Buried/Trapped penis

Buried penis was described in the early 20th century as a penis of normal size that lacks an appropriate sheath of skin and is located beneath the integument of the abdomen, thigh, or scrotum. This condition is more common in children, usually presenting in neonates or obese prepubertal boys; however, it can also be seen in adults and has been observed in both circumcised and uncircumcised individuals. Marginal cases may not be diagnosed until adulthood, when increased fat deposition accentuates the problem.

Several classification systems of buried penis have been proposed, although none has been universally adopted in the literature. Usually, differentiation among the terms includes: concealed (before circumcision), trapped (cicatricial [scarred] after circumcision), and buried (associated with adolescence and obesity). In most congenital pediatric cases, the buried penis is self-limited. In untreated adults, however, the condition tends to worsen as the abdominal pannus continues to grow.

Buried penis is a true congenital disorder in which a penis of normal size lacks the proper sheath of skin and lies hidden beneath the integument of the abdomen, thigh, or scrotum. The literature, on occasion, also refers to this condition as a hidden or concealed penis. Trapped penis is a condition in which the penis becomes inconspicuous secondary to a cicatricial scar, usually after overzealous circumcision. Webbed penis is characterized by obscuration of the penile shaft by scrotal skin webs at the penoscrotal junction.

Causes

Various etiologic factors have been proposed to explain congenital buried penis. Recent literature favors dysgenetic dartos tissue with abnormal attachments proximally and to the dorsal cavernosum. A prominent prepubic fat pad is also a common primary factor, in addition to dysgenetic dartos fascia. Secondary buried penis may be the result of an overzealous circumcision with subsequent cicatricial scar (trapped penis), a large hernia, or a hydrocele. Another possible cause of buried penis in the adult is genital lymphedema. This may be idiopathic, iatrogenic (from prior surgery), or acquired due to filariasis.

Adults with buried penis are commonly obese and often have a history of trauma or surgery. There is an observed association with diabetes mellitus, which may aggravate the pathologic process. Another additive factor in select patients includes the significant laxity of abdominal skin following gastric bypass. Adults with this condition may have undergone abdominoplasty with overzealous release of attachments between the scarpa and dartos fasciae, penile-lengthening procedures, or other genitoinguinal surgeries.

Treatment

Numerous techniques have been described for repairing the buried penis. Variations have been proposed for different presumed etiologies and to simplify the procedure. Recurrence and the need for subsequent procedures are possibilities.

In pediatric cases, sources have described the essential nature of dividing dysgenetic dartos bands and fixation of the dartos fascia to the Buck fascia dorsally in the midline, ventrally over the corpus spongiosum, and proximally along the penile shaft. Care must be taken to avoid injury to either the urethra or the neurovascular bundles.

Defatting of the mons pubis is an essential step in buried penis repair in adult patients, but opinions vary as to the value of its removal in children. This can be achieved by excisional lipectomy, liposuction, or a combination thereof. The same controversy exists regarding whether or not to take down the suspensory ligament. In the authors’ experience, this is rarely necessary and may lead to instability of the erection.

If a patient has a deficiency of longitudinal penile skin, that is in trapped penis, a plasty rearrangement of this skin can often be accomplished. If a severe deficiency of skin is appreciated, a split-thickness skin graft or full-thickness skin graft may be used. Once fixation between the skin, dartos, and tunica albuginea at the base of the penis has been performed, as described above, skin grafts are applied in spiral fashion. If the wound bed is inadequate for grafting because of scarring, the use of flaps may be considered.

Considerations

Consideration for surgical reconstruction necessitates earnest discussion with the family regarding the potential functional, cosmetic and psychosocial outcome of surgical reconstruction. Young patient with concealed penis may be ridiculed by other boys, and those with severe buried penis may have no visible penile shaft while standing and may have to sit to urinate.