Adult Acquired Buried Penis Repair

What is a buried penis?

A buried penis is a penis that cannot be seen when standing because of surrounding adipose (fat) tissue or swelling (edema). Though many obese men have a buried penis, most do not require any special treatment. If the buried penis causes issues with urinary tract infections, sexual functioning, or hygiene, then repair should be considered after having a discussion with your urologist.

What symptoms can a buried penis cause?

Symptoms depend on the severity of the condition. They are:

  • Urinary tract infections.
  • Sex organ pain (pain with erection, ejaculation).
  • Trouble with erections.
  • Dribbling of urine.
  • Not being able to expose penis (or pain when trying to expose the head of the penis).
  • Infections of the head of the penis.
  • Greater risk for penile cancer.
  • Poor cosmesis.

What causes a buried penis?

There are many causes of a buried penis:

  • Obesity: Obesity is the most common cause of adult-acquired buried penis. If the fat tissue extends beyond the head of the penis:
    • Urine and moisture are hard to clear if the penis cannot be exposed.
    • Trapping of moisture and urine leads to chronic inflammation.
    • Inflammation and infection cause scarring of the genital tissue. This makes it harder to expose the penis. This condition is often called “phimosis.”
  • Lichen Sclerosus: This is inflammation that affects the genitals and anal region. It leads to scar tissue. It happens often with a buried penis. It causes pain and irritation on the tip of the penis or foreskin. This skin can also have pale, white patches.
  • Genital lymphedema: This is not common. It happens with a break in the normal lymphatic channels. Lymphatics are small vessels that return fluid to the circulatory system. They also do other jobs. Fluid collects when the channels are disrupted. This leads to the scrotum getting bigger. Genital lymphedema is common in men that have had surgery or radiation for cancer that has extended into their lymph nodes:
  • Circumcision: If too much skin is removed at the time of circumcision, this can bury the penis.

How will my buried penis be treated?

There are many ways to treat a buried penis. Most treatment decisions are based on the goals of the patient. Common goals for patients with a buried penis are.

  • Being able to stand to urinate with an exposed penis.
  • Being able to use their penis for sex.
  • Be able to clean the tip of the penis and scrotum after urination to help with hygiene.

Each person’s case and their goals will help decide the best surgical repair.

  • Prior surgery can change the choices.
    • People with a buried penis who have been circumcised often need a skin graft.

Conservative (Less invasive) Treatments

  • Weight Loss: For men that have not attempted weight loss, it is recommended that prior to any surgical procedure to help with their buried penis that a weight loss program be started. Your urologist may refer you to a dietician. They may also refer you for bariatric surgery (gastric bypass). However, weight loss alone is usually not enough to unbury the penis.
  • Topical steroid cream: For men with a buried penis caused by a tight band of skin around the penis, a steroid cream can be applied to the skin twice daily to help “loosen” the skin.
    • For this treatment to be successful, it takes motivation. You will need to pull back the nearby tissue to expose your penis. You need to do this many times each day with the steroid cream.
    • This does not remove the extra tissue around the penis.
    • This can take weeks to months to work.
    • Unfortunately, many people cannot expose their penis enough for this. This happens if the scar tissue band is too dense or with too much extra tissue.
  • Penile skin incisions: (also known as dorsal slit, or revision circumcision): This can be a good option if a person:
    • Has a mild condition.
    • Is not healthy enough to have a major surgery.
    • For this procedure:
      1. One or more cuts are made through the scar tissue of the penile skin.
      2. The skin edges are arranged to open up the scar tissue.
      3. This exposes the penis.
    • Similar to the steroid cream, this procedure takes motivation. You will need to pull back on the nearby tissue to expose your penis many times daily.
    • Minor skin separation is common. It does not need more than antimicrobial ointment.
    • Importantly, this procedure does not remove the extra tissue around the penis. It exposes the penis by opening the scar tissue.

Definitive Treatments

  • You will need pre-op testing of your health status before surgery. Tests often are:

    • Electrocardiogram (ECG/EKG). This is to check that your heart is healthy enough for surgery.
    • Blood work. To check that your other organs are working the right way. To make sure that your blood levels are high enough.
    • Chest X-ray. To make sure that your lungs are healthy enough for surgery.
    • Medication Review. To check that your blood pressure is controlled. To check that you stop medications that can lead to bleeding before surgery. These are coumadin, aspirin, and clopidogrel.
    • You will need to stop all tobacco products before your surgery. This is cigarettes, chewing tobacco, vaping products, and nicotine gum. A urine test is often done on the day of surgery to prove this.
  • Buried penis repair surgery: The surgery will differ from person to person and will depend on the shape of your body and the health of the skin that covers your penis.
    • Your urologist will take pictures of your buried penis before surgery. These pictures are helpful for three reasons
      1. The pictures can help your urologist classify the type of buried penis you have
      2. The pictures will help plan the type of surgery that will be performed
      3. The pictures are often necessary for your insurance company to approve the surgery. .
    • The primary goal of the surgery is to expose the head of your penis. Exposure of the penis will help with urination, sexual function and hygiene (keeping the area clean).
    • The procedures often required to help expose the head of the penis include the following:
      1. Panniculectomy: The pannus is the tissue from the abdomen that can sometimes hang over the penis. For most buried penis repairs, this tissue will be left in place. If it is removed, this will require a plastic surgeon
      2. Escutcheonectomy: The escutcheon is also called the mons pubis. It is the tissue that just above the penis and below the pannus. This tissue is often removed at the time of buried penis repair.
      3. Scrotectomy/Scrotoplasty: If the scrotum is enlarged and is burying the penis, some of the scrotal tissue will need to be removed.
      4. Split-thickness Skin Graft: Once the penis has been exposed, your surgeon will determine if enough healthy skin is still remaining on the penis. Sometimes unhealthy tissue will need to be removed and then covered with skin from other areas of the body. In most cases, this skin can come from the tissue already being removed on the abdomen. Other times, the skin will come from the leg.

