Physicians are well-versed in common obesity-associated conditions, such as diabetes and hypertension. Still, there is another, less-publicised (yet highly distressing) comorbidity specific to male patients: adult-acquired buried penis (AABP).

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 “With obesity rates climbing in the United States, [AABP] is an increasingly common problem, with potentially devastating physical and psychological sequelae,” said authors publishing in Sexual Medicine Reviews.[1]

"Although medical management may be attempted, surgical intervention is the mainstay of treatment."

— Authors, Sexual Medicine Reviews

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The science of AABP

The term “buried penis” first entered the medical lexicon in 1919. This condition is also referred to as concealed, hidden, trapped, inconspicuous, or vanishing penis. Although it is increasingly diagnosed, given the ongoing obesity epidemic, authors writing in Cureus say there is limited research on the topic of AABP.[2] In one report, 87% of men who received surgery for the condition were obese.[3]

With a buried penis, the genitals are of normal size. However, skin or fat in the prepubic area engulfs the penis. In addition to morbid obesity, other causes (and comorbidities) of buried penis include the following:

• Latrogenic causes (eg, circumcision or penile/scrotal enlargement)
• Trauma
• Hidradenitis suppurativa
• Bacterial/fungal infections
• Lichen sclerosis
• Penoscrotal lymphedema (secondary to arteriofemoral bypass grafting, inguinal lymphadenectomy for penile cancer or melanoma, elephantiasis, and/or prostatectomy with pelvic node dissection)

A review published in Translational Andrology and Urology notes that, besides malignancies, chronic inflammation can predispose patients to other problems, including urethral stricture disease and the associated lower urinary tract symptoms. It can also increase the risk for infection and urolithiasis, as well as obstructive uropathy.[4]

“Lichen sclerosis associated with AABP can be a cause of often lengthy urethral strictures most commonly in the anterior urethra, a presentation that is fairly uncommon among the typical patients presenting with stricture disease,” the authors wrote.

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Primary complaints associated with AABP

Due to sexual and urological complaints, patients with AABP often present to urologists early on. Typical urological complaints relate to lower urinary tract symptoms, including hesitancy, poor flow, and voiding problems. Post-voiding issues include dribbling and incontinence. Bacterial and fungal infections may also be present.

From a psychological perspective, patients with AABP may exhibit depression and low self-esteem and may report erectile dysfunction or inability to perform intercourse.

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In the exam room

Evaluation should include a detailed history focused on the duration of time that the penis has been buried and whether weight changes occurred. In addition to asking about voiding problems and sexual dysfunction, clinicians should address benign prostatic hypertrophy, prior surgical history, injections for genital enlargement, and urethral stricture. Comorbid etiologies, including diabetes, should also be inquired about.

Physicians can examine patients in both a standing and supine position, with attention paid to whether the abdominal panniculus, the suprapubic fat pad, or both, cover the penis. The penile examination includes the presence of circumcision and possible stenosis of the meatus. Lymphedema, thickening of the skin, and whitening of the skin due to lichen sclerosis can present on the penis, scrotum, and suprapubic areas. The examiner should attempt to depress the skin and fat around the penis to expose it. Scrotal enlargement could indicate hidradenitis suppurativa. 

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Classification and treatment of AABP

Various classification systems for AABP have been proposed, as outlined by the Cureus authors. These classifications serve as a guide to surgical treatment options.

The classification by Tausch and colleagues (2016) described three grades:

• Grade 1: Viable penis skin; treated with phalloplasty with or without scrotal flap
• Grade 2: Nonviable penile skin; replacement of denuded skin with a split-thickness skin graft
• Grade 3: Genital lymphedema; excision of involved tissues, followed by adjunctive procedures if needed, followed by split-thickness skin grafting

Pariser and colleagues (2018) approached classification based on the complexity of the surgical repair:

• Category I: Penile unburying with a local skin flap
• Category II: Penile skin grafting
• Category III: Scrotectomy or scrotoplasty
• Category IV: Excutcheonectomy
• Category V: Abdominal panniculectomy

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Management of AABP

“The specific surgical intervention must be determined for each individual patient,” wrote the authors in Cureus. However, general concepts for AABP management include the following:

1. Mobilisation of the penis. (by the release of tethering bands and scars)
2. Fat removal (of the abdominal panniculus, the suprapubic fat pad, or both)
3. Appropriately suspending the base of the penis. (to prevent retraction)
4. Restoring penile skin if the penis has been denuded.

For replacement of penile tissue, there are various options, ranging from split-thickness skin grafts to full-thickness skin grafts, or a combination. Scrotectomy may also be necessary for some men. Post-op complications include abnormal scarring, granuloma formation, paradoxical penile shortening, and psychological sequelae due to deformity.

Nevertheless, the Cureus authors note that most men are “pleased with the functional and aesthetic outcome following surgical management.”

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Counselling patients

Patients often struggle with AABP, both pre- and post-operatively. The psychological implications of AABP cannot be understated, and psychiatric support is an integral part of care. Patient counselling is addressed in Translational Andrology and Urology.

“Research has shown that depression, embarrassment and self-esteem are all issues that buried penis patients confront when it comes to this condition,” the authors wrote. “Surely, bringing these concerns to providers cannot be an easy conversation for many to have. After presenting to a reconstructive surgeon, other issues could include difficulties in funding the operation through insurance and finding time for the operation.” 

Finding qualified surgeons to perform the necessary operations can add to the difficulty of receiving treatment. 

Although physicians may be tempted to suggest that weight loss alone may be adequate to treat the condition, permanent fibrotic skin changes secondary to AABP require reconstructive repair. Once the disease progresses to phimosis or glandular adhesions, medical treatments or weight loss are no longer sufficient to treat the condition. 

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Disclaimer: This story is contributed by Naveed Saleh and is a part of our Global Content Initiative, where we feature selected stories from our Global network which we believe would be most useful and informative to our doctor members.