Try out PMC Labs and tell us what you think. Learn More. Adult acquired buried penis represents the clinical manifestation of a wide spectrum of pathology due to a variety of etiologies. Buried penis can be associated with poor cosmesis and hygiene, voiding dysfunction, and sexual dysfunction.
Evaluation and management of buried penis largely depends on etiology and degree of affected tissue. It is an increasingly common problem seen by reconstructive urologists and here we present several frequently seen scenarios of buried penis and management options. Due to reduced visible and functional length of phallus, this condition is often associated with patient dissatisfaction related to cosmetic, hygienic, voiding, and sexual dysfunction.
Subsequent phimosis can lead to spraying, dribbling, urinary soilage, and skin breakdown. Often times, the meatus is not visible and can mask undiagnosed urethral disease related to lichen sclerosis LS also known as balanitis xerotica obliterans BXO. Additionally, a buried penis often limits penetrative sexual intercourse.
In some series, clinical depression has been noted in a majority of patients preoperatively 1. While weight loss may improve some symptoms for those who have a buried penis related to obesity, many men have ificant remaining prepubic fat deposition along with ptosis of the prepubic fat pad, or escutcheon, that would benefit from surgical repair 2. Additionally, severe scrotal lymphedema and genital hidradenitis often result in buried penis with a severe deficiency of normal scrotal skin to use for reconstruction.
Overall, acquired buried penis in adults has become an increasingly common problem seen by reconstructive urologists. The basic evaluation for a buried penis begins with a comprehensive history and physical examination. The history should reveal how long the phallus has been buried and if it was associated with any weight gain or loss. The penile and scrotal skin should be assessed for changes suggestive of LS skin whitening, glans fusion, etc. Associated voiding symptoms such as dysuria, straining to urinate, weak stream, dribbling, urinary tract infections, or sitting to urinate should be elucidated.
Sexual function should be evaluated including erectile dysfunction, pain with erection, or inability to penetrate due to buried phallus. Is the patient concerned about cosmetic or functional outcomes? Is the goal to void standing up or to sexual activity? Additional history should focus on relevant comorbidities such as obesity, pulmonary issues often associated with morbid obesity, diabetes, hypertension, hidradenitis, and urologic history. Prior surgical history such as lymph node dissection, circumcision, penile enlargement surgery, or genital enlargement injections should be ascertained.
Other causes of voiding dysfunction should be addressed such as history of benign prostatic hyperplasia or urethral stricture. An abdominal and suprapubic exam should be performed with notation of any overlying pannus while the patient is supine and standing.
In particular, the skin surrounding the phallus should be examined to evaluate whether there are loose attachments, an abundance of prepubic fat pad, or a phimotic ring of scar tissue. In some cases, there is an overabundance of escutcheon or a phimotic band Figure 1 which prevents evaluation of the penile shaft skin. In those cases, the patient should be counseled about the possible need for flap or graft coverage in case there is a paucity of viable skin during reconstruction.
When there is scrotal enlargement suggestive of scrotal lymphedema, the lateral scrotal and perineal skin needs to be evaluated to determine if there is sufficient supple skin for flap coverage or primary closure after excision of any effected skin and subcutaneous tissues. Moreover, where there is scrotal enlargement, the presence of any draining sinuses, abnormality of the medial thighs, or induration of the peri-anal area or armpit abnormality suggests a diagnosis of hidradenitis.
Due to inflammation and lichen sclerosis, a phimotic band often forms, pushing the phallus proximally and burying it. It can often be difficult to separate voiding symptoms related to a buried penis from symptoms of urethral stricture, especially when the phallus is buried to the extent that the underlying phallus cannot be examined.
Appointments at mayo clinic
These patients should be carefully counseled about the risk of concomitant urethral stricture disease. In patients with a suspicion of urethral stricture based on symptoms or a suggestion of meatal narrowing, the urethral meatus, fossa navicularis, and distal penile urethra can be calibrated with Bougie-a-boules.
Cystoscopy should be performed if there is any suspicion of stricture proximal to the most distal penile urethra. Patients with buried penis and long urethral strictures need careful operative planning in order to address both of their issues. In patients with a buried penis where the meatus cannot be seen on physical exam, it is often not possible to evaluate for urethral strictures pre-operatively. Management of adult buried penis varies enormously based on the quality and quantity of healthy penile, scrotal, and abdominal skin. Additionally, the etiology of the buried penis plays a large role in treatment and surgical repair.
In general, repair of buried penis involves unburying the penis, resection of any diseased or excess tissue, tacking tissue down to reform the penopubic angle, and coverage with either local skin flaps or skin grafts. Here, we have organized a series of frequently seen adult buried penis scenarios and the commonly preferred management. Obesity is a common cause of acquired adult acquired buried penis.
There are some similarities with buried penis seen in children, which is often related to poor skin suspension, abnormal excess fat accumulation in the pubic area, webbed penis due to penoscrotal webbing, or trapped penis due to scarring post circumcision 34. This is exacerbated by obesity and weight gain as the suprapubic fat pad encompasses the phallus. These patients often present with complaints of a shorter penis, difficulty having intercourse, or urinary dribbling.
On physical examination, when the skin and fat surrounding the base of the penis is compressed, the shaft of the penis is typically visible. If there is no associated inflammatory skin disease such as LS, then the patient can be counseled initially regarding weight loss, which may increase the size of the visible penis by decreasing the surrounding fat.
