Buried Penis: Correcting a Rare, Life-Altering Condition
Buried Penis: Correcting a Rare, Life-Altering Condition
Buried penis is a rare — and little-known — condition that affects an unknown number of men. It’s a problem that directly impacts urination and sexual function, significantly reducing the quality of life for impacted individuals.
Patients seek care at UW Medicine — the only institution in the Washington, Wyoming, Alaska, Montana and Idaho (WWAMI) region to offer treatment for the condition. Urologist Judith Hagedorn, MD, MHS, FACS, and plastic surgeon Jeffrey Friedrich, MD, MC, FACS, collaborate to deliver surgical therapy — a mons panniculectomy and skin graft — that can correct the problem and relieve a patient’s symptoms.
“This isn’t a cosmetic problem as many insurance companies like to view it. It’s more than that, and it requires surgical intervention,” says Hagedorn, who specializes in trauma and reconstructive urology.
And according to UW Medicine research, their multidisciplinary approach improves quality of life for most patients. It leads to better long-term urinary and sexual function for affected men, as well as better hygiene.
What is buried penis?
Buried penis often occurs in men who are morbidly obese and/or have genital lymphedema. It’s a condition where a normal-sized penis becomes hidden or trapped under skin or fat. As a result, patients can experience scarring of the penile skin.
“We typically see a cycle of inflammation leading to scarring of the skin surrounding the penis that then entraps it,” she says. Topical steroid cream to the area of inflammation and scarring can help with softening the skin and is a good first-line treatment.
Men with buried penis face multiple struggles with urination. They cannot extract and hold their penis to direct the urine stream and urine may flow over their skin and clothes, forcing many to sit to urinate and potentially use the shower or bathtub to do so. Urethral stricture disease can also accompany buried penis pathology and is difficult to diagnose due to the entrapped penis that hinders access to the urethra for evaluation. In rare instances, a patient might have a urologic condition for which a Foley catheter or cystoscopy is required (urinary retention, nephrolithiasis, hematuria). In cases like these, the patient’s urologist can perform a dorsal/lateral, releasing the tight scar ring and exposing the penis without compromising subsequent reconstruction.
It is harder, and often impossible, for patients to keep the genital area clean, increasing the risk of penile cancer. Erections become painful due to the cicatrix that entraps the penis, which can crack and bleed; penetrative sex may not be possible; and skin infections from constant moisture do develop, and in rare cases can progress into a necrotizing soft tissue infection (Fournier’s gangrene). These difficulties can have a tremendous negative impact on the patient’s quality of life and can impact their mental health.
A different approach to care
The best way to characterize and diagnose a buried penis is through a physical exam. The optimal way to examine the patient is in a standing position. The physician can palpate the head of the penis, and for some men, the penis can be exposed if the penile shaft skin is elastic and mobile. In many cases, the foreskin or remaining shaft skin is scarred and entraps the penis. In these patients, the skin cannot be retracted to expose the glans. It is tempting to offer a circumcision for these patients in the hope that the penis will release from the scarred tissue, but that will not solve the problem.
“A man only has one foreskin, and it’s typically removed in childhood in the United States,” Hagedorn says. “A second circumcision simply removes scarred shaft skin. As a result, the patient has less shaft skin overall, and the scarring of the skin can recur.” But even in men who are not circumcised, removal of the foreskin alone does not cure the problem, but rather the penis eventually gets entrapped again, this time in scarred shaft skin. This is due to the surrounding soft tissue, which does not allow the penis to be exposed.
Instead, Hagedorn and Friedrich have a better solution: a mons panniculectomy, removal of scarred penile shaft skin and skin graft to the penis. During a one-day dedicated buried penis clinic every month, they exclusively evaluate these patients and identify individuals who may be good candidates for surgery.
“This is not a glamorous problem for either urologists or plastic surgeons,” Friedrich says. “What we are doing, though, is fulfilling a need for a mysterious condition.”
During each visit, they tag-team, asking patients about their urinary and sexual function and their most bothersome symptoms. They also try to determine if the patient has any underlying bladder dysfunction that will need treatment after surgery.
Not every patient with buried penis is a good candidate for surgery. Hagedorn and Friedrich have some qualifications. Typically, patients must have a body mass index (BMI) at or below 45 and a hemoglobin A1C of 9 or less. The surgical complications increase and are very high for patients who do not meet these cutoff criteria. Patients must also be healthy enough to undergo surgery and have no debilitating heart or lung problems.
Completing surgery
Correcting buried penis is a multifaceted process. So, Hagedorn and Friedrich extend their collaborative approach to the operating room.
“Our two goals are to treat the patient’s two dysfunctions,” Friedrich says. “We want to help improve their urinary and sexual function.”
During each two-to-three-hour procedure, Friedrich performs the mons panniculectomy to reduce the excess tissue that surrounds the penis. Then, Hagedorn removes the scar tissue that entraps the penis, and they place a skin graft over the exposed areas of the shaft. They place a series of sutures that help anchor the skin around the base of the penis toward the pubic bone and put a bolster dressing around the penis to protect the skin graft.
Success rates for this procedure are high, Friedrich says. After recovery, more than 90% of patients will be able to stand to urinate and direct their stream. And many regain normal sexual function. After several years, 10-15% of patients may experience a recurrence, which is usually related to weight gain. BMI is strongly correlated with the risk of complications. A retrospective review of their cohort of patients showed that the complication risk increases almost two-fold with each 10kg/m2 increase in BMI, and at a BMI of 40kg/m2 and above, the risk of recurrence increases. They aim for a BMI cutoff of 45kg/m2 to achieve the best results and to minimize wound complications and risk of recurrence.
The right place for care
Currently, there are few places where patients with buried penis can find the care they need. Consequently, many may live with the condition rather than pursue treatment, Hagedorn says. That’s why UW Medicine is committed to increasing access to therapy.
“Dr. Friedrich, the Urology team and I have completed the most buried penis repairs in the WWAMI region,” she says. “We have the expertise to best address this problem.”
Friedrich agrees and points to their collaborative approach as the bedrock of their accomplishments.
Integrating a plastic surgeon has been invaluable for decisions on skin grafting of the penile shaft, which is often necessary once the scar on the shaft skin has been removed. They harvest the skin graft, often from the mons pannus, prior to its removal in order to spare the patient a donor site and wound to take care of.
They studied their cohort of buried penis patients, and when asked about their quality of life after the surgery, the majority reported that they’d elect to undergo the surgery again. They also reported that it has contributed to a positive change in their life. Hagedorn and Friedrich showed that the surgery is a long-term success for many patients.
“We have tremendous experience with buried penis and wonderful relationships with all members of our team,” Friedrich says. “Together, we produce good outcomes and success rates for our patients. This can be a life-changing procedure.”
