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Concealed vomiting — Clinical Guidelines

Overview

Concealed penis is a congenital anomaly characterized by a penis that appears short or hidden beneath the pubic fat pad despite having normal underlying penile development. This condition can lead to significant psychological distress in affected children and adolescents, as well as potential functional issues such as phimosis, balanitis, and difficulties with urination. It primarily affects male infants and children but can persist into adulthood if left untreated, impacting sexual function and self-esteem. Early identification and intervention are crucial to mitigate long-term adverse effects on both physical and psychological health. Understanding and managing concealed penis effectively is essential for pediatric urologists and primary care providers to ensure optimal outcomes for their patients 1 2 3 4.

Pathophysiology

Concealed penis arises from a combination of anatomical and developmental factors. At its core, the condition is marked by inadequate attachment of the penile skin to Buck's fascia and insufficient penile skin coverage, often exacerbated by excessive pubic fat or abnormal positioning of the penis within the subcutaneous tissues. The fundiform ligament may saddle abnormally on the dorsal shaft, contributing to the penis appearing buried or concealed 1 2. Additionally, cicatrix formation post-circumcision can lead to trapped penis scenarios, further complicating the anatomical presentation. These factors collectively result in a penis that appears smaller than its actual stretched length, leading to both functional impairments and psychological distress 1 3 4.

Epidemiology

The exact incidence and prevalence of concealed penis are not uniformly reported, but it is recognized as a relatively common congenital anomaly. It predominantly affects male infants and children, with no significant sex predilection noted. Geographic variations in reporting may exist, but no specific risk factors beyond congenital anomalies have been consistently identified. There is a trend towards increased clinical identification due to heightened parental awareness and aesthetic concerns regarding genital appearance. Age of presentation can vary widely, from early infancy to adolescence, depending on the severity and whether functional issues prompt earlier intervention 1 2 3.

Clinical Presentation

Children with concealed penis typically present with an apparently small penis that fails to protrude adequately during erection or even at rest. Parents often report concerns about the appearance of the genitalia and may notice difficulties such as recurrent balanitis, phimosis, or urinary symptoms like spraying during urination. Physical examination reveals a penis that retracts fully into the prepubic fat pad when not erect, with normal penile length evident upon manual elevation. Red-flag features include severe functional impairment, significant psychological distress, and signs of complications like persistent edema or infection. Prompt evaluation is crucial to differentiate concealed penis from other congenital anomalies that may present similarly 1 2 3 4.

Diagnosis

The diagnosis of concealed penis involves a thorough clinical evaluation and exclusion of other conditions. Key diagnostic criteria include:

Clinical Examination: Assessment of penile length when manually elevated versus its retracted state. Normal stretched penile length (SPL) despite apparent concealment is a hallmark.

Imaging: Rarely necessary but can be used to rule out other congenital anomalies affecting genital development.

Differential Diagnosis:

- Buried Penis: Often associated with excessive pubic fat rather than intrinsic penile issues. - Webbed Penis: Presence of scrotal skin extending onto the penile shaft. - Trapped Penis: Resulting from cicatrix formation post-circumcision. - Hypospadias: Characterized by abnormal urethral opening position.

Specific Tests and Criteria:

Stretched Penile Length (SPL) Measurement: SPL ≥ 3 cm (normal range for age) confirms normal penile development despite concealment.

Physical Signs: Absence of penile skin abnormalities, presence of normal penile shaft palpability when pressure is applied to retract the penis.

Patient History: Parental concerns regarding appearance and functional issues like hygiene or urination difficulties 1 2 3 4.

Management

Initial Management

Clinical Assessment and Counseling: Evaluate the severity and impact on the child, providing psychological support to both the child and parents.

Non-Surgical Interventions: In mild cases, conservative management with weight loss or fat reduction may be considered, though efficacy is limited 1 2.

Surgical Interventions

#### First-Line Treatments

Modified Shiraki Procedure: Involves local tissue rearrangement to expose the penis. Effective for moderate cases, with reported success in improving penile exposure and appearance 1 5 6.

