What Is the Cause for Babies to Have Hidden Penis Problems

ISRN Urol. 2013; 2013: 109349.

Buried Penis: Evaluation of Outcomes in Children and Adults, Modification of a Unified Treatment Algorithm, and Review of the Literature

I. C. C. King

Section of Plastic and Reconstructive Surgery, James Cook University Hospital, Middlesbrough TS4 3BW, United kingdom

A. Tahir

Section of Plastic and Reconstructive Surgery, James Cook University Hospital, Middlesbrough TS4 3BW, United kingdom

C. Ramanathan

Section of Plastic and Reconstructive Surgery, James Cook University Hospital, Middlesbrough TS4 3BW, Great britain

H. Siddiqui

Section of Plastic and Reconstructive Surgery, James Melt University Hospital, Middlesbrough TS4 3BW, UK

Received 2013 Sep nine; Accepted 2013 Oct 7.

Abstract

Introduction. Buried penis is a difficult condition to manage in children and adults and conveys pregnant concrete and psychological morbidity. Surgery is often declined due to morbid obesity, forcing patients to live in disharmony for years until the desired weight reduction is accomplished. No unmarried operative technique fits all. Nosotros present our experience and surgical approach resulting in an improved algorithm unifying the handling of adults and children. Methods. We conducted a retrospective analysis of patients treated for buried penis between 2011 and 2012. All patients underwent penile degloving and basal anchoring. Penile shaft coverage was achieved with peel grafts. Suprapubic lipectomies were performed on adult patients. Results. Nine patients were identified: four children and five obese adults. Boilerplate postoperative stay was 3 days for children and 5 for adults. Three adults were readmitted with superficial wound bug. One child had minor skin breakdown. All patients were pleased with their outcomes. Decision. Buried penis is a complex condition, and treatment should be offered by services able to deal with all aspects of reconstruction. Obesity in itself should not delay surgical intervention. Local and regional awareness is essential to manage expectations in these challenging patients aspiring to both aesthetic and functional outcomes.

1. Introduction

The buried penis is widely regarded equally a condition which is difficult to manage both in children and in adults. Buried penis was commencement described by Keyes in 1919 as follows: "absence of the penis exists when the penis, lacking its proper sheath of peel, lies buried beneath the integument of the abdomen, thigh or scrotum" [1]. Buried penis has most often been discussed in relation to the paediatric population [two–8], with congenital and iatrogenic aetiologies identified. Cached penis in adults may have a congenital component in some cases but is largely regarded as beingness an acquired condition as a consequence of obesity, lymphoedema, penile trauma (including circumcision), and persistent infection, usually in the presence of diabetes.

In children, presentation is often driven past parental concerns over urinary symptoms and penile size. Developed patients nowadays with symptoms which have a profound impact on their lives. Patients can complain of beingness unable to pass urine while continuing—and sometimes sitting—without soiling themselves, of having recurrent penile and urinary infections which are uncomfortable and antisocial, or being unable to achieve erections without pain, or to attain successful vaginal penetration with the consequences of damaged relationships and lowered self-esteem. Prompt recognition and treatment of these symptoms in both adults and children are thus essential to reconstruct more than normal appearance and function.

The complex interaction of meaning physical and psychological symptoms of patients with a cached penis means that treatment must exist tailored to the individual. Indeed, within the literature, no single operative technique has been described to meet all patients' needs. Algorithms have been advocated for treatment of adults with buried penis [nine, 10] to accept into account the unlike surgical approaches to this problem. Nosotros present our feel of buried penis treatment in adults and children, using a unmarried surgical technique which incorporates an understanding of the aetiology of buried penis in the two populations (Figure ane), unifying management, and streamlining our exercise into a modified treatment algorithm.

Treatment algorithm for adults and children with buried penis (adapted from [ix]).

ii. Methods

A retrospective analysis was performed for all patients who had undergone handling for a cached penis in James Cook Academy Hospital between 2011 and 2012. All patients had been treated under a single surgeon.

