Buried penis is a congenital or acquired condition in which the male genital organ has normal dimensions, but is hidden in the tissues of the scrotum or subcutaneous fat. The degree of severity of this pathology is variable, clinical manifestations depend on it: when the penis is completely immersed, urination occurs according to the female type with a spray of urine, adult men cannot perform sexual intercourse. Diagnostics includes physical examination, ultrasound, ultrasound of the scrotum and penis organs, consultation of a geneticist, endocrinologist, andrologist. Surgical treatment is aimed at releasing the penis from the surrounding tissues and restoring the natural appearance of the genitals.
Buried penis is diagnosed in newborn boys with a frequency of 1:1800 — 1:4300, or 2-6 per 10,000 population. As a separate nosological unit, the diagnosis has existed since 1954. For a long time it was believed that in young children, the vice can self-resolve upon reaching puberty. During this period, scientists have proven that a change in the hormonal background during puberty does not lead to an improvement in the situation, therefore it is impractical to postpone the operation. The optimal age for correction is 1-3 years. In children, the penis can “hide” after birth. In adults, pathology is more often acquired, there are no objective statistical data on the incidence, since not all patients go to the doctor.
The causes of the true (congenital) and acquired latent penis differ. The congenital condition is caused by improper laying of the genitals in embryogenesis without clearly established reasons. The adverse effects of radiation, bacteria, viruses, and chemicals on the mother during pregnancy are considered as predisposing factors. Infections in the first trimester, chronic alcohol and nicotine intoxication have an extremely adverse effect on the development of all organs and systems of the fetus, including the genitourinary. In a number of observations, the defect is provoked by genetic diseases. In these cases, combined developmental abnormalities are often present. Acquired buried penis cause:
- Excess adipose tissue. Pronounced obesity in the pubic area, a hanging apron of fat from the anterior abdominal wall lead to a visual decrease in the penis retracted deep into the penis, which actually has cavernous bodies of normal size. A history of abdominoplasty with excessive removal of fat mass between the fascia of the Scarpa and the scrotal fleshy shell, penis enlargement surgery in an obese man may have a side effect of a buried penis.
- Swelling of the scrotum. Violation of the outflow of lymphatic fluid (penoscrotal lymphedema) is one of the causes of a false “caught” penis. The disease occurs in men with parasitic infection (filariasis), infection with streptococcal flora, with concomitant pathologies of the cardiovascular and urinary systems. The natural appearance of the male genitals is violated by a large bilateral dropsy – the penis plunges into the enlarged scrotum against the background of fluid accumulation.
- Complicated circumcision. With circumcision, excision of too large a flap of skin or scarring processes lead to immersion of the penis deep into the scrotum. According to statistics, a buried penis is initially diagnosed in combination with phimosis in 75% of patients. Circumcision performed in this case only aggravates the problem, and subsequently skin deficiency significantly complicates the operation.
From the fourth month of gestation, differentiation of the male genitals occurs, which is triggered by androgens produced by the testes. The genital tubercle is transformed into a head, then cavernous bodies and ligamentous apparatus begin to form. Under the influence of unfavorable factors in embryogenesis (sometimes they cannot be established), underdevelopment of the tissues of the fleshy scrotum shell occurs with a violation of the elasticity of the ligamentous apparatus of the genital organ and dorsal deformation of the cavernous bodies.
Acquired pathology is the result of a violation of the normal anatomy of the genitals due to mechanical compression (shifting) by fat, fluid, and intestinal contents during hernias. After surgical interventions, a scar deformity is formed on the genitals, which does not allow the penis to come out, which contributes to its immersion in the scrotal skin.
To date, there is no general classification of this urological anomaly, but the pathology can be true (congenital, primary) and false (acquired, secondary). In clinical urology, the systematization of the syndrome of the buried penis according to the degree of severity of immersion is accepted:
- True hidden. The reason is the distal location of the suspensory ligament, a short sling-shaped ligament. A typical deficiency of the skin, which is not present with a secondary buried penis. Cavernous bodies of normal size.
- Caught. Lack of skin and narrowing of the foreskin are the main aspects of the anomaly that lead to the deepening of the penis. More often, the patient has a history of surgery to remove the foreskin.
- Secondary hidden. Against the background of fluid compression with hydrocele and lymphedema or fat with an overabundance of body weight, the skin of the male genital organ shifts. With tumescence, as the cavernous bodies are filled with blood, the erect penis straightens somewhat. The body of the penis has its own skin.
A combined defect can be expressed in a combination of the above options, and a combined one implies coexistence with another malformation of the urogenital system: hypospadias, epispadias, non-omission of the testicle (cryptorchidism), etc. Some practitioners evaluate pathology according to the severity, which is established during a physical examination. There are three stages:
- First. The head of the penis, foreskin and 1/3 of the cavernous bodies at the first stage are visible on examination. The most favorable option, surgical treatment is performed in children and men at the age of sexual activity.
