Monday, November 16, 2020

The Buried Penis

November 2020

In June of 2019 we presented a 26 yo man whose main problem was scrotal lymphedema related to hidradenitis supprativa (HS). In 2018, he had surgery at a major academic center to excise active HS lesions in both crural folds.  The operative report states that 20x8 cm were excised from the right groin and 20x6 cm from the left groin. This seems to have been antecedent to the development of scrotal lymphedema. His HS been recently managed with adalimumab, 40 mg per week. Gradually, the active inflammatory lesions have improved, although he still has some fistulous drainage. 

His main problem now is a buried penis. It’s interesting how he has adapted to this. The patient is reclusive. He lives with his parents and spends his days playing video games. When discussing these he displays a vast, enthusiastic knowledge. 

He is very anxious about spending time in hospital and prefers to stay home where his attentive parents care for him. 

We are presenting him to discuss "the buried penis," an unusual disorder, and to see if anyone has helpful suggestions. There were some recent in-depth reviews of “the buried penis” and we will see if the authors are interested in commenting.

Note:  It appears that there are surgical approaches that can help patients like this, but only a very small number of urologic or plastic surgeons have the interest and expertise in this topic.  Dr. Joel Gelman (see articles referenced below) kindly discussed the management of massive scrotal lymphedema  with me   He related the case of Wesley Warren whose 132 pound scrotal lymphedema he removed in 2013.   
 
Reference: 
1. Evaluation and management of adult acquired buried penis. Ho TS, Gelman J.
Transl Androl Urol. 2018 Aug;7(4):618-627. Free Full Text
 
2. Reconstruction of Massive Localized Lymphedema of the Scrotum: Results, Complications, and Quality of Life Improvements. Wisenbaugh E, Moskowitz D, Gelman J. Urology. 2018 Feb;112:176-180. Conclusions: Surgical treatment of MLL of the scrotum can be performed successfully for masses even up to 61 kg (134 lbs). Short-term wound complications are common, but subjective QOL scores improve dramatically. Despite expectations, most patients gained weight after mass removal, which indicates that they would benefit from a comprehensive weight loss plan that includes, but is not limited to, scrotal surgery. Free Full Text.
3. Various YouTubes of Wesley Warren's surgery can be found online.

4 comments:

  1. I wonder about rapamycin. There are a few reports showing improvement as rescue therapy with HS, and is a common treatment we use for lymphatic malformations. Could consider a vascular anomalies referral to Boston Childrens to see general surgery, IR and heme onc for imaging and management options.

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  2. Prof. Bhushan KumarNovember 20, 2020

    I think I had made comments earlier also on the same patient or another patient with similar situation. All heroic surgeries and chronic lymphatic inflammation (lymphatic channels and lymphnodes) produce hypertrophy of the tissues, edema (elephantiasis) and a situation like saxophone penis or an equivalent of this in women- esthiomene.
    No medical or surgical treatment is expected to help. Maybe loss of weight will do as good as any other procedure of course the treatment of hidradenitis has to continue for the recommended duration.

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  3. Commnet of Dato Dr. Cheng Leng Ong, Malaysia: "Thanks for another interesting case ( to dermatologists) but not so to the patient and family; even then, thankfully the young man is well taken care of of by caring parents and he may have buried himself in video games, a effective albeit temporary diversion from his disease.

    Quite extensive surgical resection of HS ( hidradenitis suppurativa ) had been done at both groins. So the lymphatic drainage of the scrotum may have been rather compromised, causing lymphoedema of the scrotum. In the third world countries it used to be common, caused by microfilaria, resulting in elephantiasis. Most present as lymphoedema of lower limbs but some have their scrotum affected, so severe that sometimes a wheelbarrow is used for his massive scrotum to help patient walk.
    Recent biologics ( adalimumab) improves our patient’s HS but not the lymphoedema, another indicator to exonerate HS as its cause. Adalimumab should be continued to improve HS as much as possible, as the present problem of lymphoedema is connected indirectly and/or directly to HS.

    As to the “ buried penis”, it is to be differentiated from “Koro”, which is a term for epidemic or rather hysteria which affect the vulnerable masses ( men), fearing that their penis will be shrunken or retracted into oblivion. It rears its head occasionally like hysteria seizing the public. Koro is known as “Suo-yang” in Chinese, which can be translated “shrinking penis”. It has its counterparts in different cultures and races. This delusional syndrome understandably settles down in the affected society, into no actual harm.

    But not this “ buried penis”. I would suggest the patient takes a medical tourism trip to seek treatment from Dr Joel Gelman, unless our good doctor knows of anyone doing similar good surgery in patient’s vicinity.

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  4. DWJ, Hawaii: "I would look into infliximab to reduce the erythema.
    A short course of prednisone like 20mg/d for 5 days to see if you get a response.
    I will share with my urology fellows."

    ReplyDelete

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