Under general anaesthetic with antibiotic encompass (Co-amoxiclav), the penis is delivered by degloving the surrounding tissues. A urethral catheter tin can be inserted to enable control of the penis and some degree of protection of the ventral urethra during autopsy, if required. A iv-0 nylon sew together is placed through the glans to give further command and enable traction of the penis. The penile shaft is circumferentially degloved from a distal coronal incision, leaving 1 cm of subcoronal cuff, to the penile base along the subdartos plane assuasive for any chordee encountered to exist released and to preserve the dorsal neurovascular bundle (Figure 2). Infected or scarred tissue is removed as necessary and sent for laboratory analysis. The penopubic and penoscrotal angles are reconstructed using three-0 PDS sutures betwixt the tunica albuginea and dartos fascia and dermis at the penile base of operations, placed in the 12, 7, and 4 o'clock positions.

Penile skin coverage demonstrating delivery of the penis from tethering tissue and resurfacing with fenestrated skin graft draped dorsally to recreate the ventral raphe.

In adults, who are all obese in our population, the procedure incorporates a suprapubic lipectomy. Marked preoperatively, the patients have suprapubic lipectomy through a "West" shaped incision based two-3 cm cranial to the penile base of operations (Figure 3). If skin is required for shaft and/or glans resurfacing, the skin is harvested from this region using a dermatome (setting 12) as a sheet graft. The backlog tissue is weighed, and the wound is closed with Scarpa's fascia and two-layer skin sutures with PDS and monocryl. 1 or two suction drains are inserted and secured with silk.

Suprapubic lipectomy can uncover the penile base of operations position (being pointed centrally) and provide a useful peel graft donor site.

Penile skin is redraped every bit necessary with native peel, with priority given to the proximal end of the penis as this will facilitate penile fixation. Pare is joined on the ventral surface to mimic the ventral raphe. Where skin has been removed or native skin is insufficient, penile coverage is completed using either full thickness skin grafts harvested preferentially from the groin in children, or split skin graft from either the excised suprapubic skin or from the thigh in adults (Figure 3). Grafts are held in identify with five-0 vicryl rapide circumferential and quilting sutures (Figure two). The distal coronal incision is closed circumferentially with an interrupted five-0 vicryl rapide suture. Penile dressing is achieved using a nonadherent vaseline-impregnated Jelonet dressings covered with a proflavine-soaked gauze support dressing. The abdomen is dressed with steristrips and an adherent dressing. A course of antibiotics is prescribed for a week, and wounds are reviewed on the third postoperative mean solar day with discharge home if mobilizing well, then coming back for graft check and catheter removal after a week. Patients are followed up as outpatients inside half-dozen weeks, at six months, and remain under review for at least a farther twelvemonth.

3. Results

A full of ix patients were treated for cached penis between 2011 and 2012 (Tabular array i). Five patients were adult men with an average age of 51 years (range 28–76). The five adults had an average BMI of 45. Presentation by the adult group consisted of a range of symptoms which were in all cases multifactorial and included difficulty passing urine (n = 3), and recurrent urinary infections (n = one), sexual dysfunction, including hurting on erection and impossible penetration (north = 3), artful concerns (northward = 3), and recurrent infections of the penis itself, including recurrent phimosis and lichen sclerosis et atrophicus (balanitis xerotica obliterans, BXO) (north = 4) and Fournier's gangrene (north = 1). 4 patients had undergone previous circumcisions, and the same patients were diabetic merely nonsmokers.

Tabular array 1

Different presentations of buried penis in children and adults.

Presentation	Children (n = 4)	Adults (n = five)
Age (years)	6 (eight yard–12 y)	51 (28–76)
BMI	Normal	45 (xxx–48)
Diabetes	—	iv
Urinary difficulties	four	4
Sexual dysfunction	—	three
Aesthetic concern	iv	iii
Recurrent infections	—	four
Fournier's gangrene	—	i
Previous circumcision	—	4
Phimosis	1	ane
Hypospadias	1	—

The remaining four patients were children with an average historic period of vi years (range 8 months–12 years). None were obese or had undergone previous penile surgery; indeed otherwise they were fit and well and developmentally normal. All four presented with poorly controlled urinary streams, and parents were uniformly concerned near the size of their child'south penis. Comorbidities included hypogonadism (n = 1), glandular hypospadias (n = 1) and phimosis (n = 1).

