Post-circumcision entrapped penis: A case report and literature review

Abstract

Introduction and importance

Circumcision represents the most common voluntary surgical intervention for male patients, characterized by the surgical excision of the foreskin. Among the potential post-operative complications, a notable condition is the surgically-induced retracted penis, wherein the phallus becomes concealed within the adjacent pubic tissue despite maintaining its standard anatomical dimensions. This clinical presentation typically emerges from medical interventions, including surgical techniques that involve excessive tissue resection, suboptimal surgical approaches, or subsequent scarring that impedes normal penile positioning.

Case presentation

We report a case of an 11-year-old boy who experienced significant urogenital complications subsequent to an unprofessional circumcision performed at age five. Throughout the subsequent years, the patient's parents noted progressive challenges, including persistent hygiene management issues, recurring urinary tract infections, and micturition-related discomfort. A comprehensive medical assessment revealed extensive dermatological scarring and tissue adhesions circumscribing the penile region, with minimal visibility of the glans.

Clinical discussion

The comprehensive management approach for this complex case centered on strategic surgical reconstruction to restore penile functionality and anatomical integrity. The surgical intervention employed a meticulously planned approach that included precise scar tissue excision, comprehensive adhesion release, and advanced reconstructive techniques.

Conclusion

Complications can arise during circumcision procedures, with excessive removal of skin tissue or incorrect surgical methods potentially leading to penile confinement issues. Swift identification of these complications and appropriate corrective surgery performed by qualified medical professionals is essential for achieving favorable patient outcomes.

Highlights

• •Primary buried penis is characterised by the penile shaft being obscured beneath the prepubic skin surface.
• •Entrapped penis can occur as a complication of circumcision in children with scrotal swelling.
• •Surgical intervention is the primary therapy for entrapped penis, with various techniques available
• •Postoperative outcomes for entrapped penis repair are good to very good, with high patient satisfaction rates.

1. Introduction

Circumcision stands as a widely performed elective procedure for infants and children globally. While routine, this surgery requires careful medical oversight due to potential adverse outcomes. Of particular concern is the post-circumcision trapped penis syndrome, where excessive scarring causes the penile shaft to become confined beneath surrounding tissue [1,2]. This condition typically develops from two main factors: overly aggressive removal of foreskin during the initial procedure or suboptimal surgical methods that lead to problematic healing patterns. Medical literature indicates that surgical complications occur in approximately 0.5–8 % of pediatric circumcisions, with trapped penis specifically affecting 0.1–0.3 % of cases [3,4].

Research demonstrates that successful circumcision outcomes depend heavily on three key factors: careful selection of appropriate patients, precise surgical methodology, and thorough follow-up care. A comprehensive analysis published in 2023 examined complication rates across pediatric circumcision procedures. The findings revealed that general complications occur in 0.5 % to 8 % of cases, while serious complications, including trapped penis, affect between 0.1 % and 0.3 % of patients. These statistics underscore the need for medical practitioners to implement robust protocols throughout the entire surgical process, from initial patient screening through post-operative monitoring [5]. The analysis revealed a significant correlation between surgical outcomes and provider expertise. Specifically, complication rates decreased markedly when procedures were conducted by experienced, credentialed surgeons within proper medical facilities [5]. The research evidence clearly demonstrates three essential requirements for optimizing circumcision safety and outcomes, which is comprehensive medical training programs, consistent implementation of evidence-based protocols, and ongoing development of surgical best practices in pediatric settings. This study has been reported using the SCARE (Surgical Case Report) criteria to ensure the quality and transparency of case reporting. [6]

2. Case presentation

A pediatric urology clinic evaluated an 11-year-old male patient presenting with penile concealment and post-urination dripping. The patient's medical history revealed normal penile development at birth, followed by recurring urinary tract infections (UTIs) due to phimosis at age 5. These recurrent UTIs—4 to 5 episodes within a year—necessitated antibiotic treatments and ultimately led to circumcision. This decision diverged from standard medical guidance, which typically advises against circumcision between ages 3 and 6 due to the potential impact on critical gender identity development during this period.

Two weeks post-circumcision, the patient developed penile entrapment, identified as a surgical complication rather than a congenital anomaly. A corrective procedure conducted six months later by a pediatric urologist failed to resolve the issue. The initial circumcision had been performed by a general practitioner, while the corrective surgery was performed at a hospital facility.

