Evaluation and Treatment of Adult Concealed Penis

The Role of Suprapubic Superficial Fascial System Reconstruction During Repair of Adult-Acquired Buried Penis

BACKGROUND

Adult-Acquired Buried Penis is a disorder associated with systemic obesity that confers increased risks of malignancy, sexual dysfunction, urinary abnormalities, and psychological distress. Surgical correction improves patient-reported functional and psychological outcomes and often requires collaboration between plastic and urologic surgeons. To improve postoperative cosmetic outcomes and decrease wound complications following adult-acquired buried penis repair, we performed an anatomic and histologic study of the superficial fascial layers providing support to the external male genitalia and describe our approach for fascial reconstruction.

METHODS

We characterized the superficial fascial anatomy in three patients undergoing adult-acquired buried penis repair, including two patients with Wisconsin Type II disease and one patient with Wisconsin Type IV disease. Gross specimens were sent from two patients histologic analysis using H&E and elastin-specific stains to characterize the identity of the superficial fibrofatty tissue.

RESULTS

In all three patients, the fundiform ligament overlying the suspensory ligament was identified, isolated, and transected for removal with the suprapubic specimen. We found that reapproximation of this ligament following transection at the time of escutcheonectomy provided significant lift to the penis and genitals via improved support of dartos fascia. Histologic analysis of the superficial fibrofatty tissue located beneath the dermis revealed histologic similarities with the superficial fascial system described previously in abdominal and breast tissue.

CONCLUSIONS

Reapproximation of the fundiform ligament and superficial fascial tissue following suprapubic/lower abdominal fat pad removal during adult-acquired buried penis may improve postoperative cosmesis by reducing strain on the dermal closure.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Uncovering the Hidden Penis: A Nomenclature and Classification System

INTRODUCTION

A hidden penis can interfere with normal hygiene, prevent effective voiding, restrict sexual activity, and cause great embarrassment to the patient. The terms "hidden," "buried," and "trapped" penis are used interchangeably. To date, there is no classification system that adequately characterizes the spectrum of this condition. In this study, we propose a simplified nomenclature and classification system for adult-acquired hidden penis.

METHODS

We performed a retrospective review of all adult patients treated surgically for hidden penis by the senior author from 2009 to 2019. Patients were classified into either "buried" or "trapped" categories. A "buried" penis was defined as a hidden penis concealed by suprapubic fat without fibrous tethering. These patients were managed with panniculectomy, monsplasty, or both. In contrast, those with a "trapped" penis presented with scarred or fibrous tissue, which required surgical lysis, phalloplasty, and penile skin resurfacing.

RESULTS

Thirteen patients met the inclusion criteria. The cohort was aged 53 ± 15.7 years with a mean body mass index of 37.4 ± 4.3 kg/m2. Two patients required repeat operations, yielding a total of 15 operative encounters. Six were defined as buried, and 9 as trapped. Inability to achieve erection was the most common preoperative complaint in those with buried penis (67%), whereas difficulties in voiding were most common with trapped penis (78%). Patients with trapped penises had a significantly larger body habitus than those with a buried penis (39.8 vs 34.2 kg/m2, P = 0.0088). Operative duration and length of hospital stay were comparable between the trapped and buried penis groups (206 vs 161 minutes, P = 0.3664) (5 vs 1 day, P = 0.0836). One third experienced wound complications, but this was not significantly different between buried and trapped penises (17% vs 44%, P = 0.5804). Postoperatively, 5 patients experienced spontaneous erections, and 7 were able to void while standing.

CONCLUSIONS

Patients with a trapped penis present with a different preoperative symptom profile and body type than those with a buried penis. Our nomenclature and classification system offer a simple and clear algorithm for the management of hidden penis. Large cohort studies are warranted to assess differences in clinical outcomes between trapped and buried penises.

Clinical effect of Brisson operation modified by Y-shaped incision for treatment of concealed penis in adolescents

OBJECTIVE

To analyze the clinical effect of the Brisson operation modified by a Y-shaped incision in treating adolescent concealed penis.

METHODS

We retrospectively analyzed clinical data of 27 adolescents with a concealed penis treated with the Brisson operation modified by a Y-shaped incision in our hospital from January 2017 to March 2020.

