Buried Penis

Buried penis, also called concealed penis, is a penis of normal size that is hidden within the suprapubic fat or scrotal skin. It is congenital in children, and acquired in adults, most often from obesity, lymphoedema, scarring or lichen sclerosus.

Complications include recurrent balanitis, urinary infection, voiding difficulty, hygiene problems, and sexual and psychological dysfunction.

Pathophysiology. In children, the penile skin is not fixed to the shaft because the dartos and Buck fascia attachments are inadequate. The shaft retracts into the prepubic fat, and the foreskin may balloon with urine.

Acquired causes in adults:

• Obesity, with a large suprapubic fat pad.
• Lymphoedema and scrotal oedema.
• Cicatrix after circumcision (trapped penis).
• Lichen sclerosus and balanitis xerotica obliterans.
• Diabetes mellitus, which adds infection and delayed healing.

The shaft is not visible at rest, with only the foreskin or a skin dimple. The penis emerges with suprapubic pressure and returns when released. Features include urine pooling, spraying, ballooning of the prepuce, recurrent balanitis and urinary infection. Adults report difficulty with hygiene, voiding and intercourse, and emotional distress.

• Examination: press on the suprapubic fat to expose the shaft, and measure stretched penile length from the pubic bone to the tip. Normal length excludes micropenis, which is stretched length more than 2.5 SD under the age matched mean.
• Examine for hypospadias, chordee, torsion, webbing, phimosis and lichen sclerosus. Biopsy suspicious glans or foreskin skin.
• Urinalysis and culture, post-void residual, and uroflowmetry for obstruction.
• Adults: body mass index, HbA1c, lymphatic assessment, and sexual function review.

Differential diagnosis.

• Micropenis
• Webbed penis
• Trapped penis after circumcision
• Hypospadias with chordee
• Lichen sclerosus with phimosis
• Disorders of sex development
• Lymphoedema of the genitalia

• Infants and young children: many improve with growth and loss of baby fat. Reassure, advise hygiene (gentle retraction and washing with water, and drying), and avoid circumcision, which removes skin needed for later repair.
• Candidal balanitis: clotrimazole 1% cream applied 2 to 3 times daily for 1 to 2 weeks. Bacterial balanitis: culture directed treatment.
• Surgery for persistent concealment after infancy, or complications: release of the dartos bands and fixation of the shaft skin to Buck fascia or the pubic area, with a preputial flap or skin graft for deficient shaft skin. Perioperative cefazolin 25 to 30 mg/kg intravenously in children (maximum 2 g).
• Adults:
  • Weight loss and glycaemic control (bariatric surgery for suitable patients).
  • Lichen sclerosus: clobetasol propionate 0.05% ointment as a thin layer once daily at night for 4 weeks, then reduced as the skin allows, with review at 3 months.
  • Surgery: suprapubic lipectomy or escutcheonectomy, penile degloving, split thickness skin graft or flap cover, and scrotoplasty with fixation of the shaft. Perioperative cefazolin 2 g intravenously (3 g if over 120 kg) as a single dose.
• Complications: infection, wound breakdown, skin graft loss, recurrence, and altered sensation.

Monitoring. Wound review at 1 to 2 weeks and 6 weeks, with reassessment at 3 and 12 months. Glycaemic and weight monitoring in adults. Lichen sclerosus carries a small risk of penile squamous cell carcinoma, so keep surveillance and biopsy any non-healing, ulcerated or raised area.

Referral and escalation. Refer to urology or paediatric urology. Urgent referral for urinary retention, necrotising infection or a suspicious skin lesion.