Procedures which preserve normal sensation and function are performed at about 6 months to reduce anesthesia risks.
Common penile anomalies can be addressed surgically if needed, but early diagnosis is key, Jeffrey T. White, M.D., Ph.D., a pediatric urologist with Norton Children’s Urology, affiliated with the UofL School of Medicine, said during a recent continuing medical education opportunity.
Common anomalies include hypospadias; turned or bent penises; penoscrotal webbing; and hidden or buried penis.
“It’s important to refer early for specialist evaluation. Sometimes with minimal amounts of torsion or penoscrotal webbing, we can still perform a newborn circumcision. But if they’re not referred until after 4 weeks of age, we won’t be able to do the newborn circumcision because they’re just too large,” Dr. White said.
Hypospadias occurs when the opening or meatus is misplaced ventrally along the midline of the penis. It also can be on the distal shaft or base of the penis, called penoscrotal hypospadias, or further back toward the anus.
“Correcting hypospadias can be quite complicated. You basically take the penis apart and then put it back together, but with normal anatomy and function,” Dr. White said.
A turned penis is called penile torsion; a bent penis is termed penile chordee.
“It’s important to understand that bends and turns can be caused by two separate entities. One is abnormal development of the skin; the second is abnormal development of the actual corporal body, the erectile tissue. It’s important to be able to distinguish between those two,” Dr. White said.
To correct skin deficiencies, the penis is degloved. After degloving, we will know whether the anomaly is due to the skin or the corporal body. There are a couple of possible approaches to correct corporal body anomalies. One way is to perform a plication, using a stitch on the dorsal aspect to bend the penis backward and to straighten the corporal body. Another approach is corporotomies — small incisions along the ventral aspect of the penis to lengthen the penis and straighten it. If the penis is turned, a flap can be used to rotate the opposite direction and pull it back.
Penoscrotal webbing occurs when a web of skin extends from the scrotum to the penis. Penoscrotal webbing can be challenging to diagnose.
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“The easiest way to diagnose it is to pick up the foreskin, and gently pull towards the ceiling, while gently pulling the scrotum towards the feet. If you see a web of skin extending between the scrotum and the penis, that’s penoscrotal webbing. If present, the scrotum will appear to insert higher on the penis than where the penis joins with the belly,” Dr. White said.
There are several ways to fix webbed penises. One is degloving and internally fixing the webbing to prevent it from being an issue. This requires one incision, a circumcising incision. A second option is to incise the webbing. If also performing a circumcision, this requires both a circumcising incision as well as another incision. The second option causes a little more pain for the patient.
“If I am performing a circumcision, I prefer to repair webbing by degloving the penis and then fixing the penopubic angle, where the penis meets the belly, and the penoscrotal angle on either side of the urethra. This tacks that area of webbing down to the base of the penis, to eliminate the appearance of webbing,” Dr. White said.
With a hidden or buried penis, the penis can be inside a large suprapubic mons.
“The buried penis repair is basically pulling the penis out, degloving it, tacking at the penopubic and the penoscrotal angles, and then closing the skin,” Dr. White said.
With any penile anomalies, newborn circumcision should be delayed. The foreskin is needed to reconstruct the shaft skin.
Typically, children don’t undergo these surgeries until they are around 6 months of age, so their chest wall is strong enough to cough and clear secretions, decreasing the anesthesia risk.
“It’s important to note that all these repairs preserve normal sensation and function,” Dr. White said.