title: Concealed penis in childhood: a spectrum of etiology and treatment.
abstract: OBJECTIVE
  Concealed penis is an uncommon condition due to poor skin fixation at the base of the penis, cicatricial scarring after penile surgery and excessive obesity. The condition varies in severity and several surgical options are available, such as excision of previous scarring, degloving the penile shaft, reconstructing the penile shaft skin with flaps, fixing the penile skin at the penopubic and penoscrotal angles, and removing excess suprapubic fat.
  
  
  METHODS
  We reviewed the records of 43 patients treated for concealed penis from 1993 to 1998. We categorized the cases as type 1-congenital concealed penis, type 2-concealed penis due to scarring from previous surgery and type 3-complex cases involving excessive obesity. Cases were reviewed in regard to surgical techniques and outcomes. We identified 18 type 1, 18 type 2 and 7 type 3 cases. Mean age of type 1 patients at surgery was 12.4 months with 1 patient presented at age 7 years. None had previously undergone penile surgery. All patients underwent complete penile degloving. To reconstruct the penile shaft flaps or Z-plasties with penile skin were used in 12 patients and scrotal skin flaps were used in 2. In 12 patients the penile skin was fixed at the penoscrotal and penopubic angles to maintain penile length and in 2 excess fat was excised. Mean age of type 2 patients at surgery was 19.8 months. All had previously undergone surgery, including hypospadias in 1 and circumcision in 17. All patients underwent complete penile degloving and the cicatricial scar that trapped the penis was excised. Penile skin flaps and Z-plasties were used in 12 cases, scrotal skin flaps were used for reconstruction in 2 and skin grafting was done in 1. In 10 patients the penile skin was fixed with sutures to maintain penile length. Mean age of type 3 patients at surgery was 15.8 years. Of the 7 boys 6 had previously undergone penile surgery. All required extensive scar excision and complex reconstruction involving penile skin flaps in 3, scrotal flaps in 5 and penile skin fixation in 6. Excessive suprapubic fat was removed in 5 patients, of whom 3 underwent liposuction.
  
  
  RESULTS
  Surgical results were uniformly good in type 1 patients except in 1 who was believed to have excessive suprapubic fat. Results were good in 14 of the 18 type 2 patients, although 2 retained excessive suprapubic fat and 2 had some unsightly scarring. No type 1 or 2 patient required additional surgery. Of the 7 type 3 patients 6 had a good result and required no additional surgery. One patient has recurrent concealed penis after 2 procedures and awaits additional surgery.
  
  
  CONCLUSIONS
  Concealed penis has a varied etiology and requires a flexible surgical approach. The common surgical options in all cases include complete penile degloving, excising the scarring due to previous surgery, removing excess suprapubic fat, reconstructing the penile skin with local flaps, and fixing the penile skin at the penopubic and penoscrotal angles.
authors.affiliation: Department of Urology, James Whitcomb Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, USA.
authors.forename: A J
authors.initials: AJ
authors.lastname: Casale
authors.forename: S D
authors.initials: SD
authors.lastname: Beck
authors.forename: M P
authors.initials: MP
authors.lastname: Cain
authors.forename: M C
authors.initials: MC
authors.lastname: Adams
authors.forename: R C
authors.initials: RC
authors.lastname: Rink
mesh_terms: D002648:Child; D002921:Cicatrix / Q000601:surgery*; D006801:Humans; D007223:Infant; D008297:Male; D009765:Obesity / Q000150:complications*; D010409:Penile Diseases / Q000209:etiology / Q000601:surgery*; D010413:Penis / Q000002:abnormalities* / Q000601:surgery*