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THE CONGENITAL CHILD AND ADULT ACQUIRED BURIED AND CONCEALED PENIS
AND THEIR RECONSTRUCTIVE MODERN SURGICAL CORRECTION


Semir A. S. Al Samarrai

 


A buried penis, also referred to as hidden or concealed penis, is a form of inconspicuous penis (Cromie et al, 1998). A buried penis is a normally developed penis that is hidden away by the suprapubic fat pad (See Fig.1,2).
The Buried syndrome has been defined as a penile buried below the surface of the prepubic skin and also to a partial or totally obscure of penis caused by obesity or radical circumcision in adults (1).
In children, it is believed to be caused by dysgenetic dartos fascial bands that cause the phallus to retract into the suprapubic fat pad (2). (Fig.3).

Adult acquired buried penis syndrome has been evaluated by others, the pathophysiology is thought to involve the obese pannus covering the phallus and subsequently leading to a chronically moist environment that promotes bacterial and fungal growth that subsequently leads to chronic inflammation with scarring, and contracture that leads to the buried penis (3).(Fig.5).
Moreover, a majority of the patients have other potential complicating factors that may impact management, including recurrent urinary tract infection, voiding dysfunction and ED (4).
The most recent data in 2009-2010 show that the prevalence of obesity in the USA worsening as 35.7% of adults were considered obese by the Center of Disease Control, 37 million men over the age of 20 were consistent obese (5). The mean BMI in cohort was 35.2 (28.3-43.8); all patients had strongly been encouraged by multiple physicians to lose weight prior to surgery.
Buried Penis is an uncommon condition in adulthood, which is most commonly a result of morbid obesity, radical circumcision or penoscrotal lymphadenoma.
It is complicated by patient co-morbidities, particularly diabetes mellitus, which likely contributes to the cycle of recurrent urinary tract infection, voiding dysfunction and erectile dysfunction ED (6).
Buried penis has been studied more frequently in the pediatric population and several etiological factors have been described, including excessive suprapubic fat, abnormal dartos fibrous bands that tether and shorten the penis, penoscrotal webbing obscuring the penoscrotal angle and entrapment by a phimotic ring caused by critical scarring after penile surgery (2,7).(Fig3,4,5,6,7).

Poor Skin fixation at the penile base can predispose to telescoping of the penile and abdominal skin distally resulting in shortening of the exposed penis.
Concealment of the penis may have psychological consequences on account of decreased visible penile length both in the flaccid and erect states. This has been associated with distortion of body image, depression, abnormal voiding, hygiene, and impaired sexual function, due to hypogonadotropic hypogonadism (Fig.9).

Surgical Treatment

Psychosocial aspects of reconstructive surgery has been studied in the reconstructive urology literature; however, data for adult acquired buried penis syndrome are lacking (8,9). The Surgical approach to exhuming the trapped penis includes delivering the glans and as much of the shaft as possible, by initially making a slit through the phimotic surface tissue. Often times, the glans will have dense adhesions that need to be taken down to reveal the entirety of the corona circumferentially. If their satisfactory shaft skin and not a significant amount of shortening as a result of previous circumcision the ventral slit can be covered with a thick split thickness skin graft.

Frequently, the available skin will have undergone irreversible scarring which will need to be excised likely down to the fascia. When there is redundant infrapubic tissue, above and inside the pubic area, because some men have large fat pads that bury and conceal the functional and visual penile length which is frequently the case in the obese patient. In these cases, excess fat is excised and restricting bands of the fascia are released to increase the visual and functional length of the penis. Moreover, aging causes suprapubic skin and fat to descend and to conceal the penis when the patient is standing. Combining fat and skin excision in an aging man provides a more attraction and youthful appearance to the escutcheon while increasing visual and often actual penile length. Examining patients in the standing position is therefore required for an accurate diagnosis in these cases, a low transverse incision has to be performed in the pubic hair if subcutaneous fat only has to be removed and if skin advancement onto the penis is unnecessary, if excess skin is excised to raise the escutcheon and give a more youthful appearance to an aging patient.
The ventral penile shaft can be visibly obscured if the scrotum extend onto the penis, causing a penoscrotal web or improperly defined penoscrotal junction. A well- defined penoscrotal junction gives the penis a longer appearance. This deformity is congenital or may result over resection of ventral skin during circumcision. A single or double Z-plasty with the vertical limb centered along the penoscrotal junction sharpens the junction, giving the appearance of more ventral length (10). A wide variety of penis enlargement and circumference of the penis to increase procedures have been performed with differing results. Faulty theoretic or autonomic designs have often predisposed to significant complications and deformities, especially if the surgeon is not technically meticulous.

