Phimosis, Adult Circumcision, and Buried Penis 

Updated: Dec 15, 2018
Author: Ryan P Terlecki, MD; Chief Editor: Edward David Kim, MD, FACS 

Overview

Practice Essentials

Phimosis

Phimosis is defined as the inability of the prepuce (foreskin) to be retracted behind the glans penis in uncircumcised males. Depending on the situation, this condition may be considered either physiologic or pathologic. Physiologic, or congenital, phimosis is a normal condition of the newborn male. In 90% of cases, natural separation allows the foreskin to retract by age 3 years.  However, phimosis persisting into late adolescence or early adulthood need not be considered abnormal.

The entity of pathologic, or true, phimosis is far less common and can affect children or adults. This is associated with cicatricial scarring of the prepuce that is often white in appearance. Phimosis may occur after circumcision if redundant inner prepuce slides back over the glans, with subsequent cicatricial scarring and contraction. Adult phimosis (ie, pathologic or true phimosis) may be caused by poor hygiene or an underlying medical condition (eg, diabetes mellitus).

Uncomplicated pathologic phimosis is usually amenable to conservative medical treatment. Failure of medical treatment warrants surgical intervention, usually in the traditional form of a circumcision or preputioplasty.

Adult circumcision

Although phimosis is the most common indication for adult circumcision, other reported indications include the following:

Studies suggest that circumcised boys are at a lower risk of urinary tract infections (UTIs). To put this in perspective, the approximate likelihood of a UTI occurring in the first year of life is 1 in 100 in uncircumcised boys and 1 in 1000 in circumcised boys.[1] A lower risk of malignancy is also reported in studies of circumcised men, although the incidence is also rare in uncircumcised men. Of note, this decreased risk seems to be associated only with infant circumcision and not with adult procedures.

The theory that circumcision contributes to prevention of sexually transmitted diseases (STDs) was encouraged by a 19th-century report of lower rates of syphilis in Jewish men. Studies have demonstrated that human papillomavirus (HPV) infection, including oncogenic HPV infection, is more prevalent in uncircumcised men, regardless of demographics and sexual history.[2]  

Citing a link between the intact prepuce and sexually transmitted infection, some authorities have gone as far as suggesting that circumcision protects against prostate cancer.[3]  Additionally, controlled studies by Tobian et al have shown the efficacy of circumcision in reducing the incidence of herpes simplex virus type 2 infection, and a follow-up study suggested that it may protect female partners from acquisition in men already infected.[4, 5]

Meta-analysis of 3 randomized controlled trials in South Africa,[6]  Kenya,[7]  and Uganda[8]  has demonstrated that circumcision decreases the risk of HIV infection among heterosexual men by nearly 60%.[9]  Data from a mathematical model suggest that routine circumcision in southern sub-Saharan Africa could prevent 2 million HIV infections over 10 years.[10]  

The results of theses studies led the World Health Organization (WHO) and Joint United Nations Program on HIV/AIDS to recommended  the use of voluntary medical male circumcision (MMC) to fight the spread of HIV infection in countries with a low male circumcision prevalence rate and a high HIV prevalence rate.[11]  Analysis of population-based surveys conducted from 1999 through 2013 in 45 rural Uganda communities lent support to this initiative, with findings that MMC coverage increased from 19% to 39% with an associated decrease in HIV incidence from 1.25 to 0.84 per 100 person-years in males.[12]  Further evaluation of these trials has shown no deleterious effects on male erectile function or sexual satisfaction, and 97.1% of female partners reported no change or improved sexual enjoyment after circumcision of their male partner.[13]

The results of the African randomized trials also sparked speculative interest in male circumcision to reduce HIV infection in the United States, especially in areas such as New York City.[14]  Pask et al have suggested that the protective benefit of circumcision against HIV infection may result from removal of Langerhans cells and that enhanced keratinization conferred by topical estrogen may therefore represent an alternative to circumcision.[15]

Other indications for circumcision exist. Genital lichen sclerosus appears to be a disease generally restricted to uncircumcised males and is often cured by circumcision.[16]  Additionally, removal of foreskin remnants has shown to be an effective modality in select patients with premature ejaculation.[17]

Buried penis

Buried penis is a true congenital disorder in which a penis of normal size lacks the proper sheath of skin and lies hidden beneath the integument of the abdomen, thigh, or scrotum. The literature, on occasion, also refers to this condition as a hidden or concealed penis. 

This condition is usually identified in neonates or obese prepubertal boys; however, it can also be seen in adults and has been observed in both circumcised and uncircumcised individuals. Marginal cases may not be diagnosed until adulthood, when increased fat deposition accentuates the problem. In most congenital pediatric cases, the buried penis is self-limited. In untreated adults, however, the condition tends to worsen as the abdominal pannus continues to grow.

Other conditions to consider include the following:

  • Trapped penis is a condition in which the penis becomes inconspicuous secondary to a cicatricial scar, usually after overzealous circumcision. 
  • Webbed penis is characterized by obscuration of the penile shaft by scrotal skin webs at the penoscrotal junction. 
  • Micropenis (also known as  microphallus) represents a penis less than 2 standard deviations below the mean in length when measured in the stretched state. 
  • Diminutive penis is a penis that is small, malformed, or both secondary to  epispadiasexstrophy, severe  hypospadias, chromosomal abnormalities, or intersex conditions.

