Concealed penis in childhood: A spectrum of etiology and treatment

Purpose: Concealed penis is an uncommon condition due to poor skin fixation at the base of the penis, cicatricial scarring after penile surgery and ex cessive obesity. The condition varies in severity and several surgical opti ons are available, such as excision of previous scarring, degloving the pen ile shaft, reconstructing the penile shaft skin with flaps, fixing the peni le skin at the penopubic and penoscrotal angles, and removing excess suprap ubic fat. Materials and Methods: We reviewed the records of 43 patients treated for c oncealed penis from 1993 to 1998. We categorized the cases as type 1-congen ital concealed penis, type 2-concealed penis due to scarring from previous surgery and type 3-complex cases involving excessive obesity. Cases were re viewed in regard to surgical techniques and outcomes. We identified 18 type 1, 18 type 2 and 7 type 3 cases. Mean age of type 1 patients at surgery wa s 12.4 months with 1 patient presented at age 7 years. None had previously undergone penile surgery. All patients underwent complete penile degloving. To reconstruct the penile shaft flaps or Z-plasties with penile skin were used in 12 patients and scrotal skin flaps were used in 2. In 12 patients t he penile skin was fixed at the penoscrotal and penopubic angles to maintai n penile length and in 2 excess fat was excised. Mean age of type 2 patient s at surgery was 19.8 months. All had previously undergone surgery, includi ng hypospadias in 1 and circumcision in 17. All patients underwent complete penile degloving and the cicatricial scar that trapped the penis was excis ed. Penile skin flaps and Z-plasties were used in 12 cases, scrotal skin fl aps were used for reconstruction in 2 and skin grafting was done in 1. In 1 0 patients the penile skin was fixed with sutures to maintain penile length . Mean age of type 3 patients at surgery was 15.8 years. Of the 7 boys 6 ha d previously undergone penile surgery. All required extensive scar excision and complex reconstruction involving penile skin flaps in 3, scrotal flaps in 5 and penile skin fixation in 6. Excessive suprapubic fat was removed i n 5 patients, of whom 3 underwent liposuction. Results: Surgical results we re uniformly good in type 1 patients except in I who was believed to have e xcessive suprapubic fat. Results were good in 14 of the 18 type 2 patients, although 2 retained exce ssive suprapubic fat and 2 had some unsightly scarring. No type 1 or 2 pati ent required additional surgery. Of the 7 type 3 patients 6 had a good resu lt and required no additional surgery. One patient has recurrent concealed penis after 2 procedures and awaits additional surgery. Conclusions: Concealed penis has a varied etiology and requires a flexible surgical approach. The common surgical options in all cases include complet e penile degloving, excising the scarring due to previous surgery, removing excess suprapubic fat, reconstructing the penile skin with local flaps, an d fixing the penile skin at the penopubic and penoscrotal angles.