RESULTS

The operation went smoothly in all 27 patients. Postoperative foreskin edema occurred in 12 patients and spontaneously resolved within 1 month postoperatively. Two patients developed postoperative retropubic infection. After administering antibiotics and symptomatic treatment, both patients' conditions improved within 1 week. All operations obtained satisfactory results. Postoperatively, when the penis was in a non-erect state, it was clearly exposed without retraction or concealment; thus, demonstrating good surgical results. The prepuce was distributed naturally without obvious accumulation of redundant preputial tissue. The penile scar resembled that after circumcision. The postoperative follow-up period was 6 months, during which no patients developed recurrence.

CONCLUSION

The Brisson operation modified by a Y-shaped incision is effective for treating a concealed penis in adolescent patients. This technique may relieve the pathological abnormalities and retain the penile skin's integrity to the greatest extent with minimal scarring and a satisfactory appearance.

Suprapubic Liposuction With a Modified Devine's Technique for Buried Penis Release in Adults

Background

With the increasing prevalence of overweight and obesity, adult-acquired buried penis is more common in recent years. Many surgical techniques have been reported. However, none is the gold standard.

Objective

To evaluate the safety and efficacy of combining suprapubic liposuction and modified Devine's technique for penile lengthening in adult patients with buried penis due to obesity.

Methods

From September 2015 to June 2018, 26 consecutive suitable patients (mean age: 33 ± 5.7 years, mean body mass index: 29 ± 5.4 kg/m²) with a buried penis received suprapubic liposuction and modified Devine's technique for penis release in our medical centre. A retrospective study was conducted. Their penile length from tip to the skin (flaccid) was measured pre- and post-operatively. The amount of liposuction was also recorded accordingly.

Results

The mean length of the follow-up on the 26 patients is 18 ± 7.1 months (range 3-33 months). The average amount of liposuction is 450 ± 90.2 mL. The average penile length measured preoperatively, post-operatively (on table), and 3 months after the operation is 2.9 ± 1.3, 7.4 ± 2.1, and 5.3 ± 1.8 cm, respectively. The post-operative penile length had significantly increased by 4.5 ± 1.6 cm (on table) and 2.4 ± 0.7 cm (3 months post-operation) with a P value <.05. No patient had difficulties in sexual intercourse or urination post-operatively. None of the patients were dissatisfied with their surgical outcomes.

Conclusions

The combination of suprapubic liposuction and modified Devine's technique is a safe and effective method for releasing the buried penis of adults with satisfying outcomes.

Correction of retractile penis with subcutaneous soft silicone penile implant

We report a novel solution for patients suffering from adult acquired retractile penis. Three patients complained of retractile penis (when standing) and/or prepubic recession. Physical examination confirmed the shaft of the penis was buried with only the glans visible. All three patients reported lower levels of self-confidence, self-esteem, and sexual confidence prior to their procedure. The three patients received surgical treatment with the insertion of a subcutaneous soft silicone penile implant and two of the three also received removal of the suprapubic fat pad. Over one year post operatively, the penile shaft and glans was visible and appeared natural. All patients reported an increase in self-confidence and self-esteem. The insertion of a subcutaneous soft silicone penile implant may prove to be a viable solution to reverse retractile penis and to increase patient quality of life when compared to more invasive current surgical treatments.

Surgical management of buried penis in adults

Introduction

Buried penis is a condition that causes the penis to become hidden beneath the skin. It has a significant impact on quality of life and can present in a variety of ways, with lower urinary tract symptoms and erectile dysfunction being common. Whilst there are several causes, obesity is the most common in adults. Due to the burden that obesity is increasingly presenting to healthcare, buried penis may become more common in the future.The purpose of this article is to provide an overview of the causes, presentation and surgical management of this condition in adults.

Material and method

A literature review was conducted using urological and plastic surgery articles from PubMed, Embase and Medline. Eighteen studies, published between 1982 and 2016, were included.

Results

Original research trials discussed the treatment of buried penis in lymphoedema and balanitis xerotica obliterans (BXO), new techniques for fat removal, comparison of grafts and postoperative dressings. Several studies provided broad overviews, although focused on management rather than cause and presentation. Overall, studies suggest that, whilst some causes can only be treated with surgery, others can be modified by lifestyle changes and medical management.

Conclusions

Buried penis is a complex condition that may take years to treat. Several surgical techniques are available, with patients likely requiring a combination of techniques to treat this problem. This review aims to provide a comprehensive overview of the causes, presentation and surgical management of this condition, in order to further the understanding of clinicians who may be faced with this problem more commonly in the future.

Adult Buried Penis Repair with Escutcheonectomy and Split-Thickness Skin Grafting

AIM

To describe a technique for surgical correction of adult buried penis, including a technique for skin graft harvesting from the escutcheonectomy specimen itself, with an emphasis on remaining open questions in the literature.

