Buried penis, hidden penis, inconspicuous, concealed or webbed penis

"Although subtly different, we consider the inconspicuous, concealed, hidden or webbed penis as minor variations of the same entity. All occur due to minor anomalies of the preputial ring. Specifically, the webbed penis represents an encroachment of the scrotal tissue onto the ventral portion of the penis. This condition results in considerable shortening of the ventral penile shaft skin compared with the dorsal skin. This can occur in two forms: (1) narrowing of the preputial ring proximal to the glans, resulting in a concealed penis, or (2) in the absence of preputial narrowing, resulting in a greater proportion of the penile shaft skin provided by he inner preputial skin than the external preputial skin (“megaprepuce”). Both of these become important when considering circumcision. In these cases, circumcision performed with a Plastibell or a Gomco clamp results in excessive removal of penile shaft skin. If the circumcising incision is made along the narrow portion of the prepuce, a cicatrix will form that will “trap” the penis. This condition (trapped penis) results in a tight, firm preputial ring that requires surgical release with a rotational flap of the dorsal inner preputial skin to the ventrum of the penis.

These conditions are all relatively common. A number of successful surgical approaches address these conditions. Our preference is to harvest a flap of inner preputial skin on its vascular pedicle, transfer that pedicle to the ventrum of the penis, and suture it in place. In this way, the natural narrowing of the preputial ring is opened and the appropriate amount of residual shaft skin and inner preputial skin can then be removed to provide for good cosmesis.

When any of these conditions are noted, it is important to refrain from newborn circumcision. Circumcision will not address the fundamental problem of proximal narrowing of the prepuce that all of these boys share."

Source:

Fundamentals of

Pediatric Surgery 2011

Edited by

Peter Mattei, MD, FAAP, FACS

The Children’s Hospital of Philadelphia, Philadelphia, PA, USA

Chapter 84

Penile Anomalies and Circumcision

BY Douglas A. Canning

Dr. Khan has expert in dealing with this condition and has 23 years experience in dealing this condition. 

Wound healing takes longer in Adult Circumcision with Shang Ring as Compare to Conventional Circumcision : Studies showed in the literature

Adult circumcision with Shang ring is quick procedure however wound healing takes longer than conventional circumcision in adults. 

A randomised clinical study with a Shang ring versus conventional circumcision showed wound healing time in the Shang ring groups was longer than conventional circumcision (maen +/-SD 19.86 +/-5.24 vs 13.42+/-2.35 days, p<0.001 significant) J Urol 2012

A systematic review and meta-analysis of circumcision with Shang ring vs conventional circumcision. Urology 2015 showed  Overall, 8 randomised controlled trials involving 3314 patients were included. Compared with the conventional circumcision group, Shang circumcision is associated with shorter operative time, lower intraoperative pain score, higher satisfaction with penile appearances, less intraoperative blood loss, lower adverse event rate, and lower wound bleeding rate. Shang circumcision appears to be a safer and more effective choice in comparison with circumcision with stitches for male patients.

One long term study showed scar width is 3.7+/- 1.6 mm (clinical medicine journal 2014)

Healing showed significant wound edges gap after removal of Shang ring and this wound heals by secondary intention, scaring with some cases.  

No study mentioned that how long adult patient feel pain after ring came off.  

Dr. Khan has performed three revision circumcisions with glue after Shang ring circumcision. Glue circumcision provide excellent cosmetic result with less pain and less complications. Patients suffered pain due to secondary healing of gapped wound for three months after Shang ring circumcision.  

This required further studies to conduct addressing this issue in Shang ring circumcision.  

Adult circumcision with glue and stitches under local anaesthesia at Thornhill Circumcision Centre, Luton

The widespread acceptance of adult local anaesthesia circumcision in the community remains debatable. We report outcomes (Glue and Stiches) from a dedicated GP clinic over two year period. Patient demographics, indications and postoperative complications were recorded prospectively.

Of 373 circumcisions (glue n=269 and stitches n=103), 230 patients had therapeutic indications including 63 (17%) balanitis xerotica obliterans and 11 (2.9%) had minor complications (infection n=6, bleeding n=2 and redo n=3) with no significant difference between the two groups.

Circumcision performed in adults remains a safe surgical option under local anaesthesia in dedicated GP surgeries.

Dr. A R Khan has performed 143 cases during this period. Four cases have a minor infection and one case has a minor bleeding. This means most of the cases have an excellent result after adult circumcision (Glue n=134 and stitches n=9). Glue circumcision in adults gives result with less pain and excellent cosmetic results. 

Tight foreskin - Phimosis in adult and children

 Is this associated with Balanitis Xerotica Obliterans (BXO) and what is best evidence based management?

“No consistently effective treatment has been developed for penile lichen sclerosus (balanitis xerotica obliterans [BXO]); however, the therapies described below have varying degrees of reported success.

1.      Topical and intralesional steroids have been used. Topical steroids can offer a reliable option only in the management of mild BXO limited to the prepuce in boys with minimal scar formation. Patients and their families must have realistic expectations with regard to the success of such treatments.

2.      Circumcision in adult and children with BXO

3.      Further treatment, or treatment of circumcised patients, is more challenging. Intraurethral steroids provide efficacious therapy for stricture disease in patients with biopsy ­proven BXO before invasive surgery.

4.      A variety of surgical techniques can be used to treat more severe penile BXO. Uncircumcised patients usually benefit from therapeutic circumcision. Provide regular follow­ up care to observe any changes in involved areas suggestive of malignancy. Foreskin preputioplasty combined with intralesional triamcinolone might be a tenable alternative as against circumcision to treat BXO.

5.      Consider surgical intervention for symptoms or signs of urethral meatal stenosis.

6.      Buccal mucuosal graft for BXO ­induced urethral stricture can work.

7.      Consultations :  Consider consultation with Dr. Khan  for the following:

a.      Therapeutic circumcision

b.      Circumcision for symptomatic phimosis or paraphimosis

c.      Significant narrowing or obstruction of the urethral meatus or changes in urinary flow

d.      In some cases of male genital lichen sclerosus (BXO), painful erections may limit sexual function.”

Source: http://emedicine.medscape.com/article/1074054

London circumcision Centre, Leyton and Thornhill clinic, Luton are the best circumcision clinic to management of tight foreskin with  penile BXO. 

PATHWAY FOR PATIENTS WITH PHIMOSIS (BXO)  

1. Assessment and advice for option of treatment like steroid cream or circumcision  

2. Consultation before the circumcision  

3. Circumcision with glue because glue circumcision is better than stitches

4. Aftercare advice following the circumcision  

5. To send biopsy to confirm diagnosis and exclude any malignancy 

6. Further treatment after 6 weeks of circumcision  

7. Follow up to GP or at our clinic  

8. Long term follow up required if biopsy proven BXO found after the circumcision  

This is only guidance and not replacement of the professional advice by  Dr. Khan