All patients had penile degloving and penile fixation, and all merely the youngest kid required skin grafts for coverage of the penile shaft. 4 of the adults underwent suprapubic lipectomy with an average of approximately one kilogram of tissue removed. Additional adult procedures during the operation included a partial glansectomy (north = i) following recurrent BXO and suspensory ligament release for some other to reach a functional shaft length. Additional intraoperative procedures for the children included a frenuloplasty (n = 1), a single-stage Snodgrass hypospadias repair (n = 1), and a megaprepucectomy (due north = 1).

Operative duration without lipectomy was 2.6 hours on average, whereas the boilerplate performance for those having lipectomy was 3.8 hours. Children remained in hospital for 3 days on average and adults remained for 5.5 days. The patient with Fournier's gangrene had a longer hospital stay (14 days) due to his acute disease. Three adults were readmitted: two due to poor bodily hygiene resulting in superficial wound infections and the third who experienced some wound dehiscence when exerting himself. The child who did not undergo skin grafting had some ventral shaft skin loss which healed by secondary intention (Table two).

Table 2

Complications following cached penis procedures.

Complications	Children	Adults
Infection	0	2
Pain	1	0
Wound dehiscence	0	i
Readmission	0	3
Return to theatre	0	1
Skin loss	i	0

All patients were followed up, ranging from 6 to 30 months; the shorter followup is due to patient selection following poor compliance (Table 3). All patients reported much improved urinary function, peculiarly with regard to continuing micturition which all felt able to attain following the surgery. Sensation over the grafts significantly varied. None reported urinary tract infections or recurrence of BXO. The teenagers and adults reported painless, constructive erections, and the few who were sexually active were able to attain painless, constructive vaginal penetration (Figures ​ 4 and ​ 5). No buried penis recurred, and all patients stated that they were pleased or very happy with their effect.

Cached penis in a ii-year-old child and the postoperative skin grafted penis at the historic period of 4.

An adult with buried penis who underwent penile shaft resurfacing.

Table 3

Postoperative outcomes post-obit cached penis surgery.

On review	Children	Adults
Ongoing urinary problems	0	0
Recurrence of infection	0	0
Improved erectile function	i	3
Effective vaginal penetration	—	ane
Altered shaft sensation	one	3
Aesthetic concerns addressed	4	5
Overall satisfaction	All happy	All happy

iv. Discussion

Clarity in the approach to buried penis direction is hindered past the disruptive use of interchangeable terminology to describe the condition. A penis may be referred to as buried [1], webbed [xi], curtained [12], camouflaged [13], or entrapped [14]. Micropenis is an entirely distinct condition with separate aetiological and anatomical features and care must be taken to mistake the unlike pathologies [15]. In addition to changes in the hypothalamic-pituitary-gonadal axis, micropenis patients lack the normal coroporal length seen in cached penis [10]. The nomenclature by Maizels et al. is widely referred to, especially in reference to paediatric buried penis, and identifies cached penis as one of iii subgroups of curtained penis [12], along with webbed and trapped. Buried penis is defined every bit a penis of normal size which is concealed within the pubic tissue due to a lack of fixation of the skin at the base of operations of the penis. By contrast, a trapped penis is secondary to scarring post-obit penile surgery, such every bit circumcision, and webbed penis is a issue of the disappearance of the penoscrotal angle due to abnormally distal extension of scrotal skin over the ventral surface of the penis. Elder clarifies his definition of buried penis (interchangeably used with concealed penis) in children every bit existence caused by an inelasticity of the dartos fascia in infancy and by arable fat on the abdominal wall in older children [thirteen]. Oh et al. further distinguish between the concealed and buried penis, stating that the aetiology of concealed penis lies in a deficiency of penile skin or inelasticity of the dartos fascia [14]. Cached penis by contrast is secondary to poor fixation of penile skin at the penile base of operations or excessive suprapubic fat [14]. The overarching consensus is thus that babyhood buried penis is in the main a built condition which can also be seen with postcircumcision scarring.

