INTRODUCTION
Buried penis is a rare pathology characterized by the normal length of the penile
shaft, however, adhered to deep planes or covered by prepubic tissues. It is associated
with physical and psychological morbidity due to impairments in sexual function, hygiene,
and self-esteem of affected individuals1.
Its etiology can be congenital or acquired, the first being related to genetic alterations
of the Dartos fascia and affecting the pediatric population. Acquired causes include
radical circumcision, local trauma, recurrent infection, periscrotal lymphedema, and
obesity2.
The treatment is considered difficult to manage because there is no consensus or a
single surgical technique3. This article aims to present one of the techniques that can be used in the treatment:
superficial liposuction and dermolipectomy of the suprapubic tissue associated with
the fixation of the base of the penis in the pubic symphysis and partial skin graft
for penile coverage.
This article was registered under CAAE 45028621.1.0000.5362 and approved by the Ethics
Committee of the proposing institution by opinion No. 4,644,902. The Free and Informed
Consent Term was obtained from the patient and his legal guardian for using information
from the medical record and images.
CASE REPORT
Male patient, 30 years old, with Down syndrome, sought medical care with his legal
guardian, complaining of difficulty urinating, performing intimate hygiene and recurrent
episodes of local infection. On physical examination, obesity, large lipodystrophy
and supralabial flaccidity were observed, with the impossibility of exposing the penile
shaft, establishing the diagnosis of buried penis associated with phimosis (Figure 1).
Figure 1 - Presence of a buried penis associated with phimosis.
Figure 1 - Presence of a buried penis associated with phimosis.
After discussion between the teams, a joint surgical correction between Plastic Surgery
and Urology was chosen.
Dissection and dermolipectomy
The patient underwent the procedure on May 11, 2020, under general anesthesia. Marking
was performed in the trapezoid suprapubic region, with the lower portion of the incision
in the midline 2 cm from the base of the penis so that the skin of this region can
be brought closer to the pubic symphysis.
Superficial liposuction of the demarcated area was performed after infiltration with
a vasoconstrictor solution (1:1,000), followed by dermolipectomy, limited to the deep
fascia, without prejudice to local lymphatic drainage due to the preservation of the
deep lymphatic vessels (Figure 2).
Figure 2 - Surgical demarcation and resection of the area.
Figure 2 - Surgical demarcation and resection of the area.
Fixation of the base of the penis to the pubis
The fascia adjacent to the base of the penis was fixed to the periosteum of the pubic
symphysis with three simple stitches using 2.0 polypropylene thread, aiming at greater
exposure of the penile shaft (Figure 3). A 4.8 suction drain was interposed at the liposuction and resected site. Synthesis
of fascia and skin was performed in two planes with nylon 3.0 single stitches (Figure 4).
Figure 3 - Attachment of the fascia adjacent to the base of the penis to the periosteum of the
pubic symphysis.
Figure 3 - Attachment of the fascia adjacent to the base of the penis to the periosteum of the
pubic symphysis.
Figure 4 - Result after resection and closure of the demarcated area.
Figure 4 - Result after resection and closure of the demarcated area.
Phimosis correction
The opening of the foreskin was particularly laborious due to the firm adhesions with
the glans and difficult identification of the planes due to longstanding phimosis
and recurrent local infections.
We opted for resection of the foreskin due to Buck’s fascia’s pathological aspect
and exposure (Figure 5). The anatomopathological examination of the resected specimen showed lichenoid dermatitis.
Figure 5 - Penile exposure.
Figure 5 - Penile exposure.
Grafting
A partial skin graft was removed from the right thigh with an electric dermatome,
and the donor area was dressed in non-adherent gauze and dry compresses. Proximal
fixation of the graft was performed at the base of the penis next to the healthy skin
and distal fixation of the same next to the glans. The suture was performed with simple
4.0 polyglactin thread stitches (Figure 6).
Figure 6 - Positioning and fixation of the partial skin graft.
Figure 6 - Positioning and fixation of the partial skin graft.
Dressing
The dressing used was the Brown type. Long sutures were left to fix the slightly compressive
dressing around the entire circumference of the penis using non-adherent gauze (Figure 7).
Figure 7 - Dressing with non-adherent gauzes.
Figure 7 - Dressing with non-adherent gauzes.
The patient remained with an indwelling urinary catheter, and the dressing was removed
on the fifth postoperative day, being discharged after the first dressing change.
He followed up with weekly outpatient visits, performing home dressings and hydrating
the grafted skin with essential fatty acids. After 3 months, good graft integration,
good healing of the donor area, adequate penile exposure and improved local hygiene
were observed, voluntary diuresis, satisfactory flow, and absence of new infectious
episodes (Figure 8).
Figure 8 - Surgical result - 3 months postoperatively.
Figure 8 - Surgical result - 3 months postoperatively.
DISCUSSION
The buried penis is associated with loss of sexual function, painful erections, poor
hygiene and psychosocial disorder. It is related to voiding dysfunction due to the
entrapment of urine by redundant tissue and phimosis, generating chronic cutaneous
exposure to urine and dermatitis, as reported by the patient4-6. It is important to rule out differential diagnoses such as micropenis since the
management of pathologies is different7. In the case described, the differentiation was made by physical examination, in
which the penile shaft of normal length was palpated but without adequate exposure
due to the suprapubic adipose tissue.
Multiple causes are related to the development of the disease in adults, such as local
trauma, congenital lymphedema and radical circumcision involving scarring and fibrosis.
Even so, obesity is the main cause in this population, a condition presented by the
patient. The increase in fat, especially in the suprapubic region, creates an environment
conducive to bacterial and fungal infection, leading to a self-perpetuating cycle
of infection and scar contraction, conditions also present in this case5,6,8,9.
The various factors involved in the pathophysiology of the buried penis must be evaluated
and addressed during treatment. In the absence of a consensus, this condition becomes
a challenge for the surgeon. The main objective is the return of urinary and sexual
function and may involve the joint action of the plastic surgeon and urologist. The
various surgical techniques described for reconstruction must be adapted to the patient’s
conditions, and many cases require a combination of procedures5.
The approach to the suprapubic tissue and lower abdomen is based on location, quantity,
and etiology, with lipectomy, panniculectomy and abdominoplasty techniques being described
5,10. In patients with significant weight loss, in which the main factor involved is sagging
of the lower abdominal skin, with consequent coverage of the penis, good surgical
results are described with conventional or anchor abdominoplasty11.
In the technique presented, we chose to perform liposuction and suprapubic dermolipectomy
due to the large amount of adipose tissue and flaccidity, with no indication for conventional
abdominoplasty due to the patient’s obesity. Superficial liposuction was performed
with preservation of the deep fascia, as described by Saldanha, aiming to preserve
the perforating and lymphatic vessels, a technique proven to be associated with a
reduction in the incidence of complications such as seroma, hematomas and skin necrosis,
in addition to enabling the treatment of lipodystrophies in all regions of the abdomen12,13.
The technique presented by Figler et al.14, which served as the basis for the case presented, was associated with the fixation
of the base of the penis in the pubic symphysis, aiming at better exposure of the
penile shaft and maintenance of the result in the long term. Initially, there is a
retraction of the skin close to this fixation suture, which in the postoperative period
is gradually released, even without local conduct such as drainage and massage.
The viability of the skin of the penile shaft determines the type of technique for
correction of the defect: excision and primary closure, z-plasties, flaps or skin
grafts5. There was resection of the diseased skin of the foreskin and penile shaft due to
local chronic inflammatory changes, with the subsequent need to cover the bloody area.
A total skin graft is usually the option due to less secondary contraction and longer
late nail length.15.16.
It is possible to use the skin of the foreskin or the resected skin in the dermolipectomy
to obtain the graft; however, in the case presented, the first presented chronic inflammation
and the second areas of dermatitis and folliculitis. A partial skin graft with a donor
area in the thigh was then chosen. Postoperative care and mobilization were a concern
of the team since the patient had an intellectual disability, corroborating the choice
of partial graft because of its greater ease and shorter integration time.16.
The technique used showed good aesthetic and functional results in the postoperative
follow-up. The patient and his legal guardian reported an important improvement in
the initial symptoms, demonstrating a satisfactory result with the procedure performed.
CONCLUSION
Due to the progressive increase in the incidence of obesity, the buried penis tends
to become an increasingly common pathology. Surgical intervention is the mainstay
of treatment, and its approach must be individualized. The presented technique proved
feasible and had favorable results concerning the patient’s initial complaints regarding
hygiene, urination, and infections. Therefore, it is a good surgical option in treating
buried penis.
REFERENCES
1. Smith-Harrison LI, Piotrowski J, Machen GL, Guise A. Acquired Buried Penis in Adults:
A Review of Surgical Management. Sex Med Rev. 2020;8(1):150-7. PMID: 31101591 DOI:
https://doi.org/10.1016/j.sxmr.2019.02.008
2. King ICC, Tahir A, Ramanathan C, Siddiqui H. Buried penis: evaluation of outcomes
in children and adults, modification of a unified treatment algorithm, and review
of the literature. ISRN Urology. 2013;2013:109349. DOI: https://doi.org/10.1155/2013/109349
3. Bilommi R. Hidden Penis in Children: Evaluation of Outcomes and Review of Literature.
Med Surg Urol. 2015;4(4):1000156. DOI: https://doi.org/10.4172/2168-9857.1000156
4. Adham MN, Teimourian B, Mosca P. Buried penis release in adults with suction lipectomy
and abdominoplasty. Plast Reconstr Surg. 2000;106(4):840-4. PMID: 11007398 DOI: https://doi.org/10.1097/00006534-200009020-00014
5. Tausch TJ, Tachibana I, Siegel JA, Hoxworth R, Scott JM, Morey AF. Classification
System for Individualized Treatment of Adult Buried Penis Syndrome. Plast Reconstr
Surg. 2016;138(3):703-11. PMID: 27152580 DOI: https://doi.org/10.1097/PRS.0000000000002519
6. Chopra CW, Ayoub NT, Bromfield C, Witt PD. Surgical management of acquired (cicatricial)
buried penis in an adult patient. Ann Plast Surg. 2002;49(5):545-9. DOI: https://doi.org/10.1097/00000637-200211000-00017
7. Cezarino BN, Lopes RI, Machado MG, Oliveira LM, Giron AM, Tavares A, et al. Micropênis.
Rev Bras Med (São Paulo). 2018;97(3):308-13. DOI: https://doi.org/10.11606/issn.1679-9836.v97i3p308-313
8. Pestana IA, Greenfield JM, Walsh M, Donatucci CF, Erdmann D. Management of “buried”
penis in adulthood: an overview. Plast Reconstr Surg. 2009;124(4):1186-95. PMID: 19935302
DOI: https://doi.org/10.1097/PRS.0b013e3181b5a37f
9. Blanton MW, Pestana IA, Donatucci CF, Erdmann D. a unique abdominoplasty approach
in management of “buried” penis in adulthood. Plast Reconstr Surg. 2010;125(5):1579-80.
PMID: 20440190 DOI: https://doi.org/10.1097/PRS.0b013e3181d5166b
10. Ho TS, Gelman J. Evaluation and management of adult acquired buried penis. Transl
Androl Urol. 2018;7(4):618-27. PMID: 30211051 DOI: https://doi.org/10.21037/tau.2018.05.06
11. Alter GJ. Pubic contouring after massive weight loss in men and women: correction
of hidden penis, mons ptosis, and labia majora enlargement. Plast Reconstr Surg. 2012;130(4):936-47.
PMID: 23018703 DOI: https://doi.org/10.1097/PRS.0b013e318262f57d
12. Saldanha OR, Pinto EBS, Matos Jr WN, Lucon RL, Magalhães F, Bello EML, et al. Lipoabdominoplastia
- Técnica Saldanha. Rev Bras Cir Plást. 2003;18(1):37-46.
13. Saldanha OR, Azevedo DM, Azevedo SFD, Ribeiro DV, Nagassaki E, Gonçalves Junior P,
et al. Lipoabdominoplastia: redução das complicações em cirurgias abdominais. Rev
Bras Cir Plást. 2011;26(2):275-9. DOI: https://doi.org/10.1590/S1983-51752011000200014
14. Figler BD, Chery L, Friedrich JB, Wessells H, Voelzke BB. Limited Panniculectomy for
Adult Buried Penis Repair. Plast Reconstr Surg. 2015;136(5):1090-2. PMID: 26182174
DOI: https://doi.org/10.1097/PRS.0000000000001722
15. Demzik A, Peterson C, Figler BD. Skin grafting for penile skin loss. Plast Aesthet
Res. 2020;7:52. DOI: https://doi.org/10.20517/2347-9264.2020.93
16. Stephen JR, Burks FN. Buried penis repair: tips and tricks. Int Braz J Urol. 2020;46(4):519-22.
PMID: 32167731 DOI: https://doi.org/10.1590/s1677-5538.ibju.2020.99.06
1. Hospital Municipal São José, Joinville, SC, Brazil
2. Universidade da Região de Joinville, Joinville, SC, Brazil
Corresponding author: Djulia Adriani Frainer Rua Rio do Sul, 270, Joinville, SC, Brazil, Zip Code: 89202-201, E-mail: djuliafrainer@gmail.com
Article received: April 16, 2021.
Article accepted: July 14, 2021.
Conflicts of interest: none.