British Journal of Plastic Surgery (1977), 30, 96-99
BURIED By B. S.
PENIS
CRAWFORD, M.B., F.R.C.S.
Plastic and Jaw Department, The Royal Hospital Annexe, Fulwood, Shejield SIO 3TD
THEREis a rare congenital abnormality in which the penile shaft is partially or completely buried in the subcutaneous fat. In partial cases, the buried proximal half of the shaft gives rise to a stumpy looking penis (Figs. I and 2). In complete cases, the penile shaft, which usually lies obliquely in the suprapubic region, is palpable but not visible, and the prepuce, which hides the glans, is more or less continuous with the abdominal wall above and the scrotum below (Figs. 2 and 3). There are few references to congenital buried penis. Glanz (1968) records a case in an adult and Innes Williams (1974) describes and illustrates a typical example. Campbell (1951) under the heading “concealed penis” describes a deformity in which there is “a rudimentary organ hidden beneath the skin of the scrotum, perineum, lower abdomen or thigh in the fatty tissues which may be unusually thick.” Warkany (1971) describes a “micropenis or concealed penis” and states that the penis is concealed in the surrounding fat, the urethra being normal, angulated or stenotic. Six cases of what I consider should be called congenital buried penis have been treated in this department in the last 20 years. This paper records observations made on them and attempts to define the various penile deformities with which confusion may occur (Fig. 2). Nomenclature. It is suggested that the term concealed penis should be applied to a relatively common condition in infancy in which the penis is concealed behind a protruberant fold of suprapubic fat. The condition is usually self-correcting but occasionally is associated with an endocrine disorder, and there may be a micropenis. Micropenis
FIG. FIG.
2.
I. An
example of partial buried penir.
Diagrams of the various penile deformities 96
described in the text.
BURIED
FIG. 3.
An example
97
PENIS
of complete
buried
penis.
should I believe be used to describe an organ which is smaller than normal for the size and age of the individual. Buried penis is defined as a condition in which the penile shaft is partially or completely buried in the subcutaneous fat. Webbed penis (Mason Brown, 1962) is a relatively common abnormality of skin cover in which there is a partial or complete penoscrotal web. It is sometimes seen in cases of buried penis but is more I believe that webbed penis and buried penis commonly associated with hypospadias. are different degrees of the same condition; some patients have features of both. Treatment of buried penis. Glanz (1968) corrected the deformity with multiple Z-plasties. Innes Williams (1974) was concerned about penile size and avoided operating in childhood “apart possibly from constructing a tubular skin extension of prepuce which the boy could pull out through his trousers”. It is obviously preferable to correct the deformity before the child starts school but if there is no problem with micturition, operation may be deferred until 3 years of age. Under general anaesthesia the glans is withdrawn gently by traction on a silk suture. This will reveal the size of the skin defect on the dorsum. In complete cases the penis will be found to be covered only by prepuce and abdominal wall, but in partial cases the distal shaft will have normal penile skin cover. In 2 of this series the prepuce was found to be redundant ventrally, and this was associated with glandular epispadias. The incision is designed to expose the penis adequately, anticipating the problem of skin cover and avoiding a longitudinal scar. It takes the form of a letter “S” marked on the dorsum with the long axis along the middle of the shaft (Fig. 4). Having raised the 30/1--G
98
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
FIG. 4. The S-shaped incision on the dorsum. FIG. 5. The result of treatment by penile release and skin graft. Note the thickened suprapubic pad of fat.
z U-shaped flaps a distinct fibromuscular layer is found tethering the shaft to the abdominal wall. This layer, which resembles dartos muscle macroscopically and microscopically, is excised or incised (depending on the size of the individual fibres) until the penis has been freed to occupy its normal relationship with the abdominal wall. The size of the defect created on the dorsum depends on the original skin deficiency. Having freed the penis satisfactorily the available skin tends to slide towards the ventral surface of the shaft if there was a shortage on that aspect. If this occurs the dorsum is covered by a medium thickness free skin graft together with flaps from the opened-out prepuce (Fig. 5). When there is no problem of skin cover the U-shaped flaps together with the prepuce may suffice to cover the dorsum. If glandular epispadias is present or if there is a marked penoscrotal web, they can be corrected later. In all cases in this series the size of the penis was within normal limits and the testicles were clinically normal. In 2, the suprapubic pad of fat was considered to be unduly thick. SUMMARY AND CONCLUSIONS
An attempt has been made to Six cases of buried penis in childhood are recorded. clarify the nomenclature of a number of penile deformities over which there has been some confusion. The treatment of buried penis, which should be completed before school age, depends upon freeing the penile shaft from abnormal attachments and
BURIED
PENIS
99
correcting the skin defect. The importance of the tethering fibromuscular bands between the penile shaft and abdominal wall has not previously been stressed. I wish to thank Mr M. Gtpson, F.R.C.S., for the drawing and members of the Photographic Department of the United Sheffield Hospitalsfor the photographs. REFERENCES “Clinical
Urology,” p. 273. Philadelphia: W. B. CAMPBELL, M. (1951). Saunders Company. Plastic and Reconstructive Surgery, GLANZ, S. (1968). Adult congenital penile deformity. 41~ 579.
Paediatric
MASON BROWN,J. J. (1962). “Surgery of Childhood”, 1st edition, p. 1160. London: Arnold. WARKANY, J. (1971). “Congenital Malformations”, p. I 103. Chicago: Yearbook Medical Publishers, Inc. WILLIAMS, D. INNES (1974). Urology in chilhood, in “Encyclopaedia of Urology”, Volume 15. Berlin, Heidelberg, New York: Springer-Verlag.
BURIED By B. S.
PENIS
CRAWFORD, M.B., F.R.C.S.
Plastic and Jaw Department, The Royal Hospital Annexe, Fulwood, Shejield SIO 3TD
THEREis a rare congenital abnormality in which the penile shaft is partially or completely buried in the subcutaneous fat. In partial cases, the buried proximal half of the shaft gives rise to a stumpy looking penis (Figs. I and 2). In complete cases, the penile shaft, which usually lies obliquely in the suprapubic region, is palpable but not visible, and the prepuce, which hides the glans, is more or less continuous with the abdominal wall above and the scrotum below (Figs. 2 and 3). There are few references to congenital buried penis. Glanz (1968) records a case in an adult and Innes Williams (1974) describes and illustrates a typical example. Campbell (1951) under the heading “concealed penis” describes a deformity in which there is “a rudimentary organ hidden beneath the skin of the scrotum, perineum, lower abdomen or thigh in the fatty tissues which may be unusually thick.” Warkany (1971) describes a “micropenis or concealed penis” and states that the penis is concealed in the surrounding fat, the urethra being normal, angulated or stenotic. Six cases of what I consider should be called congenital buried penis have been treated in this department in the last 20 years. This paper records observations made on them and attempts to define the various penile deformities with which confusion may occur (Fig. 2). Nomenclature. It is suggested that the term concealed penis should be applied to a relatively common condition in infancy in which the penis is concealed behind a protruberant fold of suprapubic fat. The condition is usually self-correcting but occasionally is associated with an endocrine disorder, and there may be a micropenis. Micropenis
FIG. FIG.
2.
I. An
example of partial buried penir.
Diagrams of the various penile deformities 96
described in the text.
BURIED
FIG. 3.
An example
97
PENIS
of complete
buried
penis.
should I believe be used to describe an organ which is smaller than normal for the size and age of the individual. Buried penis is defined as a condition in which the penile shaft is partially or completely buried in the subcutaneous fat. Webbed penis (Mason Brown, 1962) is a relatively common abnormality of skin cover in which there is a partial or complete penoscrotal web. It is sometimes seen in cases of buried penis but is more I believe that webbed penis and buried penis commonly associated with hypospadias. are different degrees of the same condition; some patients have features of both. Treatment of buried penis. Glanz (1968) corrected the deformity with multiple Z-plasties. Innes Williams (1974) was concerned about penile size and avoided operating in childhood “apart possibly from constructing a tubular skin extension of prepuce which the boy could pull out through his trousers”. It is obviously preferable to correct the deformity before the child starts school but if there is no problem with micturition, operation may be deferred until 3 years of age. Under general anaesthesia the glans is withdrawn gently by traction on a silk suture. This will reveal the size of the skin defect on the dorsum. In complete cases the penis will be found to be covered only by prepuce and abdominal wall, but in partial cases the distal shaft will have normal penile skin cover. In 2 of this series the prepuce was found to be redundant ventrally, and this was associated with glandular epispadias. The incision is designed to expose the penis adequately, anticipating the problem of skin cover and avoiding a longitudinal scar. It takes the form of a letter “S” marked on the dorsum with the long axis along the middle of the shaft (Fig. 4). Having raised the 30/1--G
98
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
FIG. 4. The S-shaped incision on the dorsum. FIG. 5. The result of treatment by penile release and skin graft. Note the thickened suprapubic pad of fat.
z U-shaped flaps a distinct fibromuscular layer is found tethering the shaft to the abdominal wall. This layer, which resembles dartos muscle macroscopically and microscopically, is excised or incised (depending on the size of the individual fibres) until the penis has been freed to occupy its normal relationship with the abdominal wall. The size of the defect created on the dorsum depends on the original skin deficiency. Having freed the penis satisfactorily the available skin tends to slide towards the ventral surface of the shaft if there was a shortage on that aspect. If this occurs the dorsum is covered by a medium thickness free skin graft together with flaps from the opened-out prepuce (Fig. 5). When there is no problem of skin cover the U-shaped flaps together with the prepuce may suffice to cover the dorsum. If glandular epispadias is present or if there is a marked penoscrotal web, they can be corrected later. In all cases in this series the size of the penis was within normal limits and the testicles were clinically normal. In 2, the suprapubic pad of fat was considered to be unduly thick. SUMMARY AND CONCLUSIONS
An attempt has been made to Six cases of buried penis in childhood are recorded. clarify the nomenclature of a number of penile deformities over which there has been some confusion. The treatment of buried penis, which should be completed before school age, depends upon freeing the penile shaft from abnormal attachments and
BURIED
PENIS
99
correcting the skin defect. The importance of the tethering fibromuscular bands between the penile shaft and abdominal wall has not previously been stressed. I wish to thank Mr M. Gtpson, F.R.C.S., for the drawing and members of the Photographic Department of the United Sheffield Hospitalsfor the photographs. REFERENCES “Clinical
Urology,” p. 273. Philadelphia: W. B. CAMPBELL, M. (1951). Saunders Company. Plastic and Reconstructive Surgery, GLANZ, S. (1968). Adult congenital penile deformity. 41~ 579.
Paediatric
MASON BROWN,J. J. (1962). “Surgery of Childhood”, 1st edition, p. 1160. London: Arnold. WARKANY, J. (1971). “Congenital Malformations”, p. I 103. Chicago: Yearbook Medical Publishers, Inc. WILLIAMS, D. INNES (1974). Urology in chilhood, in “Encyclopaedia of Urology”, Volume 15. Berlin, Heidelberg, New York: Springer-Verlag.