Pedicled Island Preputial Flap: Utilizes preputial tissue to cover and elevate the penis. Offers good cosmetic outcomes and functional improvement 1 6.

#### Second-Line Treatments

Scrotal Advancement Flap (SAF): Advanced flap technique to cover ventral penile defects, suitable for severe cases where other methods may fall short 6.

Dorsal Transverse Preputial Island Flap (DTPIF): Another flap technique providing robust coverage and exposure, particularly effective in severe concealed penis 6.

#### Refractory Cases

Advanced Musculocutaneous Scrotal Flap: For complex cases where other flaps fail, this technique offers extensive coverage and improved outcomes 5.

Modified Devine Procedure: Combines fasciectomy with skin anchoring to fully release the penis, particularly useful post-circumcision concealed penis 7 12 13.

Specifics:

Indications for Surgery: Severe psychological distress, functional impairment, or persistent physical symptoms despite conservative measures.

Contraindications: Active infections, severe systemic illnesses that preclude surgery.

Postoperative Care: Close monitoring for complications such as infection, seroma, and edema; regular follow-up visits to assess healing and functional outcomes 1 7 12 13.

Complications

Acute Complications: Infection, hematoma, seroma formation, wound dehiscence.

Long-Term Complications: Recurrence of concealment, inadequate penile coverage leading to cosmetic dissatisfaction, persistent edema, and potential erectile dysfunction in severe cases.

Management Triggers: Prompt surgical intervention for acute complications; regular follow-up to address long-term issues, including psychological support for persistent concerns 1 7 12 13.

Prognosis & Follow-up

The prognosis for concealed penis is generally favorable with appropriate surgical intervention, particularly when addressed early. Key prognostic indicators include the severity of the condition at presentation and adherence to postoperative care protocols. Recommended follow-up intervals typically include:

Immediate Postoperative: Within 1 week for wound inspection.

Short-Term (3-6 months): To assess healing, penile length, and functional outcomes.

Long-Term (Annually): To monitor for any recurrence or complications and ensure sustained psychological well-being 1 12 13.

Special Populations

Pediatric Patients

Considerations: Early intervention is crucial to prevent long-term psychological impacts. Parental counseling and psychological support are integral parts of management.

Techniques: Modified Shiraki, pedicled island flaps, and modified Devine procedures are commonly employed with good outcomes 1 7 12.

Adolescents

Challenges: Delayed presentation may complicate surgical options due to scar tissue or more pronounced psychological impacts.

Approach: Modified Brisson operation with Y-shaped incision or advanced flap techniques tailored to address complex anatomical changes 4 11.

Key Recommendations

Early Surgical Intervention for Severe Cases: Address severe concealed penis surgically to prevent long-term psychological and functional impairments (Evidence: Strong 1 3 4).

Comprehensive Preoperative Assessment: Include SPL measurement and detailed clinical examination to confirm diagnosis and assess severity (Evidence: Moderate 1 2).

Use of Advanced Flap Techniques: Employ techniques like scrotal advancement flap or musculocutaneous scrotal flap for severe cases to ensure adequate coverage and functional outcomes (Evidence: Moderate 5 6).

Postoperative Monitoring: Regular follow-up visits are essential to monitor healing, address complications, and assess patient satisfaction (Evidence: Moderate 7 12).

Psychological Support: Provide psychological counseling for both patients and parents to manage emotional impacts (Evidence: Expert opinion 3 4).

Avoid Unnecessary Circumcision: Refrain from circumcision in cases suspected of concealed penis to prevent exacerbating the condition (Evidence: Moderate 2 3).

Customized Surgical Approaches: Tailor surgical techniques based on patient age, severity, and previous interventions (Evidence: Expert opinion 1 7).

Long-Term Follow-Up: Schedule annual follow-ups to monitor for recurrence and ensure sustained positive outcomes (Evidence: Moderate 12 13).

Multidisciplinary Care: Involve pediatric urologists, psychologists, and surgeons experienced in genital reconstructive surgeries (Evidence: Expert opinion 3 4).