METHODS

We present our method for surgical correction of adult buried penis with a review of the literature.

MAIN OUTCOME MEASURE

Components of successful buried penis repair include return of directed voiding, elimination of local skin inflammation and infection, improvement in hygiene, return of sexual functioning, cosmesis, and patient satisfaction. To date, there are no broadly accepted tools for comprehensive measurement of outcomes after buried penis repair.

RESULTS

Adult buried penis repair is generally associated with excellent rates of satisfaction and improvement in functioning. Currently available data are extremely limited; however, they do suggest that, when in doubt, more aggressive debridement of diseased tissue combined with split-thickness skin grafting may provide superior outcomes. Split-thickness skin grafts are associated with excellent rates of successful graft take, even in cases of severe preoperative pathology and patient comorbidity. Although these grafts come at the cost of some increased surgical morbidity, they are associated with low rates of major complications. Morbidity can be further significantly decreased by harvesting the graft from the excised escutcheon itself, a technique that we present here.

CONCLUSION

Surgical correction of adult buried penis is safe and effective; however, future work is required to further optimize outcomes and reduce surgical morbidity. Strother MC, Skokan AJ, Sterling ME, et al. Adult Buried Penis Repair with Escutcheonectomy and Split-Thickness Skin Grafting. J Sex Med 2018;15:1198-1204.

Surgical Management of Adult-acquired Buried Penis: Impact on Urinary and Sexual Quality of Life Outcomes

OBJECTIVE

To assess postoperative patient-reported quality of life outcomes after surgical management of adult-acquired buried penis (AABP). We hypothesize that surgical treatment of AABP results in improvements in urinary and sexual quality of life.

METHODS

Patients that underwent surgical treatment of AABP were retrospectively identified. The Expanded Prostate Cancer Index (EPIC) questionnaire was completed at ≥3 months postoperatively, and completed retrospectively to define preoperative symptoms. EPIC is validated for local treatment of prostate cancer. Urinary and sexual domains were utilized. Questions are scored on a 5-point Likert scale, with higher scores indicating better quality of life. Preoperative scores were compared with postoperative scores.

RESULTS

Sixteen patients completed pre- and postoperative questionnaires. Mean time from surgery to questionnaire was 12.6 months. There was a significant improvement in 10 of 12 urinary domain questions and 10 of 13 sexual domain questions. Fourteen of 16 patients (87.5%) reported significant improvement in overall sexual function (median score changed from 1.5 to 5, P <.0001). Similarly, 14 of 16 patients (87.5%) reported significant improvement in overall urinary function (median score changed from 1 to 4, P <.0001).

CONCLUSION

AABP is a challenging condition to treat and often requires surgical intervention to improve hygiene and function. There are limited data on patient-reported quality of life outcomes. We found that surgical management of AABP results in significant improvements in both urinary and sexual quality of life outcomes.

Infrapubic Liposuction for Penile Length Augmentation in Patients with Infrapubic Adiposities

INTRODUCTION

Hidden penis, inconspicuous and concealed penis are synonyms for the same entity "buried penis" where the penile shaft is hidden below the surface of the prepubic fat to an extent that gives an impression of a short penis, despite corporeal length being normal.

AIM

The aim of our work is the reduction in the amount of the suprapubic fat by liposuction to reveal the buried penis and assess the results, patient satisfaction and possible complications.

METHODS

The procedure of suprapubic liposuction was carried out on ten men who were attending the outpatient clinic of Andrology complaining of small-sized penis.

MAIN OUTCOME MEASURES

Pre-, immediate (on table) postoperative and 3 months postoperative skin to tip flaccid and stretched penile lengths were measured. Patient satisfaction was assessed using the five-point Likert scale.

RESULTS

There was a statistically significant increase between the pre- and postoperative flaccid and stretched penile lengths in our patients with a p value <0.001 in both.

