Visual Diagnosis: Pearling: a case study

"Pearling," also known as "genital beading" is the practice of permanently inserting small beads made of various materials beneath the skin of the genitals [1]. As well as being an aesthetic practice, this is usually intended to enhance the pleasure of partners during sexual intercourse by increasing physical stimulation. It is most commonly done on the dorsal surface of the shaft of the penis where small, superficial incisions are made and beads are placed under the skin surface. Most implants are made of small inert metal beads (stainless steel, titanium) or plastic beads (nylon, silicone).This form of body modification is still practiced in various world cultures. Historically, the Yakuza of Japan, an organized crime syndicate, is the most well known for "pearling." Each pearl supposedly symbolizes each year that was spent in prison. Interestingly, "pearling" has become more commonplace in the United States, especially in the US prison system.A 19-year-old male inmate presented to our Emergency Department (ED) after attempting to purposefully cut the dorsal surface of his penis with a brand-new razor blade for self-performed "pearling." He made two horizontal incisions on the shaft, one proximal and close to the base of the penis, and one distal near the glans penis. This was performed approximately 6-7 h prior to arrival at the ED. The patient alerted the prison staff to request medical evaluation after he noted worsening pain, swelling and ecchymosis to his penis, as well as a significant amount of blood when urinating. Upon arrival, the patient appeared to be in no acute distress, without obvious active bleeding. He denied dysuria.In the Emergency Department, the patient's initial vital signs were: temperature of 37°C, pulse of 84 beats per minute, respiratory rate of 16, and blood pressure of 141/88 mmHg. His airway was patent with clear, bilateral breath sounds and unlabored breathing. On cardiac exam the patient had a regular rate and rhythm. His abdomen wa