Patient and Family Education: Educate families about the condition, treatment options, and expected outcomes to enhance compliance and support (Evidence: Expert opinion 1 2).

References

1 Pan R, Li J, Zhou Z, Liang K, Li Z, Xiao Z. Comparative efficacy of modified Shiraki procedure and pedicled Island preputial flap in the treatment of severe concealed penis in children. Scientific reports 2025. link 2 Hosseinpour M, Fazeli A, Moznebi D, Seyedyousefi S. Investigating the outcomes of full thickness skin graft in the reconstruction of concealed penis in children aged 7 to 14 years. BMC urology 2024. link 3 Jing P, Zhao D, Wu Q, Wu X. A new treatment of concealed penis: symmetrical pterygoid flap surgery. International braz j urol : official journal of the Brazilian Society of Urology 2023. link 4 Su Q, Gao S, Lu C, Wu X, Zuo L, Zhang L. Clinical effect of Brisson operation modified by Y-shaped incision for treatment of concealed penis in adolescents. The Journal of international medical research 2021. link 5 Han DS, Jang H, Youn CS, Yuk SM. A new surgical technique for concealed penis using an advanced musculocutaneous scrotal flap. BMC urology 2015. link 6 Chu Z, Ma H, Wang X, Tang R. Clinical Comparison of Scrotal Advancement Flap and Dorsal Transverse Preputial Island Flap for Severe Concealed Penis in Children: A Single-Center Retrospective Analysis. Urology 2026. link 7 Gui M, Zhang L, Wang H, He Q. How do I do it: Modified Devine procedure with sleeve dartos fasciectomy for post-circumcision concealed penis. Journal of pediatric urology 2026. link 8 Deng QF, Chu H, Cao Y, Li G. Comparison of Three Surgical Techniques for Concealed Penis in Children. Urology 2025. link 9 Yener S, Ayyıldız HNK, Güvenç FT, Yıldız ZA, İlçe Z. Surgical technique experience and results for concealed penis. Pediatric surgery international 2025. link 10 Zaontz MR, Long CJ. Technical nuances of the concealed penis repair. Journal of pediatric urology 2024. link 11 Mao CK, Peng B, Liu X, Chu H, Yu X, Tao CP et al.. Efficacy of the modified Brisson+Devine procedure for the treatment of concealed penis. European review for medical and pharmacological sciences 2023. link 12 Zhang Z, Wu H, Mao W, Gao SL, Zuo L, Zhang LF. Clinical Study of Modified Devine's Surgical Technique in the Treatment of Concealed Penis. Urology journal 2023. link 13 Chen HK, Chu YS, Hu YF. The modified Devine's procedure for the management of concealed penis in children: an experience of 131 cases. European review for medical and pharmacological sciences 2022. link 14 Ge W, Zhu X, Xu Y, Chen Y, Wang J. Therapeutic effects of modified Devine surgery for concealed penis in children. Asian journal of surgery 2019. link 15 Chen C, Li N, Luo YG, Wang H, Tang XM, Chen JB et al.. Effects of modified penoplasty for concealed penis in children. International urology and nephrology 2016. link 16 Valioulis IA, Kallergis IC, Ioannidou DC. Correction of concealed penis with preservation of the prepuce. Journal of pediatric urology 2015. link 17 Kim JJ, Lee DG, Park KH, Baek M. A novel technique of concealed penis repair. European journal of pediatric surgery : official journal of Austrian Association of Pediatric Surgery ... [et al] = Zeitschrift fur Kinderchirurgie 2014. link 18 Li Z, Wei D, Guizhen H, Miao Y, Lugang H. Pedicled skin flap of foreskin for phalloplasty in the management of completely concealed penis. Journal of pediatric surgery 2012. link 19 Yu W, Cheng F, Zhang X, Ruan Y, Yang S, Xia Y. Minimally invasive technique for the concealed penis lead to longer penile length. Pediatric surgery international 2010. link

Concealed vomiting