Department of Pediatric Urology, Ghent University Hospital, Ghent, Belgium
Many conditions involving the male external genitalia make the penis look small. Buried or webbed penis is one of those conditions. Penis size is the reason the parents bring their child to the outpatient clinic. It is important to distinguish those conditions where the penis has a normal size, from micropenis. The term micropenis refers to a penis that is completely normally formed, but is abnormally small.
KeywordsBuried penisMega preputiumWebbed penisTrapped penis
Many conditions involving the male external genitalia make the penis look small. Buried or webbed penis is one of those conditions. Penis size is the reason the parents bring their child to the outpatient clinic. It is important to distinguish those conditions where the penis has a normal size, from micropenis. The term micropenis refers to a penis that is completely normally formed, but is abnormally small .
Careful measurement (standardized as Stretched Penile Length: SPL) should me realized by gripping the glans and placing a ruler on the dorsal aspect of the penis from the pubic symphysis to the tip of the glans. Even if SPL is the standard penile measurement, it is however subject to important intra- and inter-observer variations.
As the micropenis is completely normal except for its size, the pathologic problem is probably occurring during the second and/or third trimester of intra-uterine growth. The intact urethra and foreskin proves a normal first trimester of intra-uterine growth. As penile growth is essentially taking place after the third gestational month, the pathology probably mainly depends on testosterone synthesis. The problem may be located at the level of the testes, the hypophysis, or the hypothalamus.
True micropenis should therefore be distinguished from other penile conditions, as it implies multiple endocrine and non-endocrine conditions, and should be treated by a multidisciplinary tem involving a pediatric urologic and a pediatric endocrinologist.
Many penile conditions are reported besides micropenis, but are reported under various denominations due to a lack of standardization . Buried penis is also described as inconspicuous penis, webbed penis, hidden penis, cryptic penis, concealed penis, mega preputium with concealed penis, all those terms covering one single pathologic finding: a normal penile shaft is entrapped in pubic fatty tissues, only leaving a redundant preputium visible [1, 3–5]. As its pathophysiology is unknown, many reconstruction techniques have been proposed, each supporting different pathophysiologic process.
Those primary congenital conditions have to be distinguished from acquired penile entrapment, which is observed after circumcision or other penile surgery during which too much skin has been removed. Such condition is called ‘trapped penis’ [1, 6].
Those conditions are also observed in adults, but are mostly observed as an acquired condition in which paucity of skin entrapping the otherwise normal penis occurs .
An important point to keep in mind is that all those conditions represent a formal contra-indication for a classical circumcision.
Buried Penis or Webbed Penis
Buried penis is a congenital penile malformation frequently encountered in pediatric urology . Although the true incidence of buried and/or webbed penis is unknown because of an ongoing debate about its definition, buried is probably the most frequent penile pathology after hypospadias [1, 2]. It affects children as well as adults, and can be congenital or acquired [7, 8].
Buried penis is also described as webbed penis, inconspicuous penis, hidden penis, cryptic penis, concealed penis, meaga-preputium with concealed penis, all those terms covering one single pathologic finding: a normal penile shaft is entrapped in pubic fatty tissues, only leaving a redundant preputium visible [1, 3–5, 9].
Some authors report buried penis as a different entity than webbed penis: in this case, webbed penis is the result of abnormal dartos at the level of the peno-scrotal angle, making that angle disappear, and giving the impression a penis webbed in the scrotal skin.
Symptoms can consist of cosmetic issues, as well as functional problems: voiding difficulties, urine spraying, dribbling, and ballooning.
Buried penis has to be distinguished from acquired penile entrapment, which is observed after circumcision or other penile surgery during which too much skin has been removed [5, 6]. Such condition is called ‘trapped penis’ [1, 6]. Trapped penis is therefore an acquired form of buried penis. The penile skin after circumcision forms a circumferential scar around the glans. The penis appears trapped within the scar, and is retracted in the pre-pubic fat or in the scrotum (Fig. 14.1a, b).
(a) Buried penis: only preputium is visible. (b) When applying pressure to the prepubic area, a normal penis appears, entrapped into pre-pubic fat
In Buried penis it is observed that the penis is entrapped in a cocoon of fibrotic dartos tissue and a common underlying pathologic process in all congenital penile malformation has been suggested [10–12]. In children with buried penis there seems to be a lack of elasticity of the dartos tissue, which normally allows the penile skin to slide freely on the deeper layers and allows easy stretching in erectile condition . Due to this condition the penis is retracted into the surrounding tissue.
Buried penises are associated with a high level of disorganisation of the dartos tissue, which lies probably at the origin of this condition . It was also observed that the level of dartos architecture disorganisation was strongly correlated with the clinical severity of the malformation .
Many explanations have been embryologically proposed for those conditions, with very few evidence: some authors propose the buried aspect of the penis is due to a lack of separation of the different primitive layers, rendering the penis attached to the deep fascia .
14.1.2 Surgical Techniques
The goal of surgery is to release of penis out of its cocoon, restoring normal penile length. Several surgical techniques have been proposed [6, 15–18]. Any surgical technique should include degloving of the penis to its base and fixing the penile skin and the dartos fascia to the deeper fascia to re-establish a correct peno-pubic angle and peno-scrotal angle.
Some authors describe topical administration of steroids as helpful in some cases . The majority of the real webbed of buried will anyway need surgical correction. Some authors also apply topical androgens, but Mouriquand proved it not helpful . Some authors argue surgical correction is not mandatory, and the puberty and its androgen boost will solve the problem. As application of local androgens before puberty is not efficient, the androgen boost of the puberty has even few chances of solving the problem .
There are even probably as many surgical techniques are there are surgeons operating on buried penis. Confusion further increases with the enormous number of varying principles applied to correct buried penis, based on liposuction, development of flaps, lipectomy,[16, 19–21]