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.   
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.