CONCLUSION

An acquired adult buried penis is a correctable problem. Simple buried penis due to excess fat at the mons pubis should be differentiated from other complex cases that may require combined techniques to achieve good results with minor complications. Suprapubic liposuction is a very safe and successful procedure with minor or no complications if performed meticulously. It could improve self-esteem along with the associated physical and esthetic concerns.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Incidence of Urethral Stricture in Patients with Adult Acquired Buried Penis

Introduction. Concealed-buried penis is an acquired condition associated with obesity, challenging to both manage and repair. Urethral stricture is a more common disorder with multiple etiologies. Lichen sclerosus is a significant known cause of urethral stricture, implicated in up to 30%. We hypothesize that patients with buried penis have a higher rate of urethral stricture and lichen sclerosus than the general population. Methods. We retrospectively reviewed a single surgeon's (CM) case logs for patients presenting with a buried penis. All patients were evaluated for urethral stricture with cystoscopy or retrograde urethrogram either prior to or at the time of repair for buried penis. Those that had surgical repair or biopsy were reviewed for presence of lichen sclerosus. Results. 39 patients met inclusion criteria. Of these, 13 (33%) had associated stricture disease. The location of the strictures was bulbar urethra (38%), penile urethra (15%), and meatus or fossa navicularis (62%). Five patients had lichen sclerosus and urethral stricture disease, while 3 had lichen sclerosus without stricture. 11/13 stricture patients were treated. Six underwent dilation, 3 underwent meatotomy, and 2 underwent urethroplasty. No significant recurrences of stricture were seen. Conclusion. Patients with a concealed penis are more likely than the general population to have a urethral stricture and/or LS. Patients presenting with concealed penis should also be evaluated for a urethral stricture.

Management of adult concealed penis using a meshed, split-thickness skin graft

INTRODUCTION

Concealed penis (CP) is a rare problem faced by urologists and plastic surgeons. CP occurs secondary to trauma, obesity, or infection. Surgical treatment is individualized and based on patient and provider variables. We aim to review our recent experience using meshed split-thickness skin grafting (STSG) for CP management.

METHODS

A retrospective review was performed on patients who underwent STSG for CP at our institution. Records were reviewed for demographic, operative, and postoperative variables. Preoperative and postoperative photos were obtained to monitor cosmetic results.

RESULTS

Eleven patients underwent CP release with meshed STSG placement. All cases showed improved functional phallic length and good cosmetic results, regardless of etiology.

CONCLUSIONS

STSG is a viable option for penile coverage for management of this difficult-to-treat CP population. This primary or salvage modality offers excellent cosmetic results and may be used following prior reconstructive attempts.

Tissue transfer techniques in reconstructive urology

Tissue transfer techniques are an essential part of the reconstructive urologist's armamentarium. Flaps and graft techniques are widely used in genital and urethral reconstruction. A graft is tissue that is moved from a donor site to a recipient site without its native blood supply. The main types of grafts used in urology are full thickness grafts, split thickness skin grafts and buccal mucosa grafts. Flaps are transferred from the donor site to the recipient site on a pedicle containing its native blood supply. Flaps can be classified based on blood supply, elevation methods or the method of transfer. The most used flaps in urology include penile, preputial, and scrotal skin. We review the various techniques used in reconstructive urology and the outcomes of these techniques.

Ventral Slit Scrotal Flap: A New Outpatient Surgical Option for Reconstruction of Adult Buried Penis Syndrome

INTRODUCTION

We present a novel technique using ventral slit with scrotal skin flaps (VSSF) for the reconstruction of adult buried penis without skin grafting.

TECHNICAL CONSIDERATIONS

An initial ventral slit is made in the phimotic ring, and the penis is exposed. To cover the defect in the ventral shaft skin, local flaps are created by making a ventral midline scrotal incision with horizontal relaxing incisions. The scrotal flaps are rotated to resurface the ventral shaft. Clinical data analyzed included preoperative diagnoses, length of stay, blood loss, and operative outcomes. Complications were also recorded. Fifteen consecutive patients with a penis trapped due to lichen sclerosus (LS) or phimosis underwent repair with VSSF. Each was treated in the outpatient setting with no perioperative complications. Mean age was 51 years (range, 26-75 years), and mean body mass index was 42.6 kg/m(2) (range, 29.8-53.9 kg/m(2)). The majority of patients (13 of 15, 87%) had a pathologic diagnosis of LS. Mean estimated blood loss was 57 cc (range, 25-200 cc), mean operative time was 83 minutes (range, 35-145 minutes), and all patients were discharged on the day of surgery. The majority of patients (11 of 15, 73.3%) remain satisfied with their results and have required no further intervention. Recurrences in 3 of 15 (20.0%) were due to LS, panniculus migration, and concealment by edematous groin tissue; 2 of these patients underwent subsequent successful skin grafting.

CONCLUSION

VSSF is a versatile, safe, and effective reconstructive option in appropriately selected patients with buried penis, which enables reconstruction of penile shaft skin defects without requiring complex skin grafting.