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Persistent urinary incontinence due to an incompetent bladder neck is a difficult problem in boys with a history of proximal penopubic epispadias or the exstrophy-epispadias complex. Secondary procedures are often necessary to try to improve continence. These include the use of minimally invasive endoscopic bulking agents to the use of bladder neck open reconstruction, slings and/or artificial urinary sphincters each of which carry their own potential risks and complications.
7.3 Concealed Penis
Key Points
››The penis at birth may be partially concealed due to a variety of factors including: (1) Excessive deposits of fat suprapubically, (2) Penoscrotal web, (3) Bands of tissue deep to the penis pulling under the abdominal wall, (4) Poor penile suspension, (5) Result of a circumcision, or (6) Congenital micropenis.
››Endocrine consult must be obtained in cases of true micropenis.
››In the other presentations of concealed penis, the phallus is generally normal in size and length but appears small due to its hidden appearance.
››Newborn circumcision is contraindicated in cases of significant concealment and the infant will undergo a formal correctable surgical reconstruction between 6 and 12 months of life as an outpatient procedure.
››In cases where the penis is clearly concealed or there are questions regarding possible concealment, circumcision should be deferred until consulted by the pediatric urologist.
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7.3.1 Introduction
The hidden or concealed penis (Fig. 7.10) represents a concern to the parents of their newborn son. If this is not handled properly, an ill-advised circumcision may compound this problem and, if not attended to properly, may lead to both mechanical and psychosocial problems in the older boy. Fortunately, most boys with a concealed penis can be recognized at birth and appropriate urological consultation obtained before circumcision is approved.
There are a variety of causes for the concealed penis some of which are combinations of etiologies.3, 5 These may include the presence of a large suprapubic fat pad or mons pubis (Fig. 7.11), the presence of a penoscrotal web, bands of tissue deep to the penis that pull the penis inward, poor skin suspension where the suprapubic fascia fails to anchor the penile skin to the deeper fascia preventing the normal penile contour, complication of circumcision and the presence of a micropenis.
Micropenis (Fig. 7.12) represents a congenitally small penis that is readily apparent by measuring the penis on
FIGURE 7.10. Concealed penis with penoscrotal webbing.
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FIGURE 7.11. Obese male with concealed penis.
FIGURE 7.12. Micropenis in boy with Fanconi’s syndrome.
stretch from the tip of the penis to the pubic bone. If the penis measures in the newborn less than 2.8 cm (2 standard deviations below the norm), then the diagnosis is made and endocrinology need to be consulted.7
The concealed penis that is due to the etiologies other than congenital micropenis is generally of normal size and length.
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7.3.2 Referral and Treatment
In the newborn period while the baby is in the hospital, the pediatrician needs to make the determination as to whether there is a penile issue, which would preclude circumcision until evaluated by a specialist. It is far better to consult a specialist especially in situations where there is concern of potential penile concealment but not completely obvious.
Many times a consult is called for a concealed penis that is webbed. While in many cases this is correctly diagnosed, one can perform a simple test to see if circumcision should be deferred. By placing the index and middle finger along each side of the penis (without actually touching the penis) and then pushing down toward the pubis, the penis will become exposed. If there is no ventral tethering of the penile shaft and one sees a good shaft with the penoscrotal web being obviated, then circumcision can be performed. The parents however must be taught postoperative care because many of these boys will have penile retraction inward post operatively. In those cases, one needs to “pop” the penis out during each diaper change as already described to prevent adhesions and other post circumcision issues.
If the pediatrician or family practitioner performs the newborn circumcisions in the hospital then it is imperative to use the proper technique. In all of these children, the foreskin needs to be totally freed up from its adhesions to the glans and the meatal location recognized first. This can be done with a small hemostat and no dorsal slit need be done. Next the penis needs to be fully exposed after reducing the foreskin over the glans, again using the two-finger technique described. Next a marking pen needs to be used to outline the coronal margin of the glans. Finally whether one uses a
Mogen Clamp or Gompco clamp, the foreskin is pull up to the marking pen line and then the clamp tightened and skin removed. If the doctor charged with the circumcision is uncomfortable, then the referral should be made to see the pediatric urologist in the hospital or in the office within the first 30 days of life for the procedure.