Upon clinical examination, the patient exhibited significant obesity, with a body mass index (BMI) of 31.42 (height: 146 cm, weight: 66 kg), a marked increase from his pre-circumcision weight of 25 kg. Physical assessment revealed extensive scarring and adhesions around the penile shaft and base, severely limiting visualization of the glans penis and urethral meatus. Only 1 cm of the penile shaft extended beyond the pubic fat pad. Testicular examination showed normal bilateral measurements of 2.5 cm (Fig. 1).

Fig. 1.

External genitalia demonstrating a concealed penis with the glans completely obscured by scarring and surrounding pubic fat pad.

Comprehensive parental counseling was provided, including a detailed explanation of the patient's condition, the proposed surgical approach, associated potential risks, and expected outcomes. The counseling process also included discussions regarding postoperative care, anticipated recovery milestones, and the importance of weight management to optimize long-term outcomes.

The surgical intervention, performed under general anesthesia, involved meticulous dissection to address adhesions and scarring (Fig. 2). Strategic tension suture placement facilitated adequate glans exposure, followed by lateral incisions and excision of necrotic tunica dartos fascia. Approximately 3 cm of circumferential scar tissue was removed. Penile reconstruction was achieved by mobilizing adjacent tissue without the need for advanced reconstructive techniques, such as skin grafting or staged procedures, as adequate penile skin remained available (Fig. 3). Wound closure was completed with 6-0 polydioxanone sutures (Fig. 4).

Fig. 2.

Post-adhesion release, with the penile shaft successfully exposed following the removal of scar tissue and extensive adhesiolysis.

Fig. 3.

Fixation sutures between dermis and tunica albuginea for stabilization and to maintain the penile shaft in a more prominent position post-reconstruction.

Fig. 4.

Wound closure with visible tension sutures and application of a sterile dressing.

Postoperative care included daily wound management with topical antibiotics and dressing changes for the first five days (Fig. 5). At a two-week follow-up, the patient exhibited improved urination with a maximum flow rate of 15 mL/s. By the one-month evaluation, the exposed penile length had increased to 4 cm, with satisfactory anatomical and functional outcomes. A six-month follow-up confirmed sustained improvement, with the patient and family reporting high satisfaction (8/10) regarding both cosmetic appearance and urinary function.

Fig. 5.

External genitalia on the fifth postoperative day showing significant healing, with visible penile length and absence of scarring complications. The dressing has been removed to allow for assessment of the wound and anatomical outcomes.

3. Discussion

Entrapped penis in children is a complex condition that requires careful consideration of its etiology, diagnosis, and management. This discussion will focus on the key aspects of entrapped penis in pediatric patients, addressing the reviewer's comments and incorporating recent scientific literature [4].

A key diagnostic distinction exists between two penile conditions: congenital buried penis and post-surgical entrapped penis [7]. Congenital buried penis presents as a primary condition where the penile shaft remains concealed beneath excessive prepubic adipose tissue or displays abnormalities in the penile ligament structure. In contrast, entrapped penis develops as a secondary complication following circumcision procedures, representing a distinct surgical outcome rather than a developmental condition [2]. In the case of post-circumcision entrapment, excessive removal of penile skin or improper healing can lead to scarring that confines the penis beneath the surrounding tissue [10].

While circumcision remains a routine procedure, it requires careful medical oversight to prevent complications. Research indicates that pediatric circumcision procedures have an overall complication rate between 0.5 % and 8 % [3]. More severe complications, including entrapped penis, affect a smaller subset of cases, occurring in approximately 0.1 % to 0.3 % of procedures [1]. These statistics emphasize the importance of proper surgical technique and experienced practitioners in minimizing adverse outcomes. The risk is particularly high when the procedure is performed by inexperienced practitioners or in non-medical settings [8]. This underscores the importance of having skilled medical professionals perform circumcisions in appropriate healthcare facilities.

The clinical presentation of entrapped penis in pediatric patients encompasses multiple symptoms that can significantly impact both physical health and psychological well-being [4]. Primary physical manifestations include urinary dysfunction and susceptibility to recurring urinary tract infections. Additionally, the condition often creates aesthetic concerns that become increasingly significant as patients approach adolescence, potentially leading to psychological difficulties during this critical developmental period. Accurate diagnosis involves a thorough physical examination and, in some cases, imaging studies to assess the extent of tissue involvement [7].

