December 18, 2017

Buried Penis: The Hidden Burden of Obesity

By Mélanie Aubé-Peterkin, MD and Ramón Virasoro, MD

Buried penis, a physically and psychologically challenging condition, may affect men of any age. Whether congenital or acquired, buried penis occurs when the penis is entrapped within the penopubic area, often due to excess adipose tissue or inflammation. This condition is often associated with obesity, diabetes and lichen sclerosus (LS), a chronic inflammatory condition affecting the glans penis and foreskin that is also known as balanitis xerotica obliterans (BXO).

Adult patients often present with lower urinary tract symptoms and sexual dysfunction. They often urinate within the skin that entraps their penis, causing post-void dribbling and incontinence, urinary tract infections and skin irritation. The vast majority cannot have penetrative intercourse. Circumcision has often been performed on patients with stigmata of LS, but this may induce further scarring that exacerbates their condition. On physical exam, the penis appears engulfed by the surrounding pubic fat pad and scrotal skin. The glans cannot be exteriorized as it is trapped behind a phimotic ring. A whitish, plastic appearance of the glans and fibrotic ring are signs of LS.

Treatment with topical steroids and weight loss may alleviate symptoms, but this is rarely sufficient. After drastic weight loss, persistent excess pubic fat and ptosis of the pubic fat pad often occurs, so penile entrapment often persists. Surgical repair, while a challenging procedure, is the most definitive long-term treatment and offers excellent outcomes.

Before surgery, a patient’s glycohemoglobin must be below 7%. This is especially important for diabetic and obese patients, as elevated blood sugars may impede wound healing and graft take. Patients also should not use any nicotine-containing products. In obese patients or those who have experienced recent massive weight loss, this procedure may be performed in conjunction with an abdominoplasty and with consultation with a plastic surgeon.

Buried penis repair typically consists of the following steps: pubic lipectomy, penile liberation, penopubic fixation, scrotoplasty and skin coverage with a skin graft. Skin markings for pubic lipectomy should be done immediately preoperatively, with the patient standing. A trapezoid area of pubic fat and skin – coined as the “escutcheon” due to its shield-like shape – must be removed with extreme caution so as not to injure underlying spermatic cords. A circumcising incision is performed and the penis is liberated. The penile shaft skin is often of very poor quality and must be removed. If abnormal scrotal skin is present, it is excised and a scrotoplasty is performed. The base of the penis is fixed to the pubis to further exteriorize the penile shaft. Skin coverage of the penile shaft is then performed using a split thickness skin graft. The anterior thigh is the most common site of graft harvest, although abdominal skin may be used if an abdominoplasty is concomitantly performed.  A bolster dressing is applied around the graft and kept in place for 5 days, until graft take has occurred.

Post-operative complications include wound dehiscence, most commonly along the suture line of the escutecheonectomy, and impaired graft take, which is rare if the patient’s condition was optimized pre-operatively. Patients experience decreased tactile sensation along the STSG of the penile shaft, but the recovery of sexual and urinary function is exemplary. Post-operative patient satisfaction is high.

Buried penis may be a devastating side effect of obesity, extreme weight loss and LS, but it is treatable. We encourage patients to vocalize their symptoms to their health care provider and seek appropriate care.

Mélanie Aubé-Peterkin is a Genitourinary Reconstructive Surgery fellow and Ramón Virasoro is a reconstructive urologist at the Devine-Jordan Center for Reconstructive Surgery and Pelvic Health at Urology of Virginia PLL. Dr. Virasoro is also an Associate Professor at the Department of Urology, EVMS. www.urologyofva.net