Zipper injuries that cause damage to the penis are quite uncommon. When they occur, the individual often presents to the emergency department with the prepuce stuck in the zipper after having tried unsuccessfully to manage this at home. There may be swelling, pain, bruising and edema related to this injury. The majority of affected patients are children. The majority of patients are extremely reluctant to come to the hospital for this type of problem, which can cause delays in presentation.
Typically, this injury will occur in young children who are distracted or inattentive to zipping. Less commonly, zipper injuries happen in adults. However, if it occurs, this will typically happen when the zipper is being closed by someone else, in patients with dementia, or patients with other neurocognitive disabilities.
The majority of cases are in pediatrics and young teenagers. Incidence is quite low at less than half of 1% of all emergency room pediatric cases. The penile prepuce is often caught between the fastener and zipper during the closure. This may also occur in adult patients where other persons are needed to close the zipper. 
Typically, the pathophysiology is with direct tissue damage to the prepuce or penile skin from entrapment. This injury may be associated with bleeding, swelling, pain, and direct tissue damage. Rapid extraction from the zipper is usually recommended. in general, the longer the tissue is trapped and damaged, the greater the degree of edema, scarring and tissue trauma.
The individual often presents in excruciating pain and may be difficult to examine. While most cases only involve partial involvement of the prepuce, in some cases there may be a full-thickness injury to the prepuce skin. Most of the time, patients and caregivers will have tried to extract the foreskin, and this usually causes additional tissue damage and delays their presentation to the emergency department. This usually results in further pain, swelling, and bruising.
It is preferable if the zipper can be removed without formal surgical intervention. Care should be taken to avoid further tissue injury when attempting manipulative removal. 
The following are the initial steps that can be taken to remove the zipper in the emergency room with little or no sedation or anesthesia:
1) Edema around the site of the injury can be reduced by the use of a small (narrow) elastic wrap. This will compress the involved area and reduce the edema, which will allow for easier manipulation and removal of the zipper.
2) Attempt to mechanically remove, destroy, or separate the zipper to free up the prepuce or other entrapped tissue. First, cut the cloth portion of the zipper with scissors as close as possible to the zipper teeth. This will usually allow the individual teeth of the zipper to fall out and release the entrapped skin. This can easily be done without sedation or local anesthesia. Be aware that once the skin is released, there may be bleeding due to an unsuspected injury to the underlying tissue.
3) If the above steps fail, the central or median fastener portion of the zipper can be cut with various tools. Cutting will destroy part of the zipper mechanism and help in separating the two interlocking strips. This may require the use of significant hand tools such as a hacksaw, bone cutter, or wire cutters.
4) Alternatively, application of mineral oil for five to ten minutes may help soften the entrapped skin and allow for a gentle attempt at manipulative removal. A flat end screwdriver can be used to attempt to pry the zipper open by forcibly separating the two strips of interlocking teeth. The flat end of the screwdriver is placed parallel to the zipper in an area that is open and not trapped but close to the entrapment area. The screwdriver is then slowly rotated 90 degrees which will forcibly pry the two ends of the zipper apart. This can exert substantial force and may cause pain. If successful, the released tissue may demonstrate bleeding, abrasions, contusions, and lacerations. It is also possible then to identify any potential injury to the underlying penile tissue, pancarpal, and urethra. Urology consultation is advised if any of these areas are injured beyond that of the prepuce.
If zipper removal by mechanical destruction of the zipper and gentle manipulative techniques as noted above are not successful, further treatment usually requires the application of a topical local anesthetic. This is especially useful in the pediatric population. Adults and older children may require a formal penile block.
A formal penile block with injected local anesthesia can be performed to provide immediate pain relief and allow for additional manipulation. A penile block is performed similarly to a digital or finger block. A circumferential injection is made with a local anesthetic (without epinephrine) superficially starting at the base of the penis and continues completely around the penis. Alternately, an injection can be done more deeply at the 10 o'clock and 2 o'clock positions (under Buck's fascia) on either side of the neurovascular bundle.
Treatment then proceeds as noted above. If not successful, treatment then progresses to a more surgical intervention. Incision and/or removal of part, or even all, of the prepuce in the emergency department, may be required. A urology consultation is generally recommended in these cases due to potential penile or urethral tissue injury.
A circumcision can be done as a last resort. This is usually reserved for those cases when a local excision or a dorsal slit is not feasible. If circumcision is recommended, it may need to be delayed to allow the initial traumatic edema to subside. Further, there may be cultural or religious objections to circumcision.
One thing that should not be done is to attempt painful manipulation in the emergency department without anesthesia/analgesia. This is counterproductive and uncomfortable. In children and young teenagers, anesthesia is usually required to remove the prepuce skin from the zipper. Procedural sedation with typical precaution will typically be adequate due to the short duration of the procedure. Once sedated, use of surgical instruments, such as a bone cutter, may be used to remove the zipper. The prognosis is excellent for most children. Skin injuries to the prepuce can be closed primarily with absorbable sutures. If the zipper cannot be extracted from the skin, an excision of the affected skin may be done. This can then undergo primary repair or can be left open with the edges oversewn resembling a dorsal slit-type result.
Prognosis is generally good, even with extensive soft tissue injury. Patients with urethral injuries may develop strictures.
Generally, routine wound care is satisfactory. Wound care with topical or oral antibiotics may be advised in more extensively injured patients.
Urology may be consulted for severe cases.
The patient should be advised to utilize undergarments to prevent further episodes.
an interprofessional care team of nurses, physician assistant or nurse practitioner, and physician that provides a calming atmosphere is crucial given the nature of the injury. Typically, this will involve staff that is skilled in calming or papoosing of pediatric patients. The more relaxed a patient feels, the more successful a manual technique will be. The nurse should assist the clinician in restraining the patient during the procedure as well as educating the family and patient. Probably the easiest way to deal with a zipper injury is to soak the penis and zipper with an oil. Leave it for 30 mins, and the zipper will gradually slide off with a little help from a Q-tip. All healthcare workers who work in the emergency department must be aware of this technique as it is the least painful and works most of the time. If it fails, and sedation needs to be used, the clinician and nurses should work together to assure the patient is in minimal pain. An interprofessional approach will provide the best patient outcome. (Level V)
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