- The second. Only the head with the foreskin is located outside, the cavernous bodies can be felt in the scrotum by palpation. Surgical correction is recommended.
- Third. The body of the penis and the head are sunk into the thickness of the scrotum, only the foreskin is visualized from the outside. Surgical treatment is necessary.
Clinical manifestations are variable, correlate with the stage. At the first stage, the quality of life suffers slightly. Congenital malformation often causes concern among parents who bring a child to a consultation with a pediatric urologist or surgeon. There are no pain sensations, but the prepucial sac may inflate during urination due to the accumulation of urine, constant dampness is accompanied by skin irritation.
The most severe clinical manifestations are in the third stage, they lead to social maladaptation, provoke depressive disorders. In an adult patient with a buried penis, the main complaints are the inability to achieve an erection for inserting the penis into the vagina, the need to urinate while sitting, and the spray of a jet.
Buried penis leads to erectile dysfunction and to the rejection of sexual activity. Since it is impossible to insert the penis into the vagina and ejaculate, there is a problem with conceiving a child naturally. At the third stage, urination is disrupted, the constant contact of the head with urine, the inability to carry out adequate hygienic measures lead to its irritation and inflammation. When infection enters the ascending path through the urethra into the bladder, recurrent urinary tract infections and cystitis develop.
Concomitant prostatitis is congestive in nature, since the prostate gland is not drained due to the lack of sexual activity, and venous stagnation is created in the pelvis. Urine leakage, wetness is the main reason for the attachment of contact dermatitis, which, in the absence of timely therapy, can turn into eczema. Cases of penile cancer have been described.
The diagnosis is established on the basis of physical examination and palpation of the scrotum. To exclude hereditary diseases, a geneticist’s consultation is indicated. The patient may need to be examined by an andrologist and an endocrinologist. To clarify the condition, if there are doubts, ultrasound examinations are performed.
When performing an ultrasound of the scrotum, attention is paid to the size of the hidden phallus and testicles, for this anomaly, a decrease in the size of these structures is uncharacteristic. The presence of fluid indicates in favor of dropsy. Dopplerography (ultrasound of the vessels of the penis) can show abnormalities in the development of vessels supplying blood to the cavernous bodies. X-ray examination, CT is mainly prescribed for the diagnosis of combined defects of the urogenital tract.
Differential diagnosis is performed with hypogonadism, micropenis, membranous penis. The underdevelopment of the penis associated with hypogonadism is confirmed by the study of the hormonal profile and the reduced size of the testicles on the ultrasound of the scrotum. In pediatrics, the hidden phallus is also differentiated with a delay in sexual development. Extremely rare is the congenital absence of a penis, which is combined with cleavage of the scrotum, visual manifestations of the defect are somewhat similar.
In each case, the treatment tactics are individual, there is no single approach. For some patients, a combination of several methods is used. Previously, it was believed that the type of genitals normalizes when a child reaches puberty, when active testosterone production begins. Modern urologists recommend performing surgical treatment of a true hidden phallus at the age of 1-3 years, which avoids psychological trauma and possible complications.
In children with secondary pathology, suffering from obesity, there are no absolute indications for surgery. The intervention can be performed at the age of 13-14 for cosmetic purposes, when the linear growth of the penis stops. The consultation of a nutritionist is justified, who will give recommendations on optimal nutrition aimed at normalizing weight. The tactics of surgical treatment depends on the type of pathology:
With a true hidden and caught member. Surgical intervention involves the release of the penile trunk from the skin, the intersection of the pathological ligamentous apparatus, the formation of a skin tunnel and its attachment to the base of the penis. Scar tissue is subject to excision. Some patients have skin deficiency after circumcision, which requires the use of an autograft.
Secondary hidden member. In adult patients with concomitant diabetes mellitus, it is not always possible to reduce body weight, in this situation liposuction or surgical lipectomy of fat can be performed. If necessary, the patient is operated on for hydrocele, inguinal hernia. In scrotal lymphedema, therapy depends on pathogenetic causes and is aimed at correcting the underlying disease.
Prognosis and prevention
The prognosis for the primary buried penis, without combination with other anomalies of the structure of the genitourinary system, is favorable provided the operation is performed in a timely manner. In obese men and boys, after losing weight, pathology is resolved independently. Preventive measures for a true buried penis have not been developed, but a woman during pregnancy should not take drugs at her discretion, drink alcohol, drugs, or smoke.
The risk of the appearance of a hidden phallus against the background of obesity is leveled if you maintain an optimal body weight: exercise, eat rationally. Timely access to a doctor and treatment of dropsy, inguinal-scrotal hernia, without waiting for their gigantic increase, allow you to preserve men’s health and avoid a number of complications.