Spontaneous extrusion of male genital pearling.

Pearling is a practice of inserting small beads beneath the skin of the genitalia. Patients generally underwent this practice believing that this would have made their penis bigger and able to better satisfy their partners during intercourse. Pearling can cause complications. We report a case of spontaneous extrusion of genital pearling exiting in a granuloma of the inner face of the foreskin.

Introduction

Genital pearling (or simply, pearling) is a practice of permanently inserting small beads made of various materials (metal, stainless steel, titanium, plastic, nylon, silicone) beneath the skin of the external genitalia., Pearling is also known in medico-legal literature as artificial penile nodules, observed during the external autopsy examination.

The purpose of this practice varies according to the different cultures and geographic places. Although it is peculiar in Asian societies, it has become increasingly popular also in Europe. Initially a symbol of prisoners, the implantation of beads beneath the penile skin is often performed with the aim of enhancing sexual performance and partner pleasure during intercourse even if the removal of the implanted objects because of usefulness or complications is after a short time not rarely required.

Case presentation

A 35-year-old Romanian male patient, in prison for drugs traffic, asked urological consultation because of a cutaneous lesion in the dorsal aspect of his penis following the spontaneous extrusion of a not collected plastic object which he implanted himself one year before, during the prison stay. He had been encouraged by his fellow inmates to modify his penis with the aim to enhance the sexual pleasure of his future female partners and to symbolize his crime story. On physical examination a six mm pinky lesion was into the inner face of foreskin evident (Fig. 1), it was painless, relatively hard with the typical aspect of a granuloma. The patient initially asked only for the removal of the scarring lesion, but after in-depth interview, we performed complete circumcision in order to guarantee better functional and esthetical results. The outer face of the prepuce was incised at the level of the coronal sulcus. Then, after retracting the foreskin, the second inner incision was performed about 5mm from the edge of the glans. The skin between the two incision (including the scar lesion) was sharply divided and freed from the dartos layers by electrocautery. The edges of the shaft skin were finally sewn to the new preputial collar using 3-0 absorbable sutures. At one month follow up the patient showed good compliance.

Fig. 1

Granuloma after spontaneous extrusion of a dorsal penile pearl.

Discussion

We retrospectively reviewed all the cases of male genital pearling come to our attention in the last 10 years of clinical and medico legal activity at our tertiary referral center in Italy. Totally five cases of male genital pearling were reviewed in our casuistry, four in clinical and one in medico legal setting. Table 1 summaries some notable findings of male genital pearling of our casuistry.

Table 1

Male genital pearling some notable findings.

Age	Prison/years	Drugs abuse	Procedure	Reason of implantation	No. of objects/Size, mm	Material	Reason of medical/forensic examination	Conclusion
39	Yes/12	NA	NA	NA	8/7	Plastic	Post-mortem	Autopsy findings
37	Yes/5	No	Self-made	Partner sexual pleasureCriminal symbolism	1/8	Plastic	Willing to remove it	Removed by circumcision
35	No	No	Self-made	Partner sexual pleasureReferred small penis	1/10	Silicone	Voiding disorders and pelvic pain	Still carrying
32	No	No	Private surgical setting	Partner sexual pleasureReferred small penis	2/3	Silicone	Willing to remove them	Surgically excised
35	Yes/7	Yes	Self-made	Partner sexual pleasureCriminal symbolism	1/NA	Plastic	Scarring after spontaneous extrusion	Circumcision

All the patients had made pearling in order to enhance partner sexual pleasure, one patient (the case presented) had spontaneous pearl extrusion with scarring, two patients willing to remove them and just one patient wanted to maintain it. One case with eight pearls in prepuce and scrotum was observed during autopsy in a killed man with previous criminal history. In all the cases except one, pearling was self made. The material used was silicone or plastic with a diameter varying from three to ten mm.

The origin of pearling could be found in the ancient Southeast Asia. The practice was discussed in the Kamasutra, as a method to increase sexual pleasure. Several centuries later, Antonio Pigafetta, the Italian chronicler of Magellano's circumnavigation, wrote that in the Philippine Islands, both young and old males pierced their penis in order to enhance the female pleasure during intercourse.

The practice of pearling has been reported to be more prevalent in those men of the lower socioeconomic status, prisoners, seamen, soldiers and drug addicts. Young people suffering from dysmorphophobia sometimes implant genital beads in order to ameliorate the appearance of their penis (often considered too small) and to enhance their partner sexual pleasure usually. This practice still has an important symbolic meaning in criminal culture. 22% of the prisoners in Japan had penile implants; the most part of them were members of the Yakuza criminal organization that was characterized by strict behavioral code and ritual practices of body modification with the aim to demonstrate loyalty to the clan. Implantation procedures in prison are usually self made under primitive conditions without using anesthesia and antiseptics. The penile skin is pierced using a sharp pointed object (a ballpoint pen, sharpened piece of plastic, iron rod, spoon, knife or razor), and the foreign body is pushed under the penile skin through the small incision. The beads may be inserted at different parts of the penis, dorsally (more frequently) or ventrally.

Fixed beads can cause rupture of condoms and this can be a cause of higher HIV and other sexual disease transmission.

Penile edema, infection, scarring, pain during erection, skin erosion are the most frequent complications. Penile pearling can be dangerous also for women causing abrasions and a few days of post-coital vaginal pain. We reported one case of spontaneous pearl extrusion with an evident inner face foreskin granuloma that imposed circumcision. The exeresis of the scar lesion alone would have determined an asymmetry of the preputial skin with a doubtful aesthetic result as well as the risk of scarring defects and consequently phimosis. No similar complication has been still reported.

Conclusions

Pearling appear to be quite rare in our geographical area;

Pearling could reveal previous patient experiences as patient imprisonment, actual or previous history of drug abuse or it could be just an expression of dysmorphophobia;

Pearling can cause discomfort or more severe complications to the patient who often asks for removal.

The sexual utter uselessness, its risk of complications, should always discourage this practice.

Authors declarations

The work described has not been published previously and is not under consideration for publication elsewhere; its publication is approved by all authors and tacitly or explicitly by the responsible authorities where the work was carried out; if accepted, it will not be published elsewhere in the same form, in English or in any other language, including electronically without the written consent of the copyright holder.

Informed consent and patient details

The local Ethics Committee of Policlinic Hospital of Palermo (Italy) approved the retrospective review of the selected cases (Reg. No. 11/2019), with written consent by patients.

Author contributions

MV: the conception and design of the study, acquisition of data, analysis and interpretation of data, drafting the article; AA: the conception and design of the study, acquisition of data, analysis and interpretation of data; SZ: acquisition of data, analysis and interpretation of data; AL: the conception and design of the study, acquisition of data; CP: acquisition of data, analysis and interpretation of data, drafting the article; AS: revising it critically for important intellectual content, final approval of the version to be submitted.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

None.