The Inconspicuous Penis

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The

Inconspicuous

Penis

Paul S. Bergeson, MD*; Robert

J.

Hopkin, MD*; Robert B. Bailey, Jr. MDX; Leigh C. MCGill, MDX; and

Janice P. Piatt, MD*

ABSTRACT. Objective. To describe the etiology and management of the group of abnormalities referred to as the inconspicuous penis.

Design. Analysis of 19 cases seen over a period of 2

years by chart review.

Setting. Children’s hospital in a major metropolitan

area.

Patients. Nineteen boys referred to two pediatric

urologists over a period of 2 years with penises that

ap-peared abnormally small, but on palpation and measure-ment, were found to have a normal shaft with a normal

stretched length. Diagnoses included were buried penis,

webbed penis, and trapped penis. Patients ages ranged

from 1 week to 13 years.

Findings. There were eight patients (42%) with

trapped penis, and all were complications of circumcision (age 1 week to 7 months). Of nine (47%) patients with

buried penis, two had been circumcised prior to diagno-sis. One (5%) patient had webbed penis and one (5%) had combined buried and webbed penis.

Intervention. Six trapped penises were surgically

re-paired, and two resolved spontaneously. Five patients with buried penis had surgical repair, and two are being followed up for probable repair at age 9 to 12 months. Two were not repaired because of medical conditions or

pa-rental concerns. The webbed penis was surgically re-paired as was the combined buried and webbed penis. The repairs were all successful and had no complications.

Conclusions. Inconspicuous penis encompasses a

group of conditions in which the penis appears small but the shaft can be normal or abnormal in size. Circumcision is contraindicated in these patients until they have been evaluated by a urologist. Further study is needed to de-termine the natural history of these disorders and to better

define which patients will benefit from surgical interven-tion and at what age. Pediatrics 199392:794-799; incon-spicuous penis.

Inconspicuous penis is a term used in referring to

a phallus that is or only appears to be small. Seven

urologic entities that fall under this term have been

described.1 These conditions are poor penile

suspen-sion, buried penis, webbed penis, trapped penis,

concealed penis,2 diminutive penis,1 and micropenis

(five of these are shown in Fig 1). Proper treatment is dependent on accurately diagnosing which entity is present.

From the Departments ofGenera1 Pediatrics and Umlogy, Phoenix Chil-dren’s Hospital, Phoenix, AZ.

Received for publication Nov 5, 1992; accepted May 28, 1993.

Reprint requests to (J.P.P.) Phoenix Children’s Hospital, General Pediatric

Clinic, 909 E Brill St, Phoenix, AZ 85006.

PEDIATRKS (ISSN 0031 4005). Copyright 0 1993 by the American

Acad-emy of Pediatrics.

Although the inconspicuous penis is well described in the urologic literature, a review of the pediatric literature over the past 25 years failed to reveal a

ref-erence regarding the inconspicuous penis or any of

the seven entities (except micropenis) that make up this condition. It is important, however, for pediatri-cians to be aware of this group of disorders for three reasons: first, circumcision is certainly

contraindi-cated in some3; second, the abnormal appearance of

the external male genitalia may be a source of psy-chologic trauma for children; and third, some cases may be associated with sexual dysfunction,5 pain,

and/or abnormalities of the urinary stream.1 These

problems may be prevented if the children are

re-ferred to a skilled urologist for appropriate surgical reconstruction.

A brief review of the anatomy in the genital area is

helpful in understanding the inconspicuous penis

and methods of surgical repair. Scarpa’s fascia is a

membranous fascial sheet composed of elastic tissue

which covers the anterior abdominal wall subcuta-neously. It extends inferiorly over the external ingui-nal ring and into the penis and scrotum. Dartos fascia (tunic) is a thin layer of smooth muscle fibers which is continuous around the base of the scrotum with the superficial fascia of the groin and perineum. Fi-nally, the penis is attached to the front and sides of

the pubic arch by means of the penile suspensory

ligament7 (Fig 2).

