Annals of Pediatric Surgery Vol 5, No 4, October 2009, PP 261-267

Original Article

Surgical Correction of Concealed penis Khalid Ahmed Ismail Department of surgery, Faculty of Medicine, Tanta University

Background/Purpose: A concealed penis is defined as a phallus of normal size buried in the prepubic tissue (buried penis), enclosed in scrotal tissue (webbed penis), or trapped by scar tissue after penile surgery (trapped penis). The aim of this study was to detect the etiological factors, clinical presentation and outcome of surgical correction techniques. Materials & Methods: From January 2003 to January 2008, 20 patients with concealed penis were operated upon. the mean age was 6 years and 8 months. There were 10 patients with buried penis, 7 patients with trapped penis, and 3 patients had webbed penis. The common surgical policy in most of our cases included complete penile degloving, excising the scarring due to previous surgery, fixing the penile skin at the penopubic and penoscrotal angles and reconstructing the penile skin. Results: Sixteen patients (80%) showed an excellent result as regards to the postoperative length and cosmetic appearance of the penis. Residual redundant penile skin was present in 4 patients (20%) resulting in a bulky penis which was not acceptable by parents. Excision of the excess skin was done after 6 months. Five patients (25 %) presented with mild lymphatic stasis of distal shaft that subsided spontaneously within few months. There was superficial infection in 2 cases (10%); it responded to conservative treatment. All patients were followed up for a mean period of 28 months (1-5 years). Conclusion: concealed penis has a variable etiology and requires a flexible surgical approach. Repair of concealed penis is a simple and effective outpatient procedure which alleviates the initial complaint and provides good cosmetic and functional results with greater satisfaction to the patients and their parents.

Index Word: concealed penis, buried, webbed, trapped.

INTRODUCTION

concealed penis is an inconspicuous phallus. injudicious of a concealed penis, and less A It is categorized into three subgroups, buried, frequently, a result of surgery for other pathologies 5-6. webbed and trapped penis 1. A buried penis is a An abnormal appearance of the external genitalia normal-sized penis totally buried in prepubic tissue may have psychological effects on the child and his because of lack of skin attachment to the shaft. It can family. Fear to be discovered and teased by be identified by the absence of the circumferential classmates may result in depression, feeling of groove at the base of the penis 2-3. A webbed penis is inadequacy and insecurity. Parents are frequently characterized by a ventral fold of skin that joins the worried about the future of their child. Early surgical distal shaft and scrotum obscuring the penoscrotal reconstruction may therefore benefit the child and angle 4, while the trapped penis is usually the result of parents as well. It is very important for the primary

------Correspondence to: Khalid Ismael MD. Surgery Department. Tanta University Hospitals. Tanta, Egypt. Ismail KA care physician to make a correct diagnosis and to performed by placement of absorbable sutures promote timely referral 7-8. This study was done to (polyglycolic acid 4/0 to 2/0 according to the patient's review the etiological factors, clinical presentations, age) between the dermis of the skin shaft at the base best time for surgical correction and outcome of of the penis and buck's fascia, lateral to the posterior surgical techniques to correct the concealed penis. neurovascular bundle and lateral to the , thus restoring the penopubic and penoscrotal angles respectively. The circumferential incision was then

closed with absorbable sutures (Fig. 1). In the PATIENTS AND METHODS following 5 cases, a modification of the previous technique (modified scrotal technique) was done From January 2003 to January 2008, this study After complete degloving of the shaft, as mentioned included 20 cases of concealed penis. Ten cases (50%) previously, with a circumferential coronal incision, had buried penis, 7 (35%) had trapped penis and 3 the shaft was drawn out of the cutaneous cylinder patients (15%) had webbed penis. The obese patients through an additional incision made along the scrotal with secondary concealed penis were excluded. All raphe. This maneuver allowed complete resection of cases were evaluated clinically with emphasis on true the abnormal fibrous bands of dartos and allowed length of the penis, the presence or absence of the easy placement of absorbable fixation sutures as prepuce, the length of penile skin in circumcised ventral sutures were easily applied through a patients and presence of any inflammations or transverse incision at the penoscrotal junction. The cicatrizing scars following circumcision Establishing shaft was then reinserted in the cutaneous cylinder the diagnosis of concealed penis and its category, as and the skin wounds were closed with absorbable buried, webbed or trapped, can be done with sutures (Fig2). meticulous clinical examination only; no further . Webbed penis: investigations were needed for this purpose.. A transverse incision was made at the penoscrotal Great care was directed to preoperative penile junction and, with dissection to the deep fascia, the hygiene especially in buried and trapped penis. scrotum is allowed to assume a more caudal position. During obtaining the informed consent, assessing the This was followed by circumferential dissection along expectations of patients and parents was critical. the buck's fascia freeing the penis from its deep tethering and excising any abnormal bands. Fixation Surgical Technique of dartos fascia and dermis of penile skin to Buck's General anesthesia with endotracheal intubation was fascia was done using polyglycolic acid sutures. The given to all cases and local anesthesia was avoided as scrotal incision was closed longitudinally to create the dissection of the surgical planes could then become penoscrotal angle (Fig. 3). more difficult.

