierced. The swelling caused by the piercing prevented him from retracting his foreskin. Following a penile block, his foreskin was manually reduced.
Piercing as a potential source of HIV-1 transmission also has been documented. One patient, who was reportedly not sexually active, received multiple piercings to multiple areas of his body; he had piercings to his penis, scrotum, nipples, umbilicus, tongue, chin, eyebrows, and nasal septum done at three different piercing parlors. Although the sources of his HIV-1 transmission was not confirmed, there is a high suspicion that he obtained HIV from one of the piercings.
Regulations vary from state to state. The industry is highly unregulated, and no agency is responsible for certification in piercing, which leads to a wide variation in piercing practices. No standards on sterilization methods and antibiotic use exist either. This is left up to interpretation by the piercer. Although several associations exist and online interest groups share sterilization techniques and hygiene, only a few states have regulations in place for body-piercing establishments.
Dr. Patee is an emergency medicine resident at Geisinger Medical Center; Ms. Farrah a fourth-year medical student at the Philadelphia College of Osteopathic Medicine; and Dr. Strony is an associate professor of emergency medicine at Geisinger Medical Center.
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