Conclusion

Penis enlargement and penis girth enhancement with lengthening followed by penile weight use and subsequent dermal-fat graft augmentation. Preferably ensures maximal length and girth enhancement if patient desire length and girth, the lengthening operation is performed first, followed by months of weight use. If girth enlargement were performed first or simultaneously, stretching the penis would cause thinning of the graft.
Suprapubic lipectomy or Dermatolipectomy associated with skin tacking is highly successful in enhancing penile appearance. Elimination of penoscrotal webbing is an easy, effective procedure (Fig.8).Honesty is required in as much as over optimism creates a dissatisfied and potentially hostile patient.

In our experience, patients with adult acquired buried penis syndrome would complain of poor QOL (Quality of Life) and depression symptoms secondary to altered voiding and ED. Tang et. al. reported a depression rate of 100 percent in their cohort of men undergoing surgery for obese adult acquired non- traumatic buried penis surgery and one reported contemplating suicide (11).

Fig.1. Buried Penis (A and C) Visualized by retraction (B and D)


Fig.2. Inconspicuous Penis


Fig.3. Acquired Buried Penis with Fat Pad


Fig.4. Congenital Buried Penis with Phimosis


Fig.5. Acquired trapped penis by scarring resulting from circumcision with urinary tract infection


Fig.6. Penoscrotal web resulting in a webbed penis


Fig.7. Webbed Penis with Hypoplastic Urethra


Fig.8. Lengthening and Girth Enhancement of acquired Buried Penis


Fig.9.Micropenis resulting from Hypogonadotropic hypogonadism

RERECENCES
  • Ehrilch RM, Alter GJ. Buried Penis. In: Ehrilch RM, Alter GJ, eds. Reconstructive and plastic surgery of the external genitalia: Adult and Pediatric. Vol. 1. Philadephia: Saunders; 1999: 397-401.
  • Maizels M, Zaontz M, Donovan J, Bushnick PN, Firlit CF. Surgical correction of the buried penis: Description of a classification system and a technique to correct the disorder. J Urol 1986; 136:268-71.
  • Donatucci CF, Ritter EF. Management of the buried penis inadults. J Urol 1998; 159:420-4.
  • Pestana IA, Greenfield JM, Walsh M, Donatucci CF, Erdmann D. Management of "buried" penis in adulthood: An overview. Plast Reconstr Surg 2009; 124:1186-95. Review.
  • Ogden CL, Caroll MD, Kit BK, Flegal KM. Prevalence of obesity in the United States, 2009-2010. NCHS Data Brief.2012;(82):1-8.
  • Chopra CW, Ayoub NT, Bromfield C, et al. Surgical management of acquired (cicatricial) buried penis in an adult patient. Ann Plast Surg 2002; 49:545-9.
  • Radhakrishnan J, Reyes HM. Penoplasty for buried penis secondary to "radical" circumcision. J Pediatr Surg 1984;19:629-31.
  • Herbenick D, Reece M, Schick V, Sanders SA. Erect penile length and circumference dimensions of 1,661 sexually active min in the United States. J Sex Med 2013; doi: 10.1111/ jsm.12244.
  • Ghanem H, Glina S, Assalian P, Buvat J. Position paper: Management of men complaining of a small penis despite an actually normal size. J Sex Med 2013 Jan; 10:294-303.
  • Gary J. Altar. Chapter 79: Aesthetic Surgery of the male genitalia. Reconstructive and plastic surgery of the external genitalia: Adult and pediatric. 1st ed. Philadephia: W.B. Saunders: 1999.
  • Tang SH, Kamat D, Santucci RA. Modern management of adult-acquired buried penis. Urology 2008; 72:124-7.

Correspondence:

Prof. Dr. SEMIR AHMED SALIM AL SAMARRAI
Professor Doctor of Medicine-Urosurgery, Andrology, and Male Infertility
Dubai Healthcare City, Dubai, United Arab Emirates.
Mailing Address: Dubai Healthcare City, Bldg. No. 64, Al Razi building, Block D,
2nd floor, Dubai, United Arab Emirates, PO box 13576
Email: fmcalsam@emirates.net.ae