Buried Penis: Trapped penis: Cases with buried penis were repaired using 2 techniques. In the first 5 cases, a traction suture was After excising cicatricial scar that trapped the penis applied to the glans, a circumferential coronal incision and compete penile degloving, the resultant bare area was done, and by using the Buck's fascia as the plane and remaining penile skin was assessed. of dissection, the penis was degloved to the Penile skin was used to cover the penis in 5 patients penopubic junction. Sharp dissection of the (Fig.4), while 2 patients had insufficient penile skin dysgenetic dartos fibers, to free the penis from its and split thickness skin grafting was necessary to deep tethering, was carried out. Fixation was then resurface the penile shaft (Fig. 5).

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(a) preoperative buried penis (b)placement of absorbable fixation sutures (c)postoperative result Fig. (1): Buried Penis repair

(a) additional incision along the (b) the shaft was drawn out the (c) complete resection of abnormal scrotal raphe cutaneous -cylinder fibrous bands with fixation sutures

(d) reinsertion of the shaft in the (e) closure of cutaneous incision (f) postoperative result cutaneous cylinder Fig. (2): Buried Penis repair; modified scrotal Technique

(a) webbed penis (b) fixation of dartos fascia and (c) postoperative result dermis of penile skin to buck's fascia Fig. (3): Repair of webbed penis

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(a) trapped penis (b) excising cicatricial scar and (c) postoperative result complete penile degloving

Fig. (4) : Trapped Penis without Graft

(b)exposure of the trapped penis (a)complete trapped penis (c)trapped penis with insufficient penile skin

(d)covering of trapped penis with (e)early postoperative result (f)late postoperative result split thickness skin graft

Fig. (5): Trapped Penis with Graft

E

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RESULTS trapped the penis and in 2 of them extensive scar excision was needed, so they had insufficient penile This study included 20 patients with concealed penis. skin and split-thickness skin grafting was necessary to Their ages ranged from 3 months to 15 years (mean resurface the penile shaft. age was 6 years and 8 months). Their presentation is Mean follow – up period was 28 months (1-5 years). shown in table (1). Nine patients (2 with buried and 7 Postoperative complications included; hematoma in 2 with trapped penis) were previously circumcised. The cases (10%) that resolved completely by conservative diagnosis was completely made by clinical treatment within 2 weeks, Superficial infection was examination; no investigations were needed. present in 2 patients (10%) responded to medical All patients underwent surgical repair; 10 patients treatment and subsided without any undesirable with buried penis underwent complete penile consequence. Distal shaft skin occurred degloving, excision of the dysgenetic dartos fascia, in 5 patients (25%) and resolved spontaneously within fixing the penile skin at the penopubic and a few months. Sixteen patients (80%) showed an penoscrotal angles to avoid recurrence, while in the 3 excellent result as regards to the postoperative length patients with webbed penis, only reconstruction of the and cosmetic appearance of the penis and required no penoscrotal angle was performed after excision of the additional surgery. Residual redundant penile skin penoscrotal web as normal penopubic angle was was present in 4 patients (20%) resulting in a bulky already present. Seven patients with trapped penis penis which was not acceptable by them and excision were treated by excising the cicatricial scar that of the excess skin was done after 6 months .

Table 1: patients characteristics, operative results.

Total patients Buried (n=10) Webbed (n=3) Trapped (n=7)

Presentation: Hidden penis, Difficulty in Bad cosmesis, , Difficult hygiene directing stream dysuria, dribbling between voids, recurrent UTI Pre-repair 2 _ 7

Circumcision

Complications:

• Residual redundant 3 _ 1 skin: • Hematoma: 1 - 1 • Lymphedema: 3 - 2 • Superficial Infection: - - 2

Outcome:

• Pt/Parent 7/10 3/3 6/7 Satisfaction:

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DISCUSSION concealed penis are at a risk for psychological and social trauma (14). The first description of concealed penis was given in 1919 by Keys. The first attempt at surgical correction In our study, 9 patients (45%) were previously of this problem was done by Schloss in 1959 and in circumcised. Circumcision may be a cause of trapped 1968, successful correction was performed by Glanz in penis. In addition it complicates the repair; as the an adult. since that time, numerous techniques have preputal skin can be used to cover the penile shaft been developed (2- 3). after its release (11). Therefore it is recommended that these boys should not be circumcised until a decision A concealed penis is defined as a phallus of normal is made regarding the concealed penis. size buried in prepubic tissue ( buried penis ), enclosed in scrotal tissue ( webbed penis ), or trapped Numerous techniques have been described for by scar tissue after penile surgery ( trapped penis ), repairing the concealed penis. Variations have been while represents a penis length less than 2 proposed for different presumed etiologies and to standard deviations below the mean for age when simplify the procedure (15-16-17-18-19). The modified measured in the stretched state and diminutive penis scrotal approach, which we used for correction of is seen when the penis is small , malformed or both; buried penis, has simplified the complete secondary to epispadias, extrophy, severe exteriorization of the penile shaft, with easy control of or conditions (9). This study bleeding and facilitated the application of fixation included 20 patients with normal sized concealed sutures to create the penoscrotal and penopubic penis which should be differentiated, before any angles. So, the surgeon must be aware of these treatment, from the micropenis or diminutive penis different techniques to tailor the operative steps to the and, as mentioned, this needs only meticulous clinical particular needs and the anatomic aberrations in examination. Concealed penis is not a rare entity as individual cases. previously thought. More definition, categorization Many series that reported long-term outcome of and specification of the management of these cases pediatric cases found that surgical correction resulted will raise the awareness of the medical community in excellent long-term cosmetic results. Surgery and lead to better recognition of a larger number of eliminated associated negative feelings, improved cases. penile appearance and facilitated better hygiene (20-21- Most pediatric cases with concealed penis present in 22). Most of the complications e.g. penile edema or neonates or prepubertal boys. The age in this study hematoma, and superficial infection are temporary ranged from 3 months to 15 years. Adolescents and usually resolve by conservative measures. presenting with concealed penis are usually obese, Reported rates of recurrent retraction, however range and weight loss should be advised (10). Obese patients from 1-15% and often require re-surgery. Penile shaft with secondary concealed penis were excluded from edema has been reported in 1-11% and usually this study. The timing of surgical repair of concealed resolves spontaneously. Dissatisfaction with cosmesis penis is controversial; some prefer to defer surgical is possible, but the physician should preoperatively correction until school age while others advocate assess for unrealistic expectations (23-24). The mean surgical intervention in infancy, and state that before follow-up in this study was 28 months (1-5 year). 3 years of age, surgical correction is important so that Excellent results, regarding the general appearance, the child is able to void while standing during the accessibility and easy hygiene, could be obtained in 16 period of toilet training. We think that surgery may be patients (80%). Four patients (20%) were not satisfied more helpful earlier rather than later. Surgery at an by the final results due to residual redundant penile early age relieves anxiety and improves self skin resulting in a bulky penis. confidence. Indications for surgical repair of concealed penis are numerous, for example, a concealed penis can hamper proper hygiene, trap urine and complicate voiding CONCLUSION leading to repeated infections, secondary phimosis or Concealed penis has a variable etiology. Circumcision even urinary retention (12-13). In addition, children with could be the initial cause or an aggravating factor.

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Circumcision should be deferred in these patients 10. William .Jand Cromie .A: Simple technique for until a decision has been made regarding the correction of buried penis. J Urol. 12: 19-22, 2000. concealed penis to preserve the preputal skin. Early 11. Raboei .L: Surgical management of a concealed penis. surgical correction of this problem is advocated; it Saudi Med J. 24(5): 550 - 552 , 2003. relieves anxiety and improves self confidence. 12. Donatucci CF, Ritter EF. Management of the buried Numerous techniques have been described for penis in adults. J Urol. 159(2):420-4, 1998. repairing the concealed penis. Variations have been proposed for different presumed etiologies and to 13. Chuang JH. Penoplasty for buried penis. J Pediatr Surg. simplify the procedure. Surgeons dealing with these 30(9):1256-7, 1995. cases should have a versatile approach for surgical 14. Borsellino A, Spagnoli A, Vallasciani S, Martini L, Ferro correction. The concealed penis is not as rare as stated F. Surgical approach to concealed penis: technical in some reports and raising the awareness of the refinements and outcome. . 69(6):1195-8, 2007. medical community can lead to better recognition and 15. Brisson P, Patel H, Chan M, Feins N. Penoplasty for management of a larger number of cases . buried penis in children: report of 50 cases. J Pediatr Surg. 36(3):421-5, 2001. 16. Gillett MD, Rathbun SR, Husmann DA, Clay RP, Kramer

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