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Uncovering The Hidden Penis: A New Classification System
Ledibabari M. Ngaage, MB BChir1, Joseph Lopez, MD MBA2, Yinglun Wu, BS1, Yvonne M. Rasko, MD1, Nelson Goldberg, MD1.
1University of Maryland Medical Center, Baltimore, MD, USA, 2Johns Hopkins Hospital / University of Maryland School of Medicine, Baltimore, MD, USA.

PURPOSE:
A hidden penis can interfere with normal hygiene, prevent effective voiding, restrict sexual activity, and cause great embarrassment to the patient. The terms "hidden", "buried", and "trapped" penis are used interchangeably, and to date, there is not yet a classification system that adequately characterizes the spectrum within this condition. In this study, we propose a simplified classification system and management approach for adult-acquired hidden penis.
METHODS:
We performed a retrospective review of all patients treated surgically for hidden penis by the senior author from 2009 to 2019. Patients were classified into either "buried" or "trapped" categories. A buried penis was defined as a hidden penis concealed by suprapubic fat without fibrous tethering. These patients were managed with panniculectomy, monsplasty, or both. In contrast, those with a trapped penis presented with scarred or fibrous tissue which required surgical lysis, phalloplasty, and penile skin resurfacing. A malleable custom-made foam penile splint was positioned and suture-anchored to the glans postoperatively to maintain penile length. 
RESULTS:
Thirteen patients met inclusion/exclusion criteria. The cohort was aged 53 15.7 years with a mean BMI of 37.4 4.3 kg/m2. Two patients required repeat operations yielding a total of 15 operative encounters. Six were defined as buried (Figure 1A-B) and 9 as trapped (Figure 1C-D). An inability to achieve erection was the most common preoperative complaint in those with a buried penis (67%) whereas difficulties in voiding were most common with a trapped penis (89%). Patients with trapped penises tended to be of larger body habitus than those with a buried penis (39.3 kg/m2 vs 34.9kg/m2, p=0.0522). Patients with trapped penises underwent longer operations (206 minutes vs 161 minutes, p=0.3664) and had longer hospital stays (1day vs 5 days, p=0.0836) than those with a buried penis, but this did not reach significance. One third experienced wound complications but this was not significantly different between buried and trapped penises (17% vs 44%, p=0.5804). Five patients (38%) experienced spontaneous erections and 7 (54%) were able to void while standing. 
CONCLUSION:
Patients with a trapped penis present with a different preoperative symptom profile and body type than those with a buried penis. Our classification system offers a simple and clear algorithm for the management of hidden penis. Large cohort studies are warranted to assess differences in clinical outcomes between trapped and buried penises.


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