Pediatr Surg Int (2002) 18: 668672
DOI 10.1007/s00383-002-0770-y
O R I GI N A L A R T IC L E
Jayant Radhakrishnan Asim Razzaq
Kannan Manickam
Concealed penis
Accepted: 13 July 2001 / Published online: 17 September 2002
Springer-Verlag 2002
Abstract A small phallus causes great concern regard-
ing genital adequacy. A concealed penis, although of
normal size, appears small either because it is buried in
prepubic tissues, enclosed in scrotal tissue penis palma-
tus (PP), or trapped due to phimosis or a scar following
circumcision or trauma. From July 1978 to January
2001 we operated upon 92 boys with concealed penises;
49 had buried penises (BP), while PP of varying degrees
was noted in 14. Of 29 patients with a trapped penis,
phimosis was noted in 9, post-circumcision cicatrix
(PCC) in 17, radical circumcision in 2, and posttrau-
matic scarring in 1. The BP was corrected at 23 years of
age by incising the inner prepuce circumferentially,
degloving the penis to the penopubic junction, dividing
dysgenetic bands, and suturing the dermis of the pen-
opubic skin to Bucks fascia with nonabsorbable sutures.
Patients with PP required displacement of the scrotum in
addition to correction of the BP. Phimosis was treated
by circumcision. Patients with a PCC were recircumcised
carefully, preserving normal skin, but Z-plasties and
Byars aps were often required for skin coverage. After
radical circumcision and trauma, vascularized aps were
raised to cover the defect. Satisfactory results were ob-
tained in all cases although 2 patients with BP required a
second operation. The operation required to correct a
concealed penis has to be tailored to its etiology.
Keywords Penis Concealed Trapped Webbed
Penis palmatus
J. Radhakrishnan (&) A. Razzaq K. Manickam
Division of Pediatric Surgery,
The University of Illinois,
Chicago, IL, USA
E-mail: jrpds@hotmail.com
Fax: +01-815-652-6818
J. Radhakrishnan
The University of Illinois,
1502 71st. Street,
Darien, IL 60561, USA
Introduction
The penis is inconspicuous if it is absent (penile agene-
sis), diminutive (epispadias, hypospadias, chordee), mi-
cropenis (hypothalamic, pituitary or testicular origin),
or concealed. A penis of normal size may be concealed
because it is (a) buried in prepubic tissues, (b) buried and
also enclosed in scrotal tissue (penis palmatus), (c)
trapped secondary to phimosis, post-circumcision cica-
trix, or trauma or (d) hidden because of a large hernia or
hydrocele.
Materials and methods
Between July 1978 and January 2001, one hundred and forty-three
boys were referred to us for evaluation and treatment of a con-
cealed penis (Table 1). In all patients the stretched penile length
was appropriate for age. Most of these patients presented as infants
but there were boys of all ages with the oldest being 16 years old.
Three patients had a prior failed operation for a buried penis. Two
boys are extremely obese and we are not willing to operate on them
at this time. In the remaining the degree of obesity was no dierent
from that in the population at large. We operated upon ninety-two
patients. In all the patients the immediate post operative appear-
ance of the penis was maintained on long term followup. In twenty-
nine of the remaining fty-one, the problem resolved spontaneously
while eight are still being followed. Patients with a concealed penis
due to a large hernia or hydrocele are excluded from this report.
Buried penis
Infants presenting with a buried penis were observed until two to
three years of age and operated upon if there was no evidence of
improvement. A partially buried penis generally resolved sponta-
neously as prepubic fat disappeared with elongation of the lower
abdomen. Older children were operated upon when rst seen. In all
but one patient with a buried penis the operation consisted of a
circumcoronal incision in the inner prepuce 5 mm from the corona.
Since 1985, we have also added a vertical ventral incision down
to the base of the penis as described by Redman [1] (Figs. 1 and 2).
The penis was degloved to the penopubic junction, dysgenetic
dartos fascia was divided, and the dermis of the skin at the pen-
opubic junction was sutured to Bucks fascia at the 2 oclock and
10 oclock positions and dermis at the proposed penoscrotal
 669

Table 1 Data of patients with

concealed penis Total no. of patients: 143

A. Operated: 92
1. Buried penis 49 (2 previously operated)
2. Penis palmatus 14
3. Trapped penis 29
a. Phimosis 9
b. Post-circumcision cicatrix 17
c. Radical circumcision 2
d. Trauma 1
B. Concealed penis observed: 51
1. Resolved 29
2. Being observed 8 (2 extreme obesity, 1 previously
operated)
3. Lost to follow-up 9
4. Operated elsewhere 5

junction was sutured to Bucks fascia at the 5 oclock and 7 oclock
positions. Penile skin was then wrapped snugly around the penis
and the ventral skin decit was closed. Z-plasties were used when
required. On occasion, the dorsal skin ap had to be mobilized in
the prepubic area to permit it to be advanced downward for at-
tachment to Bucks fascia. One patient was treated with the
preputial unfurling technique of Donahoe and Keating [2].
Penis palmatus
These patients had inadequate scrotal migration that varied any-
where from a webbed penis to a doughnut scrotum. For patients
with a webbed penis, after the circumcoronal incision, an inverted
V-shaped incision was made instead of a ventral midline incision,
extending downward and outward on either side of the midline
raphe onto the scrotum. Upon closure as an inverted Y, it per-
mitted the scrotum to drop downward and created a penoscrotal
junction. Doughnut scrotum was corrected by making inverted V-
shaped incisions on each side of the penis with the apex of the V at
the root of the scrotum. The incisions were either closed as inverted
Ys (Fig. 3) or the strip of tissue within the V was excised to obtain a
straight vertical suture line [3].
Trapped penis