For patient education information, see the Men's Health Center, as well as Foreskin Problems and Circumcision.

 

Background

Circumcision

Circumcision is one of the earliest elective operations known to man. Historically, this procedure has been performed for various religious reasons, social reasons, or both. The practice is considered a commandment in Jewish law and a rule of cleanliness in Islam, although it is not mentioned in the Quran. Female circumcision, better termed female genital mutilation (FGM), has been practiced for centuries by some cultures but is an unacceptable practice and without medical benefit.

Potential psychological and surgical complications have led to closer scrutiny of routine neonatal circumcision. The American Academy of Pediatrics (AAP) does not recommend routine neonatal circumcision but has concluded that the health benefits of newborn male circumcision outweigh the risks and justify access to this procedure for families who choose it. Specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer.[18]

The American Urological Association (AUA) recommends that circumcision should be presented as an option for health benefits that include prevention of phimosis, paraphimosis, and balanoposthitis, and decreased risk for cancer of the penis. In addition, the AUA noted that for the first 3 to 6 months of life, the incidence of urinary tract infections is at least 10 times higher in uncircumcised than circumcised boys.[1]

Evidence suggests that infant circumcision seems to decrease the risk of penile cancer,[19] whereas later circumcision does not. Penile cancer is a rare disease in the United States, with an incidence of 1.5 per 100,000 males. In developing countries, the incidence is higher; the disease accounts for up to 10% of malignancies in some African and South American nations. Although primarily a disease of older men, penile cancer has been reported in children. The lowest incidence has been reported in Jews, with a similar incidence in Muslims; both groups have high rates of neonatal circumcision.

The main medical indication for circumcision in children is pathologic phimosis. Infants may present with paraphimosis if their parents have retracted the prepuce and failed to pull it forward thereafter. Reduction of the foreskin under sedation is almost always possible. However, in some situations, a dorsal slit or circumcision is required (see Paraphimosis). 

In a prospective long-term study, 40% of boys treated for phimosis were found to have BXO, which has been linked to the development of penile squamous cell carcinoma (SCC).[20]  Although potent topical steroids may allow improvement and slow progression, total circumcision is the treatment of choice for BXO and may be curative.

Recurrent balanoposthitis, which affects 1% of boys, is also considered a relative indication for circumcision. However, this condition tends to be self-limited, and even if balanoposthitis is recurrent, preputioplasty and topical steroids represent alternatives to circumcision.[21, 22, 23, 24]  In patients with balanoposthitis who are sufficiently troubled to warrant surgical intervention, circumcision is always curative.

Circumcision is generally not performed in children born prematurely or those with blood dyscrasias. It should not be performed in children with congenital penile anomalies such as the following:

  • Hypospadias
  • Epispadias
  • Chordee
  • Penile webbing
  • Buried penis

Adult circumcision for phimosis is described in textbooks dating from the early 19th century. Paraphimosis results from abuse or accident, not disease, of the foreskin and can be seen at any age. It represents the second most common indication for adult circumcision. Unrecognized chronic paraphimosis or delay in diagnosis may result in urinary retention or even penile autoamputation.

Other indications for circumcision that are less common include small preputial tumors, multiple preputial cysts or condylomas, and penile lymphedema. A reasonable case may be made for circumcising boys with vesicoureteral reflux (VUR) who suffer from urinary tract infections. In addition, the foreskin may be removed to perform a biopsy of lesions hidden under the prepuce or for definitive radiation therapy for penile cancer.

Occasions arise in which urethral instrumentation—in the form of a cystoscopy or Foley catheterization—is necessary. This may be quite problematic in an adult affected by severe phimosis. In such instances, an emergency bedside dorsal slit can be performed safely and expeditiously. After being discharged, the patient may proceed to undergo formal circumcision.

Buried Penis

The first description of the buried penis was in 1919 by Keyes. The first attempted surgical correction of this problem was by Schloss in 1959; in 1968, successful correction was performed in an adult by Glanz. Since then, numerous techniques to correct buried penis have been developed. 

The primary reason that children are referred for correction of the buried penis is cosmesis. In the neonate, observation seems to be a viable option. Children younger than 3 years have a 58% chance of spontaneous resolution. Some pediatric urologists insist that this condition is a developmental stage that will resolve by puberty and feel that correction should therefore be deferred. Evidence has shown, however, that spontaneous resolution does not always occur. Also, in men and adolescents, measures such as diet and exercise are unlikely to be effective.

Others feel that, after age 3 years, buried penis requires correction. The primary reason cited is the importance of being able to void while standing during the period of toilet training. There are numerous other indications for repair. For example, a concealed penis can hamper proper hygiene, trap urine, and complicate voiding. This can lead to repeated infections, secondary phimosis, or even urinary retention. In addition, numerous investigators feel that children with buried penis are at risk for psychological and social trauma, even from an early age. Obese boys with a buried penis may be ostracized by their peers and withdraw socially. Surgery often relieves anxiety and may improve self-image.

