Management of Severe Buried Penis With Bilateral Hernia

Summary:

Buried penis, often caused by obesity, trauma, or surgery, results in penile concealment with functional and psychological effects. We report on a 72-year-old man with severe buried penis after repeated circumcision, morbid obesity, and bilateral inguinal hernias. Prior surgical procedures failed due to scarring and fibrosis. He underwent a single-stage procedure including panniculectomy, penile exteriorization with full-thickness skin graft, erection testing, and hernia repair. Postoperatively, penile exposure and function were restored, enabling standing urination and erections. This case underscored the importance of comprehensive preoperative evaluation and addressing all contributing factors, including asymptomatic hernias, to guide effective multidisciplinary management and improve patient outcomes.

Buried penis, also referred to as hidden or inconspicuous penis, is a rare condition in which the penis, including the glans, is concealed within surrounding tissue.^1,2 It is defined by the inability to visualize the glans in the flaccid state and is often associated with difficulty in urination, poor hygiene, and sexual dysfunction.² Affected individuals may experience substantial physical and psychological distress.³

The etiology is frequently multifactorial, including congenital anomalies, obesity, trauma, chronic inflammation (eg, hidradenitis suppurativa or Fournier gangrene), and surgical complications, with circumcision and penile enlargement procedures among the leading iatrogenic causes.^2–4 Although neonatal circumcision is a deeply rooted cultural and religious practice in Israel, large population studies show that it rarely causes severe complications when performed by trained practitioners in sterile conditions, with a complication rate of only 0.34%.⁵

Reconstruction of buried penis is well established, yet the role of bilateral inguinal hernias as a contributing factor is rarely described. This case emphasizes the importance of thorough preoperative evaluation, including imaging, to identify all factors and facilitate a comprehensive, single-stage surgical approach in complex iatrogenic cases. Treatment varies according to cause and severity, ranging from conservative measures such as weight loss to surgical interventions including scar release, tissue rearrangement, and penile reconstruction.⁶ Our report focused on an iatrogenic case of severe buried penis and discussed pathogenesis and surgical planning to optimize functional and aesthetic outcomes.

CASE REPORT

A 72-year-old man with a medical history of hypertension, dyslipidemia, and morbid obesity presented to our clinic. His urological history included benign prostatic hypertrophy and an uneventful circumcision in infancy.

Six years prior, he underwent surgical revision of circumcision at the urology department for recurrent balanitis xerotica obliterans. Four years later, he developed a fibrotic circumferential scar that prevented manual protrusion of the penis. The condition was treated with surgical adhesiolysis, exteriorization of the penis, and placement of multiple holding sutures at the penile base. However, postoperative follow-up revealed recurrence of the fibrotic scar, rendering the procedure unsuccessful.

On examination in our clinic, he was overweight with abundant lower abdominal wall tissue. The penis was concealed beneath a dense circumferential scar, preventing visualization and externalization of the glans. The scrotum was normal (Fig. 1). Magnetic resonance imaging revealed a 15–16 cm shaft length (from glans to base), prostatic hypertrophy, and bilateral inguinal hernias (Fig. 2).

Fig. 1.

Preoperative images. A, Frontal view. B, Lateral view.

Fig. 2.

Preoperative pelvic MRI showing the 15–16 cm shaft of the penis.

After multidisciplinary discussion, we performed panniculectomy, complete release and exteriorization of the penis with de-epithelialization, and an intraoperative erection test to exclude chordee, ensuring that at least 8 cm of flaccid shaft was exposed (Fig. 3). The shaft was covered with a full-thickness skin graft. In collaboration with the general surgery team, bilateral open inguinal hernia repair was performed using the Lichtenstein technique.

Fig. 3.

Intraoperative image showing the erection test after panniculectomy, exteriorization of the penis, and de-epithelialization.

At 1 week postoperatively, the dressing and bolster sponge were removed, showing complete graft take. The Foley catheter was removed, and the patient could urinate without difficulty. At 3 months, the graft was stable, the penis remained exteriorized at a length of 6 cm, and the patient reported satisfactory urinary function, the ability to achieve erections, and overall satisfaction with the result. (See figure, Supplemental Digital Content 1, which displays the patient 3 mo postsurgery, https://links.lww.com/PRSGO/E755.) No complications were observed, and the inguinal hernia repair remained intact. He was referred to urology for ongoing management of his prostatic hypertrophy.

DISCUSSION

Circumcision, though an uncommon cause, can lead to buried penis when postoperative scar formation constricts the penile shaft, trapping it as it is pushed proximally into suprapubic fat.³ In this patient, repeated circumcision under the incorrect assumption of an inadequate initial procedure worsened the condition. Obesity contributes significantly to buried penis by increasing suprapubic fat, which shortens apparent penile length.^6,7

The penis is anchored to the pubis by the suspensory ligament. When suprapubic fat descends over it, a moist, occluded environment develops that favors bacterial and fungal growth; this can mimic phimosis in partially circumcised men.⁸ This mechanism contributed to an erroneous decision to perform a tertiary circumcision, which ultimately led to severe functional impairment.^8,9

Importantly, bilateral inguinal hernias, an often overlooked factor, can exacerbate penile concealment by altering local anatomy and increasing tissue displacement. This multifactorial presentation is rarely described in the literature.⁸ In our case, the hernias likely contributed to the severity of the buried penis and complicated the clinical picture, which unfortunately led to an inappropriate repeated circumcision. Recognizing hernias as a significant contributing factor and addressing them during reconstruction allowed for a more comprehensive and successful surgical outcome.

Detailed history-taking and physical examination remain essential, even with advanced imaging tools.⁹ In this case, bilateral inguinal hernias, although infrequently reported as contributors, likely worsened the clinical presentation by altering local anatomy and tissue displacement. Recognizing and addressing all contributing factors, including scarring, obesity, and hernias, was critical to the success of the reconstructive approach.

A thorough preoperative evaluation, including magnetic resonance imaging, was essential to identify all factors and estimate true penile length. Despite advanced imaging and examination, intraoperative findings required adjustment of the surgical plan, such as scar release under general anesthesia to expose the glans and facilitate catheter placement.¹⁰ Intraoperative erection testing confirmed the absence of chordee and validated functional shaft length. This case highlights the importance of a comprehensive, multidisciplinary, and individualized approach to managing complex buried penis cases.

CONCLUSIONS

This case underscores the complexity of managing iatrogenic buried penis, particularly when compounded by repeated circumcision, obesity, and inguinal hernias. Optimal outcomes require comprehensive preoperative evaluation, intraoperative assessment, and readiness to adapt the surgical plan. In our patient, a multidisciplinary single-stage approach, including panniculectomy, penile exteriorization with full-thickness skin grafting, and hernia repair, restored both function and aesthetics, significantly improving quality of life. The report highlighted the potential complications of repeated circumcision and reinforces the need for individualized, thorough management strategies.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.