Penises trapped in the scrotum due to pinpoint phimosis were easily

corrected by circumcision. If these patients presented as infants
they were operated upon expeditiously, since they not only do not
improve spontaneously, but the scar tends to tighten further as it
matures. In patients with a post-circumcision cicatrix that closed
over the distal glans like an iris we rst made a vertical ventral
incision in the cicatrix to separate the skin from the glans. Al-
though all scarred skin should be removed, on occasion when the
scarring was extensive, some of the scar had to be shaved from
within to preserve skin length. All these patients required Z-plasties
or Byars aps to obtain adequate ventral skin coverage. The two
patients who had a radical circumcision and one with a post
traumatic scar following a crushed pelvis were reconstructed with
skin aps in the manner previously reported by us [4].

Results

Buried penis

Only one of the patients operated upon by the technique

Fig. 1 Illustration of buried penis and its correction, A Lateral
view demonstrating lack of attachment of skin to shaft of penis and
fat pad anterior to the pubis. B The penis is made visible by
displacing prepubic fat. A circumcoronal incision with a ventral
midline vertical extension upto the proposed penoscrotal junction
is marked. C The penis is degloved down to its base and the
abnormal dartos attachments are divided (black arrow). D
Completed repair with circumcoronal and ventral midline sutures
described had a poor cosmetic result. Upon reoperation,
we found that our sutures had either missed the dermis
or had cut through it. The sutures were noted to be
attaching mobile subcutaneous tissues to Bucks fascia.
Upon replacing the sutures appropriately through the
dermis an excellent result was obtained. Our one expe-
rience with the preputial unfurling technique was un-
satisfactory since there was considerable edema and the
buried penis recurred. Upon reexploration through the
previous incision combined with a vertical ventral inci-
sion we were able to divide dysgenetic fascia and reat-
tach the penopubic dermis to Bucks fascia with
adequate protrusion of the penis, however, in this
African-American male, the result is unsatisfactory as
670

Fig. 2 Patient with buried penis. A Completely invisible penis. B

The penis protrudes upon displacement of prepubic fat. C A Discussion
glanular stay suture is used for traction. Proposed line of incision is
marked. D After the circumcoronal incision is made and penis Buried penis was rst described by Keyes in 1919 [5]. In
is degloved it disappears upon release of traction. E Penile skin ap
is developed up to the base of the penis and dysgenetic bands have 1958, Byars and Tries were the rst to identify a trapped
been divided. F Completed reconstruction penis following circumcision [6], and in 1959 Keshin [7]
rst reported a post-traumatic penile dislocation. The
rst attempt at correction of a BP was made by Schloss
skin covering the penis has three dierent shades of in 1959 [8], who carried out an emergent circumcision
color.
Apart from the two instances mentioned above, in all
others, the parents and patients were very pleased with
the results of the operation. Only one of these patients is
sexually active so far and he does not have any com-
plaints.

Penis palmatus

In all patients with PP the BP component was addressed

adequately. Patients with a webbed penis had an excel-
lent result, while those with a doughnut scrotum and a
shawl scrotum have a slight transverse fold of skin at the
base of the penis, which had to be preserved to maintain
blood supply to the skin covering the penis.

Trapped penis

Excellent protrustion was obtained in all patients with a

primary phimosis. Of the patients with a PCC, 1 still
requires retraction of skin to prevent adhesions from Fig. 3 Inverted V-Y plasty for correction of peno-scrotal transpo-
reforming. The 3 patients who required vascularized sition. Point B slides down to convert a V into a Y as demonstrated
aps all had excellent results. in the inset