What should I expect on the day of my surgery?

  • Days or weeks before your surgery, you will get general details. This will be where and when to check in at the hospital. You will be told by phone call of the exact time to come. This will be 2 business days before to your surgery.
  • Call us if:
    • It is 2 business days before surgery, and you have not had a phone call.
    • If you have any questions.
    • Call 319-384-8008.
  • Most buried penis repair surgeries last 2 to 3 hours. An extra hour is needed for anesthesia, surgical positioning, and waking up.

What are the possible complications of my surgery?

Major complications are rare. With any surgery, some risks are:

  • Infection. People will get antibiotics before surgery. This lowers the risk of surgical-site infection. Infections after urology procedures can happen in the cut or in the urine. They often happen 3 days after surgery. Signs are fevers, chills, and redness around the wound. Antibiotics alone clear up most infections. Cuts can need to be opened for draining with some infections.
  • Skin separation. Skin infections, trauma, significant swelling, and tension on cuts can separate the skin. This can cause the wound to open. This will need packing or use of a wound-vac. Specially trained wound nurses will help with care instructions.
  • Bleeding. Injury to big vessels does not happen with this surgery. There can be a lot of blood loss. This is because of all of the small vessels involved with this surgery. The rate of blood transfusions is low for this procedure. We expect bloody drainage from the cuts for a few days after the procedure.
  • Damage to nearby structures. The penis, testicular cords and testicles are close in this surgery. There may be damage them. They can be fixed during surgery.
  • Poor Skin Graft Take. A skin graft on the penis needs a lot to happen to survive. If the graft does not survive, there can be graft loss. This is often minor and only needs normal skin care.
  • Neurologic injury or positioning injury. For surgery, pressure points on the body get pads. Positioning of the arms and legs happens to avoid nerve injury. Even with this, neurologic injuries can still happen. Most injuries will go away in the days to weeks after surgery. Some may need more intense rehab. Almost 100 out of 100 will go away with time and rehab. These injuries are more common with longer operations. This means surgery more than 6 hours.
  • Need for more procedures. Even with our best efforts a single surgery is not enough. This can be due to fluid or too much tissue around the penis. Sometimes people do not expose the penis during recovery. With this, scar tissue stops the penis from being exposed.

How many nights will I spend in the hospital?

  • Most people will spend 1 to 2 nights in the hospital.
    • If a wound-vac is placed, you will stay 4 to 5 days. A wound-vac is a machine used to put suction to skin graft
  • People often leave the hospital after they:
    • Are able to have solid food.
    • Be mobile without help.
    • If none was needed before surgery.
    • You have pain control with oral medications.

What will my incision(s) look like?

The exact cut will look different for each person. It depends on their body. A large cut is made by the waist and the top of the scrotum. With a skin graft, that part of the penis will also have a cut.

Will I have any tubes coming out of me after surgery?

This will depend on your procedure.

  • Foley catheter. This will empty your bladder. It will stay in place until your penile bandage comes off.
  • Jackson-Pratt (JP) drain. This will empty built up fluid or blood from the surgery site. Most JP drains come out before you go home. Sometimes we will keep a drain longer. You will need to record the amount that drains each day. We will teach you how to care for your drain.

What medications will I go home with?

You go home with these medications:

  • Pain medications. Most people only need these for a few days.
  • Stool softeners. Surgical anesthesia, pain and pain medications can all slow the intestinal tract. These help people have normal bowel habits. This is mainly helpful while on pain medications.
  • Antibiotics. Most people will only need these at the time of surgery.

When will I need to come back to see my urologist?

  • First post-op visit. Your return will depend on what surgery you had. It can also depend on what needs to be taken out. Most people will be seen in 5 to 10 days after surgery.
    • A Foley catheter. It will stay in until your penile dressing comes off. This can be in the hospital. It can also be at your first follow up visit.
    • Surgical drain. If you leave with a drain, it should come out in the first few days. This is if there is low drain output.
    • Staples. Often we will use skin staples to help close skin during healing. These are taken out 10 to 14 days after surgery.
  • Second post-op visit. This will vary. Most people come back 2-3 weeks after surgery. This is to make sure you are healing well.
    • Wound nurses will help with care if there are problems with skin healing.
    • It is important during healing to make sure the penis can be exposed. Sometimes you will come back for weekly visits to ensure a good repair.
  • Third post-op visit: 3 months after surgery you will come back. This is to make sure that:
    • You are healing well.
    • You have better hygiene.
    • You have better working urination.
    • You can have sex if you want to.

How will I know if I’m having a problem with my surgery?

Any surgery with a skin cut can cause an infection. You must watch for these. Some signs are:

  • Redness.
  • Swelling that gets worse.
  • Pus or murky drainage.
  • Worsening pain.
  • Skin separation.

When will I know if I am cured?

This is a major surgery. It will take a lot of time and energy to heal. There are no easy fixes for this problem. In 2 to 3 months, your cuts will heal and swelling will have gone down. Complex repairs can still change in the coming months. We will lead you through this and help you with expectations and recovery.