In 1986, Maizels et al,1 developed the first classifi-cation system for a group of five disorders they called the inconspicuous penis (Fig 1). The literature on this

subject is confusing because various authors use the

same terms but with different meanings. In this paper,

we will attempt to describe and define each of the

seven entities currently included under the term

in-conspicuous penis.

We present a review of cases of inconspicuous

pe-nis seen over the past 2 years by members of the

Gen-eral Pediatrics Section and two members of the

Sec-tion of Pediatric Urology at Phoenix Children’s Hospital. Nineteen boys qualified for inclusion in this series by meeting the definitions of Maizels et al.1 We

note the characteristics of these children, as well as

their treatment and results of treatment. The cases are described in the Table. The following cases illustrate the three categories of inconspicuous penis found in

our series: buried, trapped, and webbed penis.

CASE 1: BURIED PENIS

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ex-?/:/

L

BURIED

NORMAL

CIRCUMCISED POOR SKIN

SUSPENSION

IN CHILD

LOCALIZED ADIPOSITY

IN ADOLESCENT

Scarpa’s Fascia

Penile

Buck’s

Dartos Fascia.

Fig 2. Anatomic structures relevant to the inconspicuous penis. Fig 1. Entities comprising

inconspicu-ous penis. Used with permission from Maizels, et al.’

amination revealed a very obese, uncircumcised child with a very prominent mons pubis. Only 2 cm of the penis was visible, a!-though palpation revealed a normal penile length with well-formed corpora.

Surgery included lysis of dense dartos bands, degloving of the penis, and dissection of the shaft to the pubic bone. The foreskin and Z-plasties were used to provide appropriate covering of the shaft. Suprapubic lipectomy was also performed. At follow-up in 3 months, the penis was normally protuberant and the surgical

incisions had healed well.

CASE 2: TRAPPED PENIS

A 2-day-old underwent a routine circumcision. Examination of the penis prior to circumcision revealed a normal shaft and glans. He subsequently developed cicatricial scarring and phimosis rap-idly over a 2-week period. The penis became entrapped in scar tissue and retracted into the prepubic fat and fascia. Contractures healed over the distal glans, leaving a very small opening for

urination. He was referred to a pediatric urologist, who diagnosed trapped penis at 4 weeks of age. The contractures subsequently

softened over the first year of life. By age 1, the penis was fully

extruded, thereby eliminating the need for surgical revision of the

circumcision.

CASE 3: WEBBED PENIS

A 12-day-old newborn was referred to the department of pe-diatric urology for circumcision. A penile abnormality had been noted on the initial newborn assessment. Physical examination revealed an uncircumcised phallus with a nonretractable foreskin and significant penoscrotal webbing. Circumcision was attempted by his primary physician, but the webbing was extensive enough to prevent placement of the Gomko clamp.

The patient was observed for 6 months, but there was no change. The abnormality was subsequently repaired. Surgery con-sisted of circumcision followed by degloving of the penis, lysis of abnormal connective tissue bands, and removal of excess skin and subcutaneous fascial tissue. The procedure was finished with longitudinal closure and approximation of the shaft and coronal skin such that the penis extended appropriately. Several follow-up visits revealed good healing, with a normally positioned and

extended penis.

RESULTS

The cases listed in the Table are primarily of three types: older, very obese boys with or without proper circumcisions; infants with a large peripenile fat pad

with or without a normal circumcision; and infants

with a circumcision resulting in the complications of

phimosis and/or cicatridal scarring. In our series of 19 patients, there were 8 trapped penises (42%), 9

bur-ied penises (47%), 1 webbed penis (5%), and I case of

combined buried and webbed penis. The ages at

di-agnosis ranged from 1 week to 13 years. Ten children

had been circumcised before referraland 9 had not. Of

WEBBED TRAPPED MICRO

PENIS PENIS

the 10 circumcised cases, only 2 had a retractable fore-skin; the other 8 of these were trapped.

Thirteen patients underwent surgical procedures,

12 of whom were seen in follow-up. All were

con-sidered by their surgeon and family to have a

satis-factory or good outcome. Two patients did not

under-go repair because of parental concerns or underlying

medical problems. Three patients are currently

sched-uled for surgical repair. One of our cases of buried penis was associated with a urinary tract infection. In that patient, circumcision and lysis of adhesions were

performed to help avoid recurrent infection as well as

for cosmetic purposes.

Seven (37%) of the 19 children were not referred by

their physicians. Four of these had a trapped penis; 3

had buried penis. One case of trapped penis resolved

with conservative management. All of the other

self-referred cases were surgically repaired. One case of

trapped penis which developed after circumcision

re-sulted in the initiation of a medical liabifity suit

against the primary physician.

at Viet Nam:AAP Sponsored on September 1, 2020 www.aappublications.org/news

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Total Age at Findings Prerepair Repair

Patients Diagnosis

Circum-cision

I wk, I wk, 4 wk, 5wk,

6wk, 2 mo, 2#{189}mo, 3 mo

Phimosis and/or

cicatricial scarring;

meatal stenosis and adhesion of

foreskin to the

urethral meatus

in I case

Referred

by

Physician

Trapped

(8)

Buried

(9)

Webbed (1)

Combined: buried and webbed

(1)

1 mo, 2 mo, Buried

7 mo, 7 n-to, 12 mo, 2#{189} y, 5 y, 9 y, 13 y

Satisfactory None 4 No (50%) 4 Yes (50%)

Satisfactory 4 No 6 Yes (66%)

5 Yes 3 No (33%)

Good Yes Yes

Yes Yes

..,

I

J I ,__f

*iie_4/

TABLE Patient Data

12 d Penoscrotal webbing

2 mo Buried and

penoscrotal

webbing

All Z-plasty and release of phimotic

bands; foreskin revi-sion and skin graft in 2 cases;

I case resolved spontaneously;

I case pending

2 Degloving; incised dartos bands;

penile skin

su-tured to tunica albuginea in 2

case; I case su prapubic lipectomy

2 not repaired; 2 pending

No Circumcision;

degloving; incised

dartos bands; removal of excess skin and

longitudinal

closure

No Degloving; incised Good

dartos bands

Outcome Foreskin Retract-able

DISCUSSION

An abnormal appearance of the external genitalia

may have psychologic effects on the child and his

family.4’6 Fear of discovery and teasing by classmates may result in depression, feelings of inadequacy, and

insecurity. Boys may exaggerate the possible

func-Fig 3. Buried penis in a 12-month-old: preoperative and postoperative

ap-pearance.

tional and cosmetic significance of anomalous

geni-talia. Parents frequently worry about future potency

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Fig 4. A: buried penis. B: schematic drawing of lateral view. C: with retraction of foreskin and compression of the pubic fat pad a normal penis is exposed. D: schematic drawing of C. Used with

permission from Klauber and Sant.2

The buried penis was initially described by Keyes8’9 in 1919. It consists of a penile shaft that is otherwise

normal but that is buried within an overabundance

of prepubic fat (Figs 3 and 4). Abnormal dartos bands

Fig 5. Webbed penis. Used with

per-mission from Duckett and Snow.9

coursing between Scarpa’s fascia and the penis,

bind-ing the penis in varying degrees, have also been

described.1’2 Circumcision of the inconspicuous

pe-nis by the primary care physician is contraindicated

before the urologist examines the child.1’3 The penis may simply appear to have a redundant foreskin

and need circumcision. Instead, the penis may be

bound by dartos bands or penoscrotal webbing and

the shaft will be demonstrated to be a normal

length when freed up surgically. It is essential that

primary care physicians be aware of this fact,

be-cause a circumcision may render optimal surgical

revision difficult or impossible. In addition, the

cir-cumcision may result in an unsatisfactory result,

with cicatricial scarring and/or phimosis (trapped

penis).1’1#{176} Repair of the trapped penis is significantly more costly than simple circumcision and presents

additional surgical risks. In some cases, the dartos

bands may be palpable,1 a physical finding that

may help make the diagnosis. Buried penis may

oc-cur with or without phimosis.’2 In addition, the

pe-nis may be inconspicuous when the penile suspen-sory ligament anchors the penis to the pubic bone so poorly that the penis droops and the normal

con-tour of the phallus is lost (poor penile suspension).

Some children may have both of these problems

simultaneously.

The webbed penis consists of midline skin webs and/or dartos bands at the penoscrotal angle which

bind the ventrum of the penis to the scrotum (Fig 5).

This obscures the penoscrotal angle and the penis

as well.1’9 This fusion may be complete, with total

absence of differentiation of the penis from the

scro-tum, or incomplete, with one or more webs of varying

length connecting the penis and scrotum.13 The

webbed penis may occur rarely as an isolated

anomaly, but more commonly occurs in conjunction

with a hypospadias, chordee, or micropenis.115

The trapped penis is characterized by the shaft of the penis being bound down in scar tissue and thus

becoming embedded in the scrotum and prepubic

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LI

Fig 6. Trapped penis with cicatricial scarring and phimosis.

fat,16’17 (Fig 6). This can be seen after trauma or

over-zealous circumcision. However, it may also occur

after an appropriate circumcision when the buried

pe-nis is contained within an enlarged fat pad, allowing

the penile skin to be pushed forward and heal over the glans. The most common antecedent in the literature is a circumcision which removes an excessive amount of skin from the penile shaft as well as the prepuce. The trapped penis may also be the result of removing too little inner preputial skin. In this instance, the raw edges of the incised foreskin protrude beyond the dis-tat portion of the glans. With nothing to separate them, they may heat together. As healing takes place, the penis is tethered by scar tissue which retracts the penis, frequently leaving little more than the urethra visible. Of the children in our series, 42% came to us with this iatrogenic complication.

Physical examination of the trapped penis may

re-veal a scarred or irregularly shaped glans with

ap-parent displacement of the meatus and/or tenting of

the scrotum or skin of the lower abdomen toward the

base of the penis. There may be a history of delayed healing of the circumcision due to extensive tissue damage.16

Some authors3 have used the term concealed penis

to pertain to the phallus that is normal but concealed behind overlapping suprapubic fat. It exists only in extremely obese individuals.

A penis may be small and malformed as a result of

epispadias/exstrophy, severe hypospadias, persis-tent m#{252}llerianstructures, or chromosomal abnormali-ties. These individual entities are well described in the

literature. This category is sometimes referred to as

the diminutive penis and is distinguishable from

mi-cropenis since the micropenis is small but not

mat-formed)’6 The micropenis may be secondary to a

number of endocrine abnormalities involving the

hypothalamic-pituitary axis such as hypopituitarism,

Kallmann’s syndrome, and Prader-Willi syndrome.

Rudimentary testes and anorchia may be associated

with micropenis.2

All of the urologic entities under the term

incon-spicuous penis except micropenis and diminutive

pe-adequate corpora and demonstrate the normal length of the stretched penis. The normal range for newborns is 3.5 ± 0.7 cm.2’18

Cases have been reported in which in error, a cir-cumcision was done to help expose an inconspicuous penis. There was no increased exposure, however, and valuable foreskin, which could have been used in subsequent surgery, was lost. In many cases when the shaft of the penis is surgically allowed to protrude normally, there is insufficient skin to cover the shaft fully. Use of the foreskin becomes vital for optimum

surgical repair. In some cases no repair may be

needed and the urologist may proceed with a simple

circumcision. However, this decision should remain

with the surgeon and the primary care physician should leave the foreskin intact.

The various surgical repair procedures are well

de-scribed in the literature. An array of techniques are

available including Z-plasties, lipectomy, liposuction, dartos band release, vascularized skin flaps,

split-thickness skin grafts, and anchoring of the skin at the

base of the penis to the pubic periosteum.1’2’6’#{176}’26’9’2#{176} Some authorities believe the treatment of choice for the concealed penis (with a true overlapping abdomi-nat fat pad) is weight reduction,3 although this has not

been uniformly effective and may be difficult to

achieve and maintain.1’6”1’2’ Lipectomy and liposuc-tion may be valuable.

The indications for surgical treatment of the incon-spicuous penis are not clear. The appearance of the inconspicuous penis of many, but not all boys will improve with growth.’#{176}Case 2 is a dramatic example of this. This 2-month-old child with a trapped penis

and only a very small opening for urination

devel-oped a normal penis by age I year. The natural history of these entities, including how many boys will

spon-taneously attain an acceptable appearance and at

(6)

sur-Devine has described adults with persistent

bur-ied penis. Reflecting on his experience with

adoles-cents who have experienced no improvement over

time, Shapiro1#{176} suggests the existence of anatomic

variants that are permanent. Devine describes a range

of severity of tethering of the penis by dartos bands.

Some bands connect to the proximal penis, but others

course to the coronal margin, the latter being the most

severe. Some of our younger patients have

demon-strated such extensive binding of the penis by elastic dartos bands at surgery that it seems unlikely that this excessive fibrous tissue would resolve spontaneously. Conversely, children whose pubic fat is easily

re-traded to reveal a normal penis may well deserve

lengthier observation. In the future, we hope,

physi-cians wifi learn to identify early in life those variants

that will self-correct in infancy. We have observed

marked improvement of an infantile trapped penis

(case 2). Time, and perhaps progressive retraction of the foreskin by a caretaker, may correct many of these.

While definitive indications for surgical repair are

being developed, we must keep in mind that boys

with an inconspicuous penis are conscious of this

problem prior to puberty and that surgery may be

most helpful “earlier rather than 1ater.””3 Children with urinary tract infection associated with a webbed

or buried penis should be considered for early

surgical correction.

Several articles describe an improved self-image

after surgery for patients with the entities described

herein, in children old enough to have sufficient

awareness of their problem.3’10’14 When the parents

were asked, they were said to have been highly

mo-tivated to have the surgery done and are commonly

pleased with the results.

The primary care physician’s liability in this area

seems high. Forty-two percent of the cases in this se-ries had a complication of their circumcision neces-sitating surgical revision. One of the cases in this

se-ries resulted in a law suit against the primary care

physician because of a poor result after circumcision.

To quote Devine, “unless concealment of the penis is

recognized, this can be an anatomic, a psychologic, and a litigious disaster.”1

Thirty-seven percent of our cases were self-referred to the urologist, perhaps indicating underrecognition

and underreferral by medical professionals. Further

education of the medical community regarding the

inconspicuous penis is important. Several papers

state that the buried penis is a rare entity.3’62#{176}In the

past 4 months, as modest awareness of our interest in

this subject came about our community, the

num-ber of referrals has risen dramatically. We suggest

that these entities are not as rare as previously

thought and, with better recognition, larger numbers of cases will be diagnosed and treated.

ACKNOWLEDGMENTS

We thank Sally McClanahan for expert secretarial assistance, Tern Jones and Cindy Hale for artistic assistance, and Edmond Gonzales, MD, for his insightful review of this paper.

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14. Masih RK, Bresman SA. Webbed penis. IUrol. 1974;111:690-.692

15. Perlmutter AD, Chamberlain JW. Webbed penis without chordee. I

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16. Levitt SB, Smith RB, Ship AC. Iatrogemc microphallus secondary to

circumcision. Urology. 1976;472-47479

17. Radhakrishnan J, Reyes HM. Penoplasty forburied penis secondary to

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18. Jones KL. Penilelength charts. In: Smith’s Recognizable Patterns of Human Malformation. 1988;(4):704-705

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THE INFORMATION EXPLOSION

“Data, data everywhere, but not a thought to think.”

Jessie Shera. Quoted by: Paulos JA. Beyond Numeracy. New York: Vintage Books; 1992.

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1993;92;794

Pediatrics

Piatt

Paul S. Bergeson, Robert J. Hopkin, Robert B. Bailey, Jr, Leigh C. MCGill and Janice P.