While weight loss may not lead to resolution of buried penis, this will likely help facilitate eventual repair and offer other health benefits in a population often associated with ificant comorbidities. While tacking hypermobile skin is often sufficient in patients with obesity, patients with more ificant morbid obesity often face additional challenges to surgical repair. As patients gain weight, there is often a preferential deposition of adipose in the suprapubic area that persists even after weight loss or bariatric surgery 2.
Since the phallus remains tethered to the pubis by the suspensory ligament, the redundant suprapubic fat pad eventually completely surrounds the penis. With burial of the glans and meatus, patients often have to sit to void due to dribbling. A combination of poor hygiene and persistent moisture trapped near the penis le to chronic bacterial or fungal colonization. Chronic colonization can lead to inflammatory skin contracture and the formation of a phimotic ring of scar.
I have bumps on my penis. is this normal?
This often in invagination of the penile shaft skin and further burial of the phallus. Over time, the penile shaft skin will often break down and there will be a paucity of healthy penile tissue during time of surgical repair. Additionally, patients may have a degree of burial due to descended escutcheon or ificant overlying pannus.
In more severe cases of morbid obesity, surgical repair may include a formal panniculectomy, dermatolipectomy, and the tacking of the penopubic subdermis to the rectus fascia. If a morbidly obese patient presents with ificant escutcheon that limits examination of the glans, meatus, and penile skin, we counsel the patient extensively preoperatively regarding the potential for there to be a deficiency of penile skin and possible need for local flap or graft coverage.
Additionally, patients are counseled about the risk of encountering undiagnosed meatal or urethral stricture associated with chronic inflammation and LS at the time of surgery since it is difficult to discern between the voiding symptoms of a buried penis alone compared to that of a buried penis associated with a urethral stricture. Additionally, if there is ificant escutcheon or overlying pannus that will need to be surgically removed, a concomitant escutcheonectomy or panniculectomy may be indicated at the time of buried penis revision.
The penis and foreskin
In cases that involve panniculectomy, it is our preference to include the expertise of a plastic surgeon. Many patients have concomitant comorbidities such as diabetes, hypertension, and chronic obstructive pulmonary disease COPD that increase their risk of perioperative complications and every attempt should be made to optimize patients medically preoperatively and insure the risk of surgery is acceptable.
The surgical approach is influenced by the specific factors identified on physical examination performed with the patient in the supine and standing positions prior to surgery that may be contributing to the buried penis. The suprapubic incision and amount of skin and subcutaneous suprapubic fat removed is individualized based on the above findings. The goal is to excise and lift the excess pubic skin and reduce the pubic fat, which may or may not include abdominoplasty.
When there is then apparent hypermobility of the dorsal penile skin, this can then be address with tacking of the penopubic subdermis to the rectus fascia. Often times, the penile skin can be mobilized for dorsal coverage leaving remaining ventral skin deficiency. If the defect is small and the scrotal skin is normal, a ventral slit scrotal flap can be used to cover the defect with a Z-plasty 5. A vertical incision is made on the scrotum with relaxing incisions to the right and left to form a Z.
The scrotal skin flap is carefully mobilized taking care to preserve the rich blood supply of the underlying dartos fascia. A rotational flap is then advanced for penile skin coverage. Advantages of mobilizing a local scrotal flap include avoiding the morbidity associated with taking skin grafts. Scrotal skin is often supple, is easily mobilized, has no subcutaneous fat, and often offers an acceptable cosmetic result.
Due to its high vascularity and dual blood supply, scrotal flap necrosis rates are rare 6. In a retrospective review of 18 patients who underwent a scrotal skin flap to the penis, 15 patients reported satisfactory sexual outcomes and sensation 6. However, scrotal skin does have the disadvantage of being hair-bearing as well as having rugae, leading to a differing cosmetic appearance compared to normal penile skin.
In some cases, skin grafts are necessary for adequate coverage and will be discussed below. An acquired adult buried penis may be seen in patients who develop LS, a condition that is often associated with obesity. Often times, inflammatory changes of the distal penile skin or the circumcision suture line in circumcised patients in development of scar tissue and formation of a cicatrix Figure 1. This traps the penis proximally, resulting in invagination and tunneling of the penis underneath the penile skin.
Urine often pools beneath this tissue, leading to chronic colonization of bacteria and further inflammatory changes. When present chronically, this can lead to denudation of the tissue. In other patients, the inflamed distal penile skin does not cover the glans but is rather permanently fused to the glans giving the false appearance of phimosis. If the patient is uncircumcised and there is adequate penile skin proximal to the prepuce, circumcision represents an effective treatment for the phimosis and the associated buried penis. Moreover, in uncircumcised men, circumcision is often considered curative of LS limited to the prepuce.
In circumcised men, management with a repeat circumcision may further worsen the skin defect and bury the shaft more proximally. We often treat initially with a course of high potency steroid cream to decrease inflammation and soften the tissue, which may avoid the need for surgery. We prefer the use of clobetasol 0.
In patients with voiding symptoms or the appearance of involvement of the urethral meatus, it is important to evaluate the urethra with Bougie-a-boule calibration, cystoscopy, and when there is confirmation of a stricture, urethral imaging with a retrograde urethrogram and possibly a voiding cystourethrogram.