Penile concealment is an uncommon urologic condition that often prompts concerned parents to seek the care of a urologic surgeon. Some patients are candidates for intervention, but others can be managed expectantly. The decision to intervene should be based on a discussion with the family, which should include the anticipated outcomes as well as the risks and benefits of the procedure. Indications for intervention are not limited to but include an improvement in cosmesis, pooling of urine, sprayed urine stream, recurrent balanitis, and difficulty with access for hygiene.
Maizels first categorized hidden penis into a classification system according to etiology. The differential diagnosis for penile concealment includes buried penis, penile engulfment, trapped penis, webbed penis, and micropenis. With the exception of micropenis, patients with penile concealment will have normal shaft length despite their clinical appearance. In neonates, this condition is most commonly caused by a lack of adherence of deep penile fascia to overlying penile shaft skin. This may be exacerbated by a generous suprapubic fat pad that is thicker than the length of the flaccid penis. After neonatal circumcision, excessive redundant inner shaft skin may result in penile adhesions. The term buried penis is used to describe the condition in which the entire penis is concealed beneath the skin. This occurs in two distinct age groups, (1) newborn and toddlers and (2) obese adolescents. In “webbed penis,” the skin at the penoscrotal junction conceals the penis because of a paucity of ventral shaft skin that may have been removed at circumcision but may be congenital. In contrast, “trapped penis” is caused by prior surgical intervention, most commonly circumcision, in which the foreskin develops a cicatricial scar that entraps the penis. Finally, micropenis results in penile concealment because of the diminutive nature of the phallus in which the stretched penile length is less than 2.5 standard deviations below mean length. Patients who are discovered to have micropenis should be referred for endocrine evaluation.
Several factors have been attributed to the development of penile concealment. As noted by , all patients in the neonatal age group had some overlap in the following: penile tethering by fibrous dartos bands, lack of adherence of penile skin, penoscrotal webbing, and excessive suprapubic fat. An important shared characteristic was the shortened length of ventral penile shaft skin and excess inner preputial shaft skin that frequently results in symptomatic penile adhesions.
It is important for the surgeon to appreciate that penile concealment may occur before circumcision, which illustrates that this anomaly is congenital and not uniformly the result of neonatal circumcision. The lack of normal dartos fascial attachments to the underlying Buck fascia results in the loss of the penopubic and penoscrotal angles, both of which should be addressed at the time of surgical intervention. Additionally, this condition may be dynamic and not initially recognized at the time of neonatal circumcision. Concealment may be exacerbated as the result of increased deposition of suprapubic fat as the neonate ages. If recognized, the pediatric provider should guard against neonatal circumcision.
Most patients in the infant age group present around the first year of life after circumcision. The best results with regards to hygiene, access to the phallus, and improved negative concerns are obtained when intervention is performed in this younger age group. However, some boys or young men do not develop penile concealment until adolescence. In this cohort, concealment occurs in conjunction with significant weight gain and obesity. First-line therapy should include caloric restriction. Surgical options in this older population include suction lipectomy or excision of excess suprapubic fat in addition to the correction of penile concealment. Although the long-term success has been substantiated in the neonatal cohort, less favorable outcomes have been reported in adolescence.
Clinically, penile concealment may have a similar appearance regardless of circumcision status. The penis may reside well below the external shaft skin ( Fig. 122.1, A ), which may result in complete removal of shaft skin during neonatal circumcision. In rare cases, before circumcision, the penis may be completely engulfed in scrotal skin and lack shaft skin altogether ( Fig. 122.1, B ). Rarely, after circumcision, the cicatrix may constrict, and the phallus may become trapped with resultant ballooning of the foreskin and pooling of urine ( Fig. 122.1, C and D ). Typically, this causes the inner preputial skin to become very inflamed from chronic exposure to urine, which may create some challenges during surgical repair.
Incision and Exposure
If the patient has been previously circumcised, a tight cicatrix may be encountered, which prevents reduction of the foreskin. The initial incision through the scar should be made dorsally to avoid injury to the urethra. A ventral counterincision can then be made to release the tight phimotic skin. If feasible, a circumferential incision is made along the entire previous circumcision scar with care taken to completely remove this fibrotic tissue to allow adequate lymphatic drainage after the repair. If uncircumcised, an incision 3 to 5 mm from the corona should be made circumferentially. It may be useful to place a traction suture through the midline glans to facilitate exposure.
Degloving and Removal of Fibrous Dartos Bands and Scrotal Fat
Sharp dissection should be performed to allow for adequate exposure of the concealed penis. The dissection should occur within the avascular plan just above Buck fascia. With penile degloving, the abnormal fibrous Dartos fascial bands should be completely released dorsally and laterally. Equally, high-riding scrotal fat that tethers the penis ventrally should be released as well. An example of these Dartos fascial bands and scrotal fat is demonstrated in Fig. 122.2 .