The document discusses inconspicuous or buried penis. It defines true micropenis as a penis that is more than 2.5 standard deviations below the average size for age. Concealed or buried penis is caused by surrounding structures like excess fat or skin obscuring the penis. The document outlines penile development and covers various anatomical causes of buried penis like webbing or prior circumcision issues. It also proposes a novel penoscrotal flap technique for buried penis management and emphasizes differentiating conditions to properly diagnose and reassure parents.

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www.ugm.ac.id Locally Rooted, Globally Respected
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Dealing With Inconspicuous
Penis; Tricks of The Trade
Dr. dr. Prahara Yuri, Sp.U(K)
Divisi Urologi, Departemen Ilmu Bedah, Fakultas Kedokteran,
Keperawatan Dan Kesehatan Masyarakat , Universitas Gadjah
Mada/ RSUP Dr. Sardjito Yogyakarta

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OUTLINE
● 1. Introduction (Definition and Overview of inconspicuous penis)
● 2. Anatomy and Physiology (Normal Development, Discussion of expected size, shape, and
function of the penis at different ages)
● 3. Diagnosis of inconspicuous penis
● 4. Management
● 5. Take Home messages

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Introduction of Inconspicuous Penis
A group of anatomical abnormalities in which the penis
looks smaller than is expected. First introduced in the
medical literature by Bergeson et al. In 1993
Micropenis can be defined as true micropenis which
results from a defect in the hypothalamic–pituitary–
gonadal axis