Why should a hidden penis be corrected?
The answer to that question is that it should not be corrected unless the patient is having a circumcision. Hidden penises will get better after puberty. If a hidden penis is not corrected during a circumcision, a concealed penis can occur:
Correcting the hidden penis with penoscrotal or penopubic skin tacking will allow the circumcision to heal without concealment. Once the penis is healed, the penoscrotal tacking is no longer needed — although it could provide a nicer cosmetic appearance for a few months/years.
In the postpubertal age, we don’t really see hidden penises. Adult urologists do see them in the morbidly obese (>400 lbs) men and in these men, penoscrotal skin tacking would do absolutely nothing to correct their problem. These men need major plastic surgery procedures involving large panniculectomies and abdominoplasties with penile skin replacement. Really, really, big procedures.
To reiterate: a hidden penis repair in prepubertal boys consisting of penoscrotal skin tacking is only necessary to allow the circumcision to heal without concealment. The hidden penis repair would not change the penile appearance after puberty in any significant way — in other words, the penis will look the same after puberty with or without the hidden penis repair as long as the penis heals without concealment.
What do doctors usually do for hidden penises?
In the United States, most boys whose parents want them to be circumcised and who also have hidden penis, undergo a hidden penis repair and circumcision in the operating room under general or spinal anesthesia. With this procedure, the circumcision is started and the penile skin is degloved down to the penoscrotal junction. Permanent or absorbable sutures are then placed internally to tack the penoscrotal skin to the proximal penis to prevent it from hiding. After this step, the circumcision is completed.
The procedure is usually done after the age of 3 months to decrease the risk of anesthesia and avoid admitting the patients to the hospital for observation — babies under 3 months who have general anesthesia are usually observed in the hospital overnight.
The disadvantages of having to do the circumcision under general anesthesia include:
- Costs 30 times more than doing it in the clinic
- Has to be done later in life and thus some of the protective effects of circumcision are lost in the first few months of life.
- General anesthesia is riskier than local anesthesia
- Inconveniences related to fasting and taking time off work.
What is the alternative?
The alternative is to do the hidden penis repair at the time of the office Gomco circumcision. In my practice, I do office Gomco circumcision under local anesthesia in babies up to 6 months of age. If they have a hidden penis I recommend doing penoscrotal skin tacking sutures to prevent concealment.
This is how I do it:
- Do the Gomco circumcision as usual.
- Before placing the dressing, using gauze to hold on to the head of the penis pull on the head towards 9 o’clock, and then place an external penoscrotal skin tacking suture at the 3 o’clock location:
- Then repeat the procedure but this time pulling towards 3 o’clock and placing the penoscrotal tacking suture at 9 o’clock:
- I use a 5-0 chromic on an RB-1 needle. The suture has to be placed deep before turning to come out. You know you are in the right place if it is difficult to slide out the suture.
The sutures are usually gone in 1 month but by that time the penis has healed without concealment. The parents still have to continue to pull down on the foreskin to clean around the penis until the baby is around 3 years of age which is when the hidden penis improves. I don’t use this technique for older patients having the circumcision done under general anesthesia.
I have not had problems with bleeding or urethral injury but those could potentially happen.
A hidden penis repair with circumcision under general anesthesia could be avoided by applying the external tacking technique described. A study randomizing boys to Gomco/External tacking-under local versus Circumcision/Internal tacking-under anesthesia with outcomes assessed >1 year later would be very informative.