Ehrlich and Alter suggest that the term buried penis for adults refers to a penile shaft which is buried beneath the surface of the prepubic skin and to a penis which is partially or totally obscured secondary to either obesity or injudicious circumcision [16]. Developed buried penis is viewed largely every bit an acquired condition with a dissimilar pathophysiology from that of children, although some authors consider that some milder forms of dysgenic dartos fasical bands may not exist present until adulthood [10], which somewhat blurs the distinction. Warren argues that whereas in boys excess fatty is but a contributing factor to penile encroachment, information technology is causative in men [17]. Male weight gain preferentially involves the abdominal and suprapubic region, and this fatty, one time present, is difficult to lose through either dieting or practice. The penile fixity to the pubis results in an apparent length loss as the suprapubic fatty pad increases in size [x]. This enveloping fat encourages a moist environs platonic for bacterial growth [9] which results in a wheel of infections which results not only in contracture of the skin surrounding the distal penis, but also in the recruitment of prepubic skin to invaginate the shaft [10], creating a circular scar which traps the penis [9, 18]. Infections are further compounded past the presence of diabetes and its sequelae. Inflammation of surrounding tissue through genital lymphoedema and scarring induced from trauma or circumcisions serves to promote and perpetuate such processes.

There appears to be no reliable data at present about the incidence of cached penis in adults, and it is likely that the number of patients with this condition is far greater than the population presenting to the hospital. No specific BMI value is linked to the probability of having a buried penis [19]. With obesity becoming increasingly prevalent across the world, this is a condition that will be inevitably more than frequently present for treatment. Certainly, symptoms of uncontrolled direction of micturition stream, severe sexual dysfunction with painful erections and inability to accomplish vaginal penetration, in improver to inability to maintain even basic hygiene or visualize one's penis, will likely likewise outcome in circuitous psychological comorbidities. Surgical intervention however must be embarked on with circumspection: it is established that obese patients have a high risk of complications [twenty], especially in the presence of diabetes, with wound breakup, infection and systemic postoperative complications. The role of preoperative counseling to address the psychological consequences of this status and to prepare patients for the postoperative interventions is tremendous and should not be overlooked.

Treatment for buried penis should aim to restore an artful and functional penis [21]. The wide diversity of approaches to correcting this problem reflects the different perceptions of aetiology. Having reviewed our results and methods, we retrospectively adapted established treatment algorithms [five] to create a single common pathway for buried penis in children and adults (Effigy i). Through comparison with current literature, each phase tin can be seen to follow a logical understanding of the underlying pathologies in buried penis. Dissection of the dartos and Buck'due south fascia with division of chordee is commonly performed, though the arroyo of the autopsy does vary, with some clinicians preferring to make incisions at the penopubic or penoscrotal junction with dissection distally to costless the shaft [2–4, 8], some working proximally [10, 22] and others using a combination [v]. In our experience, release from distal to proximal enables clear and safety visualization of the dissection plane and of the neurovascular structures, adhesions, and chordee. Some clinicians induce artificial erections with saline to determine the adequacy of release of adhesions [9, 10], but we take not adopted this into our practice.

Borsellino maintains that the central to correction is release of the abnormal dartos attachments and fixation of the penile skin to Buck's fascia [5]. Reinforcement at the penoscrotal and penopubic angles is widely skillful, though the approach (via stab incisions [three] or autopsy), number of sutures (from two to 4) [3, 6, ten], and placement of sutures (90 degrees [half dozen], 120 degrees [three], and 180 degrees apart [7, 10]) vary betwixt clinicians. Nosotros find the placement of three sutures at 120 degree angles sufficient for penile support and positioning.

The excision of excess fat is largely reserved for adult patients. Whilst liposuction [7] and pubic lipectomy [4] have been described in the treatment of paediatric buried penis, nosotros feel that fat removal in children is largely unnecessary because at a immature age, obesity can exist cocky-corrected [6] with judicious exercise and dietary advice. Joseph argues that excision of suprapubic fatty in children does non give satisfactory results because the abnormal position of the corporal bodies remains [8], whereas others simply assert that removal is unnecessary and can crusade an unsightly ledge in children [5]. Understanding that excess suprapubic and abdominal fat is a significant causative and perpetuating agent in adult buried penis, removing at least some fat is key to a successful outcome. Practise varies from liposuction—acknowledged to be relatively ineffective lonely [3, 23, 24]—to excisional mons lipectomy [17], suprapubic lipectomy [22], panniculectomy [eighteen, 21], and abdominoplasty [23, 24] through a host of different approaches. Closure too ranges from anchoring rectus fascia to pubic periosteum [21, 22], to the suspensory ligament [17], through intermission of the superficial base of penis fascia to the deep abdominal fascia [9]. We have found that following a suprapubic lipectomy unproblematic layered closure addresses the fat immediately overlying the dorsum of the penis, permits a significant weight of tissue to be removed, and enables tension-free closure of skin to reduce the risk of wound breakdown. Similar to other clinicians [23], the use of a "West" incision importantly avoids a central line of tension in the abdominal wound.

Finally, penile coverage has been achieved through dissimilar combinations and permutations. If no penile shaft skin is identified as being abnormal, direct closure may be possible. In our series, the but patient suitable for direct closure encountered wound breakdown, suggesting that penile skin in affected individuals may exist unhealthy even if they announced normal on a macroscopic level. Z-plasties may be used [6, 25], specially for correction of penoscrotal webs, as may the recruitment of local tissue and flaps [2, 26]. Skin grafting is increasingly favoured in spite of concerns regarding contracture and complications [5, 8]. There is no consensus as to whether outcomes are improved with split thickness peel grafting [2, 9, ten, 22, 26, 27] or full thickness peel grafts [17, eighteen], or whether they should be applied in a spiral [10] or nonspiral style to help graft take. We employ full thickness grafts to small defects, particularly in children, in a direct nonspiral style over the ventral surface of the penis and have non encountered any loss of graft, and no functional brake has been reported by our patients. Our use of hand-fenestrated split up thickness canvas graft for larger areas has healed well and aesthetically with an anatomical recreation of the midline raphe. Hand fenestration is not always necessary as multiple quilting sutures forming part of the internal splint allow for fluid drainage. The use of proflavine wool tie-overs, fibrin glue [22], negative pressure systems [28–thirty], and foam [18] suggests that a dressing which exerts pressure on the graft or replaced skin is helpful. Our experience of proflavine-soaked wool necktie-overs in grafts all over the body is strongly positive and is acceptable to patients in the postoperative flow. The catheter allows for better aftercare in the postoperative period, with Co-amoxiclav as our preferred antibiotic cover.

five. Conclusion

Buried penis is a status which is difficult to treat both in children and in adults. The nomenclature of buried penis is confusing because the aforementioned term is practical to a built condition affecting children because of dysgenic fibrous bands as to an caused condition in adults rooted in obesity. A spectrum exists however linking these poles with circumcision, a causative cistron in both adults and children, and the possibility that mild built deformities may non present until machismo when other factors, such as obesity, trauma, or infection, might occur and compound the condition. With the rising prospect of a more than obese patient population, plastic, paediatric, and urological surgeons are likely to run into this uncommon status more frequently. With no consensus held over when a cached penis should exist corrected in childhood and with no universally accustomed paradigm for the surgical management of adults, farther work is required to develop our understanding of this condition which carries significant concrete and psychological morbidity. We present a modified treatment algorithm to unify and streamline the practice in both adults and children.

Early on recognition of cached penis is certainly the fundamental to prompt treatment, equally is the local and regional awareness of reconstructive service provision. These patients are often left to lose their desired weight to see the effect of pare shrinkage and the delivery of safe anaesthesia, which may result in patients waiting for years for treatment, so compounding their existing complaints. Information technology is very likely that units offering reconstructive services may take to treat such patients who are notwithstanding morbidly obese if anaesthetically fit in society to resolve their significant issues regarding function and form.

Conflict of Interests

The authors declare that there is no conflict of interest regarding the publication of this paper.

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What Is the Cause for Babies to Have Hidden Penis Problems

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3893803/

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