The surgical management of entrapped penis requires a tailored approach based on two key factors: the condition's severity and the availability of viable penile tissue [2]. For cases presenting with limited scarring, surgeons may achieve successful outcomes through adhesiolysis procedures combined with strategic redistribution of existing penile skin. More severe cases, however, often necessitate advanced reconstructive techniques, including Z-plasty procedures or the introduction of skin grafts to achieve optimal functional and cosmetic results [9]. It is important to note that surgery aims to improve cosmetic appearance, restore function, and prevent complications like urinary obstruction or recurrent infections. Unlike neonatal complications, the presented case required surgical intervention years later, underscoring the necessity for individualized treatment plans.

The success of entrapped penis surgery heavily depends on diligent postoperative management and monitoring [2]. Medical evidence indicates that patients require consistent follow-up evaluations for at least six months following the procedure, as some cases may necessitate additional surgical intervention if functional or anatomical issues persist. The required time interval between successive surgeries should be carefully considered, based on anatomical and functional abnormalities, as emphasized in cases of severe complications [5]. Additionally, topical corticosteroids and carefully guided manual retraction techniques during the early recovery phase can significantly enhance long-term outcomes by minimizing the risk of tissue re-adhesion [5].

Research demonstrates that genital abnormalities in pediatric patients can have substantial psychological ramifications [4]. Children affected by conditions such as entrapped penis frequently experience mental health challenges, including heightened anxiety, depressive symptoms, and diminished self-esteem. Therefore, a multidisciplinary approach involving urologists, pediatric psychologists, and social workers is often beneficial. Contrary to the assumption that conditions like buried penis, hypospadias, epispadias, and micropenis are contraindications for circumcision, circumcision may be performed under skilled hands, often concurrently with corrective surgery for these anomalies, ensuring optimal timing and outcomes.

Prevention of entrapped penis requires a comprehensive educational approach regarding circumcision's risks and benefits [8]. Medical professionals should provide detailed guidance to parents regarding optimal procedural timing, with recommendations generally favoring the neonatal period for elective circumcisions. When considering circumcision for older children, healthcare providers must carefully evaluate the potential psychological implications of genital surgery, particularly during critical developmental stages [5].

The clinical management of pediatric entrapped penis presents significant challenges that require a multifaceted treatment approach, combining surgical intervention with comprehensive preventive strategies [2]. While surgical correction often serves as the primary treatment modality, the medical community increasingly emphasizes prevention through enhanced education about circumcision techniques and optimal procedural timing [3]. Research priorities in this field should focus on developing standardized treatment protocols applicable across diverse pediatric populations, while simultaneously conducting longitudinal studies to evaluate long-term patient outcomes [1]. Healthcare providers must maintain vigilance in both preventive education and treatment optimization, ensuring that practitioners and parents understand the associated risks and importance of proper surgical execution, particularly regarding the timing of elective circumcisions during the neonatal period [8]. This comprehensive approach, incorporating both preventive measures and refined treatment strategies, offers the most promising path forward in addressing this challenging condition and improving outcomes for affected pediatric patients.

4. Conclusion

Prompt surgical correction of post-circumcision entrapped penis is essential to prevent adverse physical and psychological outcomes, particularly diminished self-image. The medical community must strengthen circumcision education and practice standards to reduce the risk of this complication and its associated psychosexual implications for patients' long-term wellbeing.

Author contribution

Veryne Ayu Permata: Conceptualization, Investigation, Resources, Original draft preparation, Project administration, Review, and Editing. Johan Renaldo: Supervision, Investigation, Resources, Original draft preparation, Review, and Editing.

Consent

The patient's parents have provided written authorization for the publication of this case report and its associated images. This consent documentation is available for verification by the journal's editor-in-chief upon request.

Ethical approval

This study received formal ethical approval from the hospital's Ethics Committee, with approval reference number 1261/109/4/II/2022.

Guarantor

The Guarantor is Veryne Ayu Permata, who accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

Research registration number

Not required.

Funding

This research was conducted without external funding support.

Conflict of interest statement

The authors affirm that they have no conflicts of interest related to this publication.