In adults, buried penis tends to worsen over time as they accumulate more fat. The cicatricial scar does not loosen on its own over time. Urinary and sexual complications can greatly affect daily life. Therefore, surgery is likely necessary in these patients.

Relevant Anatomy

The penis is composed of paired corpora cavernosa, the crura of which are attached to the pubic arch, and the corpus spongiosum (see image below). The proximal portion of the corpus spongiosum is referred to as the bulb of the penis, and the glans represents the distal expansion. The urethra traverses the corpus spongiosum to exit at the meatus. The cavernosal bodies produce the male erection when they are engorged with blood.

Cross-section through the body of the penis. Cross-section through the body of the penis.

The fascial layers of the penis are continuous with the fascial layers of the perineum and lower abdomen. Dartos fascia represents the superficial penile fascia. Deep to this lies the Buck fascia, which covers the tunica albuginea of the penile bodies. Proximally, the Buck fascia is in continuity with the suspensory ligament of the penis, which attaches to the symphysis pubis.

The penis is supplied by a superficial system of arteries that arise from the external pudendal arteries and a deep system of arteries that stem from the internal pudendal arteries (see images below). The superficial blood supply lies in the superficial penile fascia and supplies the penile skin and prepuce. The internal pudendal artery, which arises from the hypogastric artery, gives rise to the penile artery. The penile artery then gives rise to the bulbourethral artery, the urethral artery, and the cavernous artery (deep artery of the penis) before terminating as the dorsal artery of the penis.

The arterial blood supply of the penis arises from The arterial blood supply of the penis arises from the internal pudendal artery. The internal pudendal artery gives off branches to the bulbar artery, cavernosal artery, and dorsal penile artery. The bulbar artery continues on as the bulbourethral artery to supply the urethra. The cavernosal artery gives rise to the helicine arteries that are end arteries. The dorsal artery of the penis gives branches off to the circumflex arteries.
Dorsal view of the arterial and venous blood suppl Dorsal view of the arterial and venous blood supply of the penis.

Somatic nerve supply to the penis comes by way of the pudendal nerves, which eventually produce the dorsal nerves of the penis on each side. Although cutaneous innervation to the penis is primarily from branches of the pudendal nerve, the proximal portion is supplied by the ilioinguinal nerve after it leaves the superficial inguinal ring. The prepuce has somatosensory innervation by the dorsal nerve of the penis and branches of the perineal nerve. The glans is primarily innervated by free nerve endings and has poor fine-touch discrimination.

Pathophysiology

Phimosis

The foreskin of an uncircumcised child should not be forcefully retracted. This may result in significant bleeding, as well as glanular excoriation and injury. Consequently, dense fibrous adhesions may form during the healing process, leading to true pathologic phimosis.

Adult phimosis may be caused by repeated episodes of balanitis or balanoposthitis. Such infections are commonly due to poor personal hygiene (failure to regularly clean under the foreskin).

Phimosis may be a presenting symptom of early diabetes mellitus. When the residual urine of a patient with diabetes mellitus becomes trapped under the foreskin, the combination of a moist environment and glucose in the urine may lead to a proliferation of bacteria, with subsequent infection, scarring, and eventual phimosis.

Buried penis

The penis is properly formed by 16 weeks' gestation. Congenital buried penis is caused by a developmental anomaly in which the dartos fascia has not developed into the normal elastic configuration to allow the penile skin to move freely over the deeper tissues of the penile shaft. Instead, the dartos layer is inelastic, which prevents the forward extension of the penis and holds it buried under the pubis.

Other possible contributing factors to congenital buried penis include excess prepubic fat, scrotal webbing, deficient penile skin, loose skin, an abnormally low position at which the crura separate, abnormal attachments between the Buck fascia and the tunica albuginea, and insufficient attachment of dartos fascia and skin to the Buck fascia.

The pathophysiology of buried penis in adults differs from that in children and includes iatrogenically induced scar contracture with concurrent descent of the abdominal fat pad. Because the penis is suspended from the pubis by the suspensory ligament, it remains fixed, unlike the prepubic fat. As fat descends over the penis, excessive moisture and bacterial overgrowth may occur. Chronic infection may lead to skin maceration and more scar contracture, further aggravating the problem. In many children, this condition is self-limited. However, in adults, total body fat content typically increases with age, causing the buried penis to worsen over time.

Etiology

Phimosis

Physiologic phimosis is the rule in newborn males. Formation of the prepuce is complete by 16 weeks' gestation. The inner prepuce and glans penis share a common, fused mucosal epithelium at birth. This epithelium separates via desquamation over time as the proper hormonal and growth factors are produced. Thus, neonatal circumcision is a surgical treatment of normal anatomy.

Pathologic, or true, phimosis has several different etiologies. The most common cause is infection, such as posthitis, balanitis, or a combination of the two (balanoposthitis). Diabetes mellitus may predispose to such infections.

