Current Concepts and Quality of Life following Adult Acquired Buried Penis Repair
By: Chris Staniorski, MD; Daniel Pelzman, MD; Paul Rusilko, DO, FACS | Posted on: 01 Nov 2021
Adult acquired buried penis (AABP) is a condition characterized by entrapment of the phallus within a suprapubic fat pad or cicatrix. This concealment and the resultant chronic inflammation can lead to increased incidence of urethral stricture, sexual dysfunction, depression, and penile cancer.1 Due to the permanent fibrotic penile skin changes present in this population, weight loss alone is usually inadequate; rather, surgical removal of the surrounding dense scar tissue with or without penile skin grafting has become a mainstay of treatment (fig. 1).
Briefly, our preferred surgical approach first requires circumferential release of cicatrix scar tissue, from Buck’s fascia and the lower abdominal wall to the level of the suspensory ligament (fig. 2). This step results in a completely degloved penis. Frequently, the remainder of the suprapubic fat pad is excised (escutcheonectomy) and a well-vascularized, tension-free abdominal wall flap is brought down to the base of the penis and sutured to Buck’s fascia to prevent reburying. A Blake drain is placed under this flap. A partial scrotectomy utilizing a W-plasty technique is performed for cosmesis. Finally, a split-thickness skin graft is harvested from the patient’s thigh and secured to Buck’s fascia.2 Skin can also be harvested from the excised escutcheon to further decrease the morbidity of the surgery. Other groups have reported use of local skin flaps for penile skin coverage.3 A penile bolster dressing and Foley catheter are left in place for 1 to 2 weeks postoperatively. Patients are allowed to resume sexual activity after 2 months. Most patients typically stay 1 to 2 nights in the hospital, a significant decrease from previously described techniques, and some groups have described acceptable outcomes with outpatient buried penis repair.4
This approach and similar techniques have been studied in multiple single center cohorts which have demonstrated improvements in sexual and urinary function, social interaction, psychological health, and overall surgical satisfaction. Studies reporting quality of life outcomes which used the above surgical approach are summarized in the table with their methods of measurement and findings. Overall, these data suggest positive results following surgical AABP reconstruction for patients. The most common domains measured include sexual and urinary function. In terms of sexual function, several studies reported improvements in erectile function, ability to reach orgasm, and frequency of sexual activity. Urinary function also improved for most patients, with improved rates of hygiene, voiding symptoms, and ability to stand while urinating.5-7 Mental health has also been studied in AABP patients. Rybak et al examined rates of depression in this population and found a dramatic and encouraging improvement from 64% to 18% postoperatively.7 While survey responses may provide granular data about individual outcome domains, possibly the most important parameters to share with patients when considering the benefits of reconstruction include the overall satisfaction that patients have following the procedure, more than 85% would choose surgery again and 74% felt this led to a positive change for their lives.5,8 These numbers provide a useful framework when discussing benefits of surgical correction and possibly referring patients for reconstruction. Importantly, these benefits appear to be durable, with followup times of around 3 years in some series.5,8 Despite encouraging findings, most studies are single center retrospective reviews with small numbers of patients. Surveys used are largely repurposed for use in buried penis outcomes. We would expect and hope that larger populations and collaborative studies will confirm these findings in the future.
Table. Summary of quality-of-life outcomes for AABP reconstruction
|Reference||No. Pts||Av Followup||Method of Measurement||Findings|
|Rybak et al 20147||11||Not reported||European Organization for Research and Treatment of Cancer (EORTC) 15 Quality of life (QOL)
Center for Epidemiologic Studies Depression Scale (CES-D)
International Index of Erectile Function (IIEF)
|Sexual Function – erectile dysfunction rates decreased from 91% to 63%
Urinary Function - 91% reported improved voiding + could stand with stream
Quality of life - 91% of population had improved scores*
Depression – rates decreased from 64% to 18%*
|Voznesensky et al 20178||12||31 mos||Post-Bariatric Surgery Quality of Life Questionnaire (PBSQoL)
|Quality of life - improvements in skin rashes, difficulty fitting into clothing, embarrassment, difficulty shopping*
92% would choose surgery again
83% felt surgery led to pos change
|Hampson et al 20175||27||39 mos||Individual Questions
|Sexual Function – improved rates of sexual activity + erectile function
Urinary Function – Improved rates of genital hygiene + ability to stand to urinate
85% would choose surgery again
74% felt surgery led to pos change
85% felt surgery had remained long term success
|Theisen et al 20186||16||12.6 mos||Expanded Prostate Cancer Index (EPIC)||Sexual Function – Improvements in 10/13 domains, 87.5% pts noted overall benefit*
Urinary Function – Improvement in 10/12 domains, 87.5% noted overall benefit*
|* Statistically significant improvement.|
Important comorbidities have come to light with buried penis and the environment of inflammation associated with the condition, namely urethral stricture and penile cancer. Stagnant urine remains in contact with the skin in this condition and is thought to lead to cycles of inflammation and infection that can drive formation of lichen sclerosis. This is proposed to contribute to urethral stricture formation with one study finding 31% of one cohort of buried penis patients presenting with stricture; moreover, these were lengthy anterior urethra strictures, an atypical presentation that would be more associated with lichen sclerosis. These strictures can be repaired at the time of buried penis repair and further contribute to urinary outcomes and improved quality of life. This process may also place patients at risk for malignancy, with work showing a 7% prevalence of penile cancer among buried penis patients.9 Although no long-term data are present, we hypothesize that removal of the chronically inflamed skin would decrease the incidence of penile cancer and urethral stricture.
Overall, an improved, more consistent approach to surgical repair has provided positive outcomes for buried penis patients. This approach also allows for management of comorbid conditions such as stricture and a method to evaluate the health of the surrounding skin. Data suggest that patients are likely to experience improvements in sexual and urinary function in addition to possibly more surprising psychological improvements in self-confidence and decreased rates of depression. Due to the increasing incidence, early recognition of AABP and prompt referral to a genitourinary reconstructive specialist is essential. Future work must examine long-term postoperative outcomes.
- Staniorski CJ and Rusilko PJ: The concealed morbidity of buried penis: a narrative review of our progress in understanding adult-acquired buried penis as a surgical condition. Transl Androl Urol 2021; 10: 2536.
- Fuller TW, Theisen KM, Shah A et al: Surgical management of adult acquired buried penis. Curr Urol Rep 2018; 19: 22.
- Pestana IA, Greenfield JM, Walsh M et al: Management of “buried” penis in adulthood: an overview. Plast Reconstr Surg 2009; 124: 1186.
- Erpelding SG, Hopkins M, Dugan A et al: Outpatient surgical management for acquired buried penis. Urology 2019; 123: 247.
- Hampson LA, Muncey W, Chung PH et al: Surgical and functional outcomes following buried penis repair with limited panniculectomy and split-thickness skin graft. Urology 2017; 110: 234.
- Theisen KM, Fuller TW and Rusilko P: Surgical management of adult-acquired buried penis: impact on urinary and sexual quality of life outcomes. Urology 2018; 116: 180.
- Rybak J, Larsen S, Yu M et al: Single center outcomes after reconstructive surgical correction of adult acquired buried penis: measurements of erectile function, depression, and quality of life. J Sex Med 2014; 11: 1086.
- Voznesensky MA, Lawrence WT, Keith JN et al: Patient-reported social, psychological, and urologic outcomes after adult buried penis repair. Urology 2017; 103: 240.
- Pekala KR, Pelzman D, Theisen KM et al: The prevalence of penile cancer in patients with adult acquired buried penis. Urology 2019; 133: 229.