and permitted the raw area proximal to the corona to
granulate in by having the mother retract the skin on a
daily basis. At the time of the report, 2 years later,
retraction was still required. In 1968, Glanz [9] success-
fully corrected a BP in a 57-year-old man by making
multiple ventral and dorsal Z-plasties on the penis.
The majority of our patients presented when the pe-
diatrician, parents, or older boys themselves were con-
cerned about the size of the penis. In addition, patients
with a BP who were voiding into the preputial sac were
persistently wet. Balanoposthitis and urinary infections
can occur, but did not in our patients [1012]. Older
patients also had diculty directing the urinary stream,
which sprayed, and they were wet after voiding. In the
29 patients in whom the problem resolved spontaneously
there was no phimosis or post circumcision cicatrix,
their prepubic fat pad was not excessive and there was a
circumferential groove at the base of the penis.
Glanz [9] attributed buried and webbed penis to
abnormal attachment of skin due to an embryonic carry
over of a vestigial cloacal veil whereas Crawford [13] felt
that dorsal dysgenetic bromuscular bands caused the
buried penis. We agree with Devine [14] and Cromie [12]
who indicate that since these dysgenetic dartos bands
are only attached at the corona the penis retracts and
adequate attachment of skin to the shaft of the penis is
prevented. Johnston [15] wondered whether these dys-
genetic bands were cause or eect. We disagree with
Wollin [16] who states that the defect is ventral rather
than dorsal and with Joseph [17] who blames it on infe-
rior displacement of the root of penis. He believes that fat
and areolar tissue secondarily ll the space created and
he does not believe that the fat pad worsens the situation.
In our opinion and that of others [11, 18], a large sup-
rapubic fat pad does seem to contribute to the problem.
Casale [19] attributes the problem to the presence of a
web, hypermotility of the angle of the penis, a circum-
ferential scar and disproportionate obesity.
We classied concealed penis on the basis of the type
of operation required to correct it (Table 1). Other
classications have been proposed by Crawford [13],
Hinman [20], Maizels [11] and Bloom [21]. Only Maizels
[22] and Burkholder [10] have noted an association with
renal anomalies. Other genito-urinary anomalies are not
to associated with the condition.
We believe that, in the infant, if the buried penis has
not resolved by two to three years of age it will require
correction. It is also important that the patient be able to
void standing up when he is toilet trained.
Numerous operative procedures have been described
for management of the buried penis. Hinman [23],
Perlmutter [24] and Masih [25] used a two-stage proce-
dure requiring burial in the scrotum. Hinman also ex-
cised the suprapubic fat pad. Others have used skin aps
alone to [2, 9, 16, 26], while Johnston [27] sutured the
penis to the pubic periosteum, Crawford [13] divided
only the dysgenetic fascia, and Burkholder and Newell
[10] placed a short penile prosthesis. Maizels et al. [11]
combined removal of prepubic fat as described by
671
Hinman [23] and attachment of the penis to the pubic
periosteum as described by Johnston [27].
It appears that the following elements are required
for successful correction of a BP: (1) degloving of penile
skin down to the base of the penis; (2) division of dartos
bands that dislocate the penis; (3) unfurling of penile
skin to cover the shaft; (4) suture of the dermis at the
penopubic and penoscrotal junctions to Bucks fascia;
(5) snug wrapping of penile skin around the penile shaft;
(6) creation of a penoscrotal angle; and (7) Z-plasties for
ventral skin closure.
Prior to 1985, we carried out the above procedure
through a circumcoronal incision only. Division of the
dartos bands and accurate approximation of the pen-
opubic dermis was dicult through this incision and, in
fact, resulted in 1 failure. Addition of the ventral vertical
component described by Redman [1] not only made the
dissection and suturing more precise, but also permitted
the penile skin to be snugly wrapped around the shaft of
the penis and to develop a well-dened penoscrotal an-
gle. Numerous modications of the Redman procedure
have been described [12, 14, 1719, 2834]. Although we
believe the suprapubic fat pad adds to the problem, we
do not remove it since it reaccumulates, as occurred in 2
patients who came to us after a prior failed operation
that involved its removal. We are also reluctant to suture
Bucks fascia to the pubic periosteum, since it could
cause pain during an erection.
PP occurs in a wide spectrum. In the webbed penis
the scrotum creeps up onto the penis, and along with
correction of the BP a penoscrotal junction has to be
created by an inverted V-Y-plasty or Z-plasties. At the
other end of the spectrum of inadequate scrotal migra-
tion is the doughnut scrotum which results in a toad in
the hole penis and the Shawl penis, in which a hor-
izontal skin fold runs dorsally at the base of the penis. In
these patients the dorsal conuence of the scrotum is
displaced ventrally by making V-Y plasties on either side
or by rotating scrotal skin aps from the dorsal to the
ventral aspect in addition to correction of the buried
penis. Care has to be taken to place the apex of each
inverted V such that the base of the dorsal skin ap to
the shaft of the penis is as wide as possible and retains its
blood supply.
Patients with a trapped penis due to a post circum-
cision cicatrix or phimosis essentially require a circum-
cision which, in the former instance, should carefully
avoid excessive removal of skin.
Patients with a denuded penis due to a radical
circumcision or after trauma have been treated in
various ways including use of vascularized aps [4],
split-thickness skin grafts [35], multiple Z-plasties [9,
34] and two-stage repair after burying the penis in the
scrotum. Our personal preference is for vascularized
aps.
In conclusion, a smooth transition from prepubic
skin to penile skin is indicative of a buried penis. A
trapped penis can be dierentiated from it by the pres-
ence of a circumferential groove at the base of the penis.
672
Neonates with a buried penis should not be circumcised
at birth.
Acknowledgements The authors wish to thank Dr. Russell Pearl
for his illustrations.
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