Adult circumcision is most commonly performed to correct phimosis. When circumcision is performed for phimosis, 25%-46% of removed foreskins are histologically normal. Other indications for adult circumcision include the following:

  • Infection without phimosis
  • Paraphimosis
  • Bowen disease
  • Carcinoma
  • Condylomas (warts)
  • Trauma
  • Religious or social reasons
  • Disease prophylaxis (eg, HIV infection)
  • Personal preference

Buried penis

Various etiologic factors have been proposed to explain congenital buried penis. Recent literature favors dysgenetic dartos tissue with abnormal attachments proximally and to the dorsal cavernosum. A prominent prepubic fat pad is also a common primary factor, in addition to dysgenetic dartos fascia. Secondary buried penis may be the result of an overzealous circumcision with subsequent cicatricial scar (trapped penis), a large hernia, or a hydrocele.

Adults with buried penis are commonly obese and often have a history of trauma or surgery. There is an observed association with diabetes mellitus, which may aggravate the pathologic process. Another additive factor in select patients includes the significant laxity of abdominal skin following gastric bypass.[25] Adults with this condition may have undergone abdominoplasty with overzealous release of attachments between the scarpa and dartos fasciae, penile-lengthening procedures, or other genitoinguinal surgeries.

Another possible cause of buried penis in the adult is genital lymphedema. This may be idiopathic, iatrogenic (from prior surgery), or acquired due to filariasis.[26]  When massive scrotal lymphedema infection is the cause of buried penis, it is most likely secondary to infection that causes obstruction or aplasia of the draining lymphatic system. This massive lymphedema encases the penis. The most common infections are lymphogranuloma venereum and filarial infestation with Wuchereria bancrofti, which are seen in African and Asian populations but rarely in the United States or Europe.[27]

Epidemiology

Approximately 1 in 6 men in the world are circumcised. In the United States, the estimated prevalence of circumcision in men and boys aged 14 to 59 years was 80.5%, based on data from the National Health and Nutrition Examination Surveys 2005-2010. [28]

Nearly all males are born with physiologic phimosis. Data have shown that the foreskin is retractable in 90% of boys by age 3 years. Only 1% of boys have physiologic phimosis that persists until age 17 years. Thus, most healthy adult men should not have phimosis; the presence of the disorder in an adult male should raise the suspicion of balanitis (infection of the foreskin), balanoposthitis (infection of glans and foreskin), diabetes,[29] or malignancy.

Congenital buried penis is uncommon. The incidence of buried penis in adulthood is unknown, but it is highly likely that many cases go unreported.

Prognosis

Phimosis does not recur after proper circumcision. If too much penile skin is left, a repeat circumcision may be necessary for medical or cosmetic reasons. In adults, some permanent skin-color discrepancy along the suture line of the circumcision may occur. Overall, careful attention to proper surgical technique will allow for a pleasing cosmetic result.

Reported results of buried-penis repair in pediatric and adult cases have generally been good. Surgery often provides immediate excellent cosmetic results with low rates of complications. Brisson et al (2001) contend that both patients and their parents derive psychological benefits from the procedure.[30]  This assertion seems to be confirmed by postoperative surveys. In addition to improved confidence, improvement in personal hygiene and voiding result from buried-penis repair in both pediatric and adult patients. Adult patients often also report improved sexual performance.

 

Presentation

History

Phimosis

Congenital or physiologic phimosis is clinically asymptomatic so is not a cause for concern. It is often associated with "ballooning" of the foreskin during voiding. This is a self-limited phenomenon that, in the absence of pathologic phimosis, does not indicate urinary tract obstruction. Pathologic, or true, phimosis is far less common. Symptoms include skin irritation, dysuria, bleeding, and occasionally enuresis or urinary retention. Physical examination usually reveals white cicatricial scarring at the preputial ring. 

Pathologic phimosis may be due to balanitis xerotica obliterans (BXO), a genital form of lichen sclerosus et atrophicus. This condition affects both men and boys and represents an absolute indication for circumcision, which may be curative. The etiology of BXO is unknown, and it may represent a premalignant state. Clinically, it presents as severe phimosis and possibly meatal stenosis, glanular lesions, or both.

In older men, when the phimosis is severe, the distal foreskin often appears swollen and erythematous with cracked fissures (see image below). Men who are affected report pain and discomfort during sexual activity or when they attempt to retract the foreskin. Unlike in the pediatric population, lower urinary tract voiding symptoms are absent. In older men, acquired phimosis is often associated with poor hygiene but may be a product of diabetes mellitus.

In a prospective study comparing 28 men with acquired phimosis and preputial fissures to 28 controls with acquired phimosis without preputial fissures, the incidence of undiagnosed diabetes with a combination of acquired phimosis and preputial fissures was 100% compared to a 7.1% incidence of diabetes in patients with acquired phimosis but no preputial fissures. The researchers noted that over 60% of the cohort studied were younger than 45 years old and concluded that phimosis with preputial fissures was a specific sign of undiagnosed DM in young men. Patients presenting with phimosis and fissures should undergo serum testing for diabetes.[31]

Phimotic foreskin. The distal foreskin is edematou Phimotic foreskin. The distal foreskin is edematous, with cracked fissures. The patient was unable to retract the foreskin.

Buried penis

Most pediatric cases of buried penis present in neonates or prepubertal boys. The most common age range of patients at presentation is 6 months to 1 year. Adolescents who present with buried penis are usually obese, and weight loss should be advised. Patients may be uncircumcised or circumcised; the latter complicates repair. One series found that 77% of children presenting with buried penis had been previously circumcised, emphasizing a need for pediatric urologists to educate primary care physicians.

The reasons for presentation vary. Often, parents are concerned because they are unable to see the penis, which may also complicate proper hygiene. Occasionally, they may witness ballooning of the foreskin with voiding, and children may be persistently wet if they are voiding into the preputial sac.

Adolescents may report dysuria, dribbling between voids, trouble directing their urinary stream because of difficulty holding the penis, or embarrassment in the locker room. Some patients have a history of balanitis and balanoposthitis, and some have undergone a radical circumcision or even multiple circumcisions.

In addition to some of the symptoms seen in children, adults may present with sexual complaints. These include painful erection, sexual embarrassment, and difficulty with vaginal penetration, especially if the tip of the glans does not project past the male escutcheon. This condition may lead to the inability to void in a standing position and may cause the patient to soil himself while urinating in the seated position. Obesity and diabetes mellitus are commonly associated comorbidities.

When massive scrotal lymphedema is present in adults, a complete history should be obtained. Patients should be questioned on recent travel to Asia or Africa, which are endemic to lymphogranuloma venereum and Wuchereria bancrofti infestation, the most common infections seen in massive scrotal lymphedema. A history of recurrent epididymitis also may play a role.[27]  

 

Physical Examination

All uncircumcised adult men should have the foreskin retracted to exclude occult carcinoma as a part of a complete urologic examination. Squamous cell carcinoma of the penis may manifest as an ulcerated fungating mass of the glans or the prepuce. Alternatively, carcinoma in situ or penile carcinoma may appear as a velvety macular lesion of the glans (erythroplasia of Queyrat) or the penile shaft (Bowen disease).

Phimosis

Physical examination usually reveals white cicatricial scarring at the preputial ring. 

Meuli et al devised the following scoring system to rate the severity of phimosis:[32]

  • Grade I - Fully retractable prepuce with stenotic ring in the shaft

  • Grade II - Partial retractability with partial exposure of the glans

  • Grade III - Partial retractability with exposure of the meatus only

  • Grade IV - No retractability

Buried penis

On physical examination, which should include a supine evaluation, the penis may be concealed because it is buried in prepubic tissues; buried and enclosed in scrotal tissue (penis palmatus); trapped by phimosis, traumatic scar tissue, or postcircumcision cicatrix; or hidden secondary to a large hernia or hydrocele. A smooth transition from prepubic to penile skin indicates a buried penis. Trapped penis demonstrates a circumferential groove at the base of the penis. 

 

Treatment

Medical Care

Phimosis

Applications of steroid creams (0.05% betamethasone) have been used to manage phimosis medically.[33]  The usual regimen is application of the steroid cream once or twice daily for 4-6 weeks. Studies have shown a success rate of 87% with this treatment. Higher rates of success have been reported with concomitant preputial stretching exercises.

If a patient has concomitant balanitis or balanoposthitis, depending on the etiology, he may be treated with topical antibiotics or antifungals. Patients with diabetes mellitus should be advised on proper serum glucose control.

Buried penis

Buried penis cannot be treated medically. The separate entity of trapped penis following neonatal circumcision has been successfully treated with topical betamethasone and manual retraction.

Surgical Therapy

Phimosis

In the United States, circumcision is the surgical treatment of choice for correction of phimosis. In European countries, however, preputioplasty is often used. Although these techniques are outside the scope of this discussion, patients should be aware that these prepuce-preserving methods exist.

Adult circumcision can be performed under local or regional anesthesia and commonly involves either the dorsal slit or the sleeve technique. In China, however, standardization with a device known as the Shang Ring has proven effective, with a substantial decrease in both operative time and anesthetic requirements.[34] The dorsal slit is often useful in patients with phimosis, and the sleeve technique may allow for better hemostasis in patients with large subcutaneous veins.

A properly performed circumcision eliminates phimosis, as well as the risks of paraphimosis and frenular tears or bleeding associated with sexual intercourse.

Buried penis

Numerous techniques have been described for repairing the buried penis. Variations have been proposed for different presumed etiologies and to simplify the procedure. Recurrence and the need for subsequent procedures are possibilities. While the challenge of repair may seem daunting for most general urologists, reconstructive experts have reported unanimous success of a lasting nature.[35, 36, 37, 38]

 

Preoperative Details

Obtaining proper informed consent before the procedure is critical. In particular, inform patients of potential risks, which include bleeding, hematoma formation, infection, suture disruption, inadvertent injury to the urethra or glans, removal of too much or too little skin, and a change of sensation during intercourse.

With regard to surgery for the buried penis, patients should be aware of a 1-15% chance of recurrence (secondary concealment) that may necessitate reoperation. Risk factors specifically relating to the correction of a buried penis in adults include a predisposition to erectile dysfunction and loss of sensation over the skin-grafted area for those presenting with eroded penile shaft skin secondary to inflammation and bacterial infections.[27]  

Patients undergoing circumcision for recurrent balanitis should be free from infection before the procedure.

Intraoperative Details

Surgical repair for phimosis

With the patient in a supine position, the genital area is prepared with povidone-iodine solution. Shaving or clipping of the pubic hair is usually unnecessary.

A general anesthetic is recommended in children. A local anesthetic may be used in adults. Local anesthesia is accomplished by administering a dorsal penile nerve block followed by a ring block.

A mixture of equal volumes of 0.5% bupivacaine (Marcaine) and 1-2% lidocaine (Xylocaine) without epinephrine is common. A potential complication of epinephrine use is local tissue ischemia. The maximum recommended dose of lidocaine without epinephrine is 4.5 mg/kg, or 315 mg in a 70-kg male.

Dorsal slit circumcision

To perform the dorsal slit circumcision, clamp the foreskin at the 12-o'clock position with 2 straight hemostats to limit bleeding. See image below.

Dorsal-slit technique. The redundant foreskin is c Dorsal-slit technique. The redundant foreskin is clamped at the 12-o'clock position for 2 minutes for hemostasis.

Sharply incise the tissues between the 2 clamps perpendicular to the corona. Make the proximal circumscribing incision. See images below.

In the dorsal-slit technique, the clamped foreskin In the dorsal-slit technique, the clamped foreskin is incised sharply between the 2 hemostats.
The dorsal slit is being completed, and the circum The dorsal slit is being completed, and the circumscribing incision (proximal skirt) has been made.

Excise the foreskin at its base (approximately 1 cm proximal to the coronal sulcus) with scissors to produce a cosmetically attractive circumcised penis. The amount of skin left below the coronal sulcus should be no more than 1 cm long to prevent edema, adhesions, and, occasionally, paraphimosis. See image below.

Dorsal-slit technique. Redundant foreskin has been Dorsal-slit technique. Redundant foreskin has been excised. The distal circumcision incision is 1 cm from the coronal sulcus.

Ligate superficial veins and obtain hemostasis with electrocautery.

Circumferentially approximate the proximal and distal edges of the foreskin with 4.0-5.0 absorbable sutures (children) or 3.0-4.0 absorbable sutures (adults) in an interrupted fashion. See image below.

Dorsal-slit technique. Proximal and distal skirts Dorsal-slit technique. Proximal and distal skirts are approximated circumferentially with absorbable sutures in an interrupted fashion.

During the circumcision, the use of a thin tapered (noncutting) needle is recommended because it is less traumatic to the tissues and causes less bleeding.

Bacitracin ointment is used to lubricate the suture material (eg, chromic) to facilitate passage of the suture through the delicate skin tissues. This is especially helpful in the pediatric population. Alternatively, mineral oil may be used as a lubricant.

Sleeve technique

The sleeve technique is an attractive alternative for circumcision.

After proper anesthesia has been achieved, mark the redundant foreskin with a marker.

Before making the initial incision, take care to measure out the correct amount of foreskin to be removed. This is accomplished by gently stretching out the penis with an index finger applied to the penoscrotal junction and noting the indentation of the coronal sulcus through the penile skin.

Outline the coronal sulcus with a marker. This is the proximal skirt of the circumscribing incision. The distal skirt of the circumscribing incision is approximately 1 cm proximal to the corona. When this is properly performed, a sleeve of foreskin is present between the 2 incisions, and the remaining penile skin does not remain too short or too long. See images below.

In the sleeve technique, the circumcision is start In the sleeve technique, the circumcision is started by making a circumscribing proximal incision. The incision is carried down to the Buck fascia.
In the sleeve technique, a distal incision is made In the sleeve technique, a distal incision is made 1 cm proximal to the coronal sulcus.

Clamp the redundant foreskin between the circumcision incisions at the 12-o'clock position and incise it. See image below.

Sleeve technique. Redundant foreskin is clamped at Sleeve technique. Redundant foreskin is clamped at the 12-o'clock position with 2 straight hemostats. Next, the foreskin is incised between the 2 hemostats.

Remove the sleeve by using electrocautery. See image below.

Sleeve technique. The excess foreskin is peeled of Sleeve technique. The excess foreskin is peeled off. The shaft of the penis is displaced downward using a stack of sponges as the redundant foreskin is removed.

Obtain hemostasis with cautery and ligatures. If circumcision has been performed properly, the proximal and distal skirts should approximate well without tension. See image below.

Sleeve technique. Excess foreskin has been removed Sleeve technique. Excess foreskin has been removed completely.

Once hemostasis has been achieved, circumferentially approximate the edges of the foreskin with 3.0-5.0 absorbable sutures in either a running 4-quadrant closure or an interrupted fashion. Admittedly, while a sutured closure is most commonly used, 2-octyl cyanoacrylate (2-OCA; Dermabond, Ethicon) represents an alternative.[39] Correct technique allows for proper cosmesis. See images below.

Sleeve technique. The edges of the penile skin are Sleeve technique. The edges of the penile skin are approximated with absorbable sutures.
Sleeve technique. The circumcision is completed wi Sleeve technique. The circumcision is completed with excellent cosmetic result.

Surgical techniques for buried penis

In pediatric cases, sources have described the essential nature of dividing dysgenetic dartos bands and fixation of the dartos fascia to the Buck fascia dorsally in the midline, ventrally over the corpus spongiosum, and proximally along the penile shaft. Care must be taken to avoid injury to either the urethra or the neurovascular bundles.

Defatting of the mons pubis is an essential step in buried penis repair in adult patients, but opinions vary as to the value of its removal in children. This can be achieved by excisional lipectomy, liposuction, or a combination thereof.[40] The same controversy exists regarding whether or not to take down the suspensory ligament. In the authors’ experience, this is rarely necessary and may lead to instability of the erection.

In 2004, Frenkl et al described a simple technique for the repair of buried penis in children, as follows:[41]

  • First, a traction suture is placed in the glans, and local anesthetic is instilled along the subcoronal circumference.

  • A circumcision incision is then used, and, using the Buck fascia as the dissection plane, the penis is degloved to the penopubic junction.

  • As the next step in the operation, numerous authors describe sharp dissection of dysgenetic dartos fibers.

  • Fixation is then performed between the Buck fascia and the dermis at the base of the penile shaft with 5-0 sutures at the 3- and 9-o'clock positions.

  • The circumferential incision is then reapproximated at its origin with interrupted absorbable suture.

Cromie et al (1998) applied a similar technique in adults for correction of buried penis that involved making a circumferential incision of the inner preputial skin layer proximal to the corona, unfurling the incised skin from the penile shaft, and leaving a coronal collar of approximately 1 cm.[42]

Brisson et al (2001) add a longitudinal incision on the penile shaft ventrally, along the median raphe. They utilize this exposure to allow for additional points of fixation between the skin and the tunica albuginea.[30]

In 1998, Donatucci and Ritter reported their technique for correction of buried penis in adults as follows:[43]

  • If a pannus is to be resected, the amount to be removed is estimated with consideration of avoiding undue tension upon closure. Both liposuction and panniculectomy have been used in these operations. Generally, if excess skin with poor tone is present, panniculectomy should be performed instead of liposuction.

  • Resection is done in an elliptical fashion down to the mons pubis, which is mobilized to the base of the penis. The mons pubis is then resuspended with sutures between the superficial fascia at the penile base and the deep fascia of the abdominal wall. The wound is closed over a drain with gentle pressure over the pubic area.

  • A traction suture is placed in the glans to facilitate dissection, and a Foley catheter is used to protect the urethra. The scar contracture is released, and the penis is degloved to the base along the Buck fascia, with preservation of neurovascular bundles. Adhesions are separated as they are encountered, and chordee is corrected.

  • Artificial erection is used to confirm chordee correction and to determine tissue needs for optimal construction. This maneuver is performed using a Penrose drain as a tourniquet at the penile base and injecting 50-100 mL of sterile saline into the corpora cavernosa with a 21-gauge butterfly catheter. If adequate length is not obtained, the suspensory ligament is divided and resuspended from the symphysis pubis with 1-0 silk sutures with the penis in traction.

  • If a patient has a minimal deficiency of longitudinal penile skin, a plasty rearrangement of this skin can often be accomplished. If a severe deficiency of skin is appreciated, a split-thickness skin graft may be used, either from a panniculectomy specimen (if available) or from the lateral thigh.[44] (Other authors, such as Chopra et al [2002], feel that a full-thickness skin graft is more appropriate.[45] ) Once fixation between the skin, dartos, and tunica albuginea at the base of the penis has been performed, as described above, skin grafts are applied in spiral fashion. If the wound bed is inadequate for grafting because of scarring, the use of flaps may be considered.

  • A penile block at the conclusion of the procedure may provide better postoperative pain control.

A more recent description has described a W-shaped excision that may allow for minimal dog-ear deformity.[46]

Postoperative Details

Adult circumcision

Following adult circumcision, many urologists choose not to use a dressing. However, either petroleum jelly and sterile gauze or Xeroform petrolatum gauze may be wrapped around the penis circumferentially, followed by application of sterile gauze and a nonadhesive elastic wrap.

In adults who have undergone circumcision, discharge medications should include oral narcotics. The dressing is removed 24-48 hours after surgery. The patient should wear loose-fitting briefs after surgery, and he may shower but should wash gently around the incision site.

Full recovery may require 4-6 weeks of complete sexual abstinence.

Buried-penis surgery

Following surgery for buried penis with skin grafting, the authors’ preference is to use a vacuum-assisted closure, negative-pressure dressing in addition to an indwelling Foley catheter. Pressure of 75 mm Hg is maintained for 5 days, with the patient on bed rest. Upon removal, the patient is discharged with a regimen of petroleum gauze dressing changes.

In patients who have undergone panniculectomy, a pressure garment may be worn over the surgical site for 4-6 weeks. In patients who have undergone liposuction, a pressure dressing is left in place for 7 days.

Children have few restrictions after surgical correction of the buried penis. Adults, however, must refrain from strenuous activity, heavy lifting, and sexual activity for 6 weeks after operation. Despite avoidance of sexual activity, erections are encouraged to avoid subsequent restriction by graft contraction.

Complications

Circumcision

Circumcision is a safe surgical procedure that is well tolerated in nearly all patients. However, as with any surgical procedure, complications are possible. Examples include bleeding, infection, hematoma, swelling/lymphedema, pain, and poor cosmesis. Certainly, given the risk of adverse events, circumcision should be performed only by competent medical professionals, as cases of self-circumcision by members of the general public have produced tragic outcomes.[47]

Postoperative bleeding is the most common complication. It usually occurs when a scab is pulled off as the dressing is being removed. However, sutures can also be torn by erections before healing is completed. Bleeding can often be controlled with direct pressure. Rarely, electrocautery or ligature is required.

Infection after circumcision is uncommon and, if encountered, may be treated with local or oral antibiotics.

Urethral injury is extremely rare. A urethral injury that can result from circumcision is a subcoronal urethrocutaneous fistula. This condition necessitates surgical correction.

Suture sinus tracts can occur if a simple suture becomes epithelialized before suture absorption. These frequently go unnoticed and are likely inconsequential.

Postoperative adhesions may lead to formation of skin bridges between the circumcision incision and the glans. These adhesions are typically on the dorsal surface and therefore may present an obstacle to proper hygiene.

The most devastating complication associated with circumcision is amputation of the penile shaft. A recent report detailed repair of such complications by corporal advancement with accompanying fat flap interposition and skin grafting.[48] It is also possible to inadvertently remove an excessive amount of foreskin, requiring either grafting or a flap reconstruction. Another postcircumcision complication, although rare, is keloid formation. While topical application of steroids has been used, surgical excision remains the standard modality of treatment.[49]

A study by Fink et al (2002) examined the sexual effects of adult circumcision.[50] They found that circumcision in the adult appears to result in worsened erectile function and decreased penile sensitivity. However, sexual activity did not change, and satisfaction was actually improved. Given that 93% of the patients in that study underwent surgery for pathology, circumcision may have alleviated enough sexual apprehension to allow unmasking of previously unidentified erectile dysfunction. Although many investigators feel that circumcision reduces penile sensitivity, an increase in ejaculatory latency time may, in some cases, be considered an advantage.

Some have speculated that the mucosal cuff length following circumcision may be associated with premature ejaculation. However, an evaluation of 84 men found no association between these entities and concluded that circumcision has no deleterious effect on sexual function.[51] Furthermore, recent reports of a direct comparison between circumcised and uncircumcised men found no difference in genital sensitivity.[52]

In evaluating the effect of circumcision on a woman's sexual enjoyment, O'Hara et al (1999) reported that the women surveyed preferred intercourse with uncircumcised men.[53] The authors suggest that coitus with a circumcised partner reduces vaginal secretions and decreases continual clitoral stimulation. However, a number of the women surveyed were recruited via the newsletter of an anticircumcision organization.

Buried penis

Correction of the buried penis is a simple and effective procedure with few recurrences or complications. Two series that reported on the long-term outcome of pediatric cases found that the correction resulted in excellent long-term cosmetic results. Higher success rates were found in patients who had the correction as toddlers than in those who had the correction as adolescents. Herndon et al (2003) found that most parents felt that the surgery eliminated associated negative feelings and that it enhanced penile appearance and facilitated better hygiene.[54]

Most of the complications reported after surgery for buried-penis correction are temporary. Reported rates of recurrent retraction, however, range from 1-15% and often require additional surgery. Observation is a viable option for mild cases. Ventral edema has been reported in 1-11% of cases and usually resolves spontaneously. Dissatisfaction with cosmesis is possible, but the physician should preoperatively assess for unrealistic expectations. Postoperative sexual dysfunction has been reported, but conditions predisposing to buried penis often carry a higher likelihood of erectile dysfunction.

Studies in an animal model show that buried penis may induce microscopic changes related to erectile dysfunction, including decreased activity of nitric oxide synthase and loss of smooth muscle.[55] These changes seem to be directly related to the duration of the condition. Pain upon erection may be seen with suturing of the Buck fascia to the pubic periosteum. Additionally, it needs to be recognized that the area of the skin graft will be insensate.

Patients who have undergone penile reconstruction may present with poor graft healing, flap necrosis, or complaints of decreased sensitivity in the grafted area. Patients may also present with persistent redundancy of the penile skin or reaccumulation of the abdominal fat pad.

Diet

Adult patients undergoing surgery for a buried penis are often obese (BMI >30), even with substantial weight loss or weight loss surgery, the overhanging suprapubic pad that is secondary to obesity remains in adults. Whether or not the overhanging panniculus will be removed with weight loss, it is still imperative to educate and advise these patients on increasing physical activity, improving diet, and achieving weight loss before surgery to minimize obesity-related surgical complications.[27]  

Long-Term Monitoring

Routine follow-up after adult circumcision is advisable, but not mandatory. Patients may be seen 2-3 weeks after the operation so that the incision can be examined to see if it has appropriately healed. Following buried-penis repair, both pediatric and adult patients may be seen at 2 and 6 weeks after surgery.