Introduction:
Buried penis and scrotal lymphedema are congenital or acquired genital conditions. A buried penis represents a broad spectrum of causes. It can be due to obesity, tissue laxity, scrotal enlargement surgery complications, or scrotal lymphedema. A buried penis can lead to poor cosmesis, hygiene, voiding issues, and sexual dysfunction. On the other hand, scrotal lymphedema (termed elephantiasis) can be caused by obstruction, aplasia (failure to develop), or hypoplasia (lack of cells in an organ) of lymphatic vessels (the lymphatic system collects excess fluid draining from cells and tissue).
What Is a Buried Penis?
A buried penis is a condition in which it gets buried under the scrotum, thigh, or abdomen. However, the size and function of the penis are usual. It can affect children and older individuals. The penis is hidden in the tissue above the pubis due to poor skin fixation at its base. Some of the causes include excess fat, obesity, fluid retention, complications after circumcision (excessive or less amount of removal of the foreskin during circumcision causes the remaining skin around the penis to be pulled forward), ligament problems, and scrotal lymphedema. Severe scrotal lymphedema can bury the penis and is often associated with morbid obesity. Scrotal masses that bury the penis can even grow over 60 kilograms.
What Is Scrotal Lymphedema?
Scrotal lymphedema is swelling of the male genital area due to excessive fluid deposition in the soft tissue. The scrotal skin is thickened and ulcerated in severe cases. This can lead to swelling and pain in the affected area, leading to chronic infection involving the leg or arm. The swelling of the scrotum can reach a large size. Further, it can become doughy, filled with fluid, thickened, and chronically infected. The causes of scrotal lymphedema are blockage or damage to the lymphatic system, cancer treatment or surgeries, and radiation therapy.
What Is the Surgical Procedure for Buried Penis and Scrotal Lymphedema?
Surgery for both conditions is complicated. Surgery is done by a team of doctors, including a urologist and a plastic surgeon. The cause guides the treatment of the diseases. The response depends on the reversal of lymphatic derangement. The less invasive treatments are compression therapy in scrotal lymphedema and weight loss in obese patients. However, in long-standing lymphedema, it results in fibrosis. As a result, it warrants more aggressive therapy. Before surgery, a thorough physical examination includes a general assessment of the patient’s body and functional status. An abdominal and suprapubic (above the pubic area) exam should be performed while the patient is supine and standing. In scrotal enlargement, a doctor must determine sufficient supple skin for flap coverage after excision of any affected skin and subcutaneous tissues.
There are many surgical options for a buried penis and scrotal lymphedema. In most cases, the skin is involved and needs removal. There are many advantages of mobilizing a local scrotal flap. Scrotal skin is supple, mobilized, has no subcutaneous fat, and offers an acceptable cosmetic result. Furthermore, scrotal flap necrosis (death) rates are rare due to the rich blood supply. In a study of 18 patients who underwent a scrotal skin flap to the penis, 15 reported satisfactory sexual outcomes and sensations. However, scrotal skin has the disadvantage of being hair-bearing and having an irregular surface. Therefore, it may have a different cosmetic appearance than normal penile skin.
Thigh flaps can also be used in the absence of nearby scrotal tissue. A mesh skin graft (skin from the donor site is stretched to cover a larger area) is also used in penile skin defects.
The testicular tissue is full of lymphatic fluid and must be removed. The testicles and spermatic cord are preserved and unaffected by lymphedema. However, in severe cases, the penile skin can be avulsed off by the weight of the affected scrotum.
Skin grafts are necessary for adequate coverage in some patients. The various steps in skin graft surgery include:
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A catheter is inserted into the urethra to stabilize the penis and protect the urethra.
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Surrounding tissue is separated from the penile shaft.
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In obese individuals, fat removal from the abdomen is done.
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Scarred and infected tissue is removed from the affected area.
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Surgical suction catheters are inserted through small incisions to remove the fat cells.
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Excess skin and fat tissue that hangs down the genitals and thigh is removed. The procedure is called a panniculectomy.
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The fat pad above the pubic area is removed, known as escutheonectomy.
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A skin graft is done as the shaft of the penis is degloved. Skin for grafting is taken from the thigh.
What Are the Complications Related to a Buried Penis and Scrotal Lymphedema?
A buried penis can lead to problems in urination. Other complications include skin infections, urinary tract infections (UTIs), balanitis (inflammation of the penis head), difficulty achieving an erection, difficulty in sexual intercourse, low self-esteem, depression, and anxiety.
What Are the Risks of the Surgery of a Buried Penis and Scrotal Lymphedema?
Surgery of the buried penis and scrotal lymphedema is successful and has no possible side effects. Moreover, the patient gets cured without any recurrence. Also, patients after surgery have normal urination and genital sensation. Still, certain risk factors are painful erections, swelling of the penis, and unhealed or poorly healed skin grafts.
What Happens After the Surgery of a Buried Penis and Scrotal Lymphedema?
A catheter is placed up to a week after the surgery to support the penis and protect the urethra.
Adults are discharged after three or four days of the surgery and are recalled after a week for the removal of the catheter and follow-up. Antibiotics are also prescribed for a week. On the other hand, children can be discharged on the same day. A regular checkup with the doctor is advised till one-year post-surgery.
Conclusion:
Scrotal lymphedema and a buried penis are emotionally distressing and physically disabling conditions. Difficulties with hygiene, urinary incontinence, unesthetic appearance, loss of libido, and immobility are some symptoms. However, buried penis and scrotal lymphedema are rare conditions. These can be treated successfully without any chance of recurrence. Management can be challenging and largely depends on the etiology and the degree of the affected local tissues. While surgery has a high incidence of wound complications, patients experience significant improvement in quality of life. When combined with postoperative weight loss, surgical repair can benefit patients by improving urinary and sexual function and their mental well-being.
