Buried Penis in Adults

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Abstract

Adults with a buried penis are unable to void normally and perform sexually. Some may even present with life-threatening infections. Surgical reconstruction to unbury the penis and remove surrounding obstructive tissue will frequently improve a patient’s urinary and sexual health.

INTRODUCTION

The buried penis in adults is frequently associated with obesity and penoscrotal lymphedema (fluid retention in penile and scrotal skin). It may also be seen after overzealous and repeated circumcision. The buried penis is aptly named because it accurately describes a phallus engulfed by fat/subcutaneous tissue and skin. This may disrupt normal hygienic urination and prevent sexual function. Management of this with weight loss is ideal but often impractical. Furthermore, even with adequate weight-loss, the penis may remain buried. Radical reconstructive surgery is oftentimes the only treatment.

ANATOMY

Obesity can lead to excess fat and skin accumulation around the penis. An overhanging abdomen, which doctors call pannus, rarely contributes to the buried penis. However, overhanging suprapubic tissue called the escutcheon will frequently envelop a normally exposed penis. This creates a pseudocavity where the glans (tip of penis) sits at the bottom of a “well” filled with sloughed skin and urine. The scrotum is usually uninvolved unless penoscrotal lymphedema, cellutis, and abscesses complicate the clinical picture.

DIAGNOSIS AND EVALUATION

Most patients with a buried penis are morbidly obese with associated medical problems including hypertension, diabetes, and depression. They invariably complain of difficult urination in the standing position. Patients will also report decreased urinary stream, hesitancy, incomplete bladder emptying, and straining—a related group of complaints collectively called obstructive urinary symptoms. Some may even reveal that voiding in the bathtub is the only way they can prevent urine spillage elsewhere. Normal sexual function is also prohibited by their body habitus.

Patients frequently present with body mass indices well-over 30kg/m 2 (30 is the lower limit of obesity). Practitioners will usually be unable to visualize the penis. Retraction of tissue may be helpful for examination if the surrounding skin is not edematous or infected.


Fig. 1: Buried penis in 39 year old man seen in clinic.



Fig. 2: Patient had prior attempt at repair with circumcision with resultant worsening of his buried penis. He continues to have obstructive urinary symptoms and skin irritation from pooled urine.


Occasionally, the penis can only be identified by palpation thru a pseudocavity created by the eschutcheon. Some patients, obese or not, will have primary genital lymphedema with indurated skin. Some will have erythema (redness) and/or fever that may indicate cellulitis, abscess, or Fournier’s gangrene—a life threatening necrotizing soft tissue infection that needs urgent debridement. Some patients may have associated lichen sclerosus causing pruritus (itching) and urethral stricture disease. LS is hard to diagnose because of the escutcheon. It is therefore sometimes found intraoperatively.


Fig. 3: Buried penis with large escutcheon. The scrotum is lymphedematous and inflamed as well, requiring concomitant removal.


PREOPERATIVE PREPARATION

Obese patients frequently have many health problems that will require preoperative optimization prior to extensive reconstructive surgery. They may be referred to their primary care physician, cardiologist, pulmonologist, and anesthesiologist prior to surgery. We routinely order electrocardiograms, chest x-rays, blood work, urinalysis and urine culture before surgery.

SURGICAL MANAGEMENT

Multiple techniques for the management of the buried penis have been published by plastic surgeons and urologists. We endorse a technique similar to that described by Tang et al which involves unburying the penis, removing inflamed penile shaft skin, removing the prepubic fat pad (escutcheonectomy), placing a split thickness skin graft (STSG) around the denuded penile shaft, and scrotectomy/scrotoplasty (removal/recreation of the scrotum) if needed1.

Five general steps are utilized for surgical treatment of the buried penis:

1. Penile adhesiolysis (release from surrounding tissue) with or without penile shaft skin removal. A holding suture (2-0 prolene) is placed thru the glans penis and retracted outward to delineate the penis. Occasionally a dorsal slit procedure is required to expose the glans penis. With the penis held outward, we expose the penile skin and determine whether we need to remove it or keep it.

2. Dermatolipectomy (skin and fat removal) which includes eschutcheonectomy with or without scrotectomy. Excess surrounding and inflamed tissue is resected in it’s entirety. We even perform lipectomy of the surrounding skin while making sure not to “thin out” the dermis too much as this will compromise blood supply. Neighboring well-vascularized skin is required for wound defect coverage.


Fig. 4: Penile shaft skin removal and escutcheonectomy/srotectomy defect.


3. Penile fixation to remaining tissue. Using multiple layers of absorbable suture, we secure the base of the penis to the surrounding dermis and fascia. This will prevent recurrence of a buried penis. Occasionally, a circular opening is made in the de-fatted skin flap for proper positioning of the penis.

4. STSG for penile shaft coverage; graft usually obtained from eschutcheon or thigh. If the penile shaft skin is inflamed and diseased, we remove the skin and place STSG. We use a dilute fibrin sealant to help with graft take.


Fig. 5: Base of penis is secured to neighboring tissue and STSG is placed on the denuded penile shaft.


5. Scrotoplasty. When the scrotum is involved with the escutcheon or if the scrotum is inflamed, the entire scrotal skin is removed. Neighboring healthy skin–often ample in supply–is used to reconstruct the scrotum and cover the testicles. Sometimes the testicles are placed under the inner thigh skin (thigh pouches) and the wound defect is closed primarily.

POSTOPERATIVE CARE AND FOLLOW-UP

Patients are kept on bedrest for 24 hours to facilitate skin graft take. The day after surgery, urethral catheters are removed and patients are encouraged to walk and void on their own. Penile wound dressings are changed and patients are taught how to change them themselves. On postoperative day 2, the patient may shower and change his own dressing. Patients are then sent home on postoperative day 3 or 4 depending on how well they do. Strict weekly or every other week follow-up is required to verify appropriate wound healing. Most STSG donor sites heal well within several weeks. STSG recipient sites (the penile shaft) frequently have good take; small areas of poor graft take heal by secondary intention without incident. On occasion, eschutcheonectomy wound dehiscence is observed and this will require immediate surgery or a period of observation followed by further reconstructive surgery depending on the severity of this complication. Scrotoplasty wounds heal very well and rarely cause problems. After 1-2 months–if the wounds heal as expected–patients are seen less frequently. In general, patients experience immediate improvement in their voiding symptoms. After 6 weeks (duration needed to allow adequate healing of penile STSG placement), somepatientsregain their sexual function.

CONCLUSION

Adulthood buried penis can be a debilitating and embarrassing disease. Attempts at weightloss are often futile as the sole treatment since most patients will still have a buried penis despite successful diet and exercise programs. A commitment to better health combined with surgical interventionis frequently the most effective way to manage this disease. Surgery is the only way to treat this disease when it is associated with soft tissue edema and infection.The immediate return of normal voiding function and a later return of sexual function are the primary benefits of buried penis corrective surgery.

1Tang SH, Kamat D, Santucci RA. Modern management of adult-acquired buried penis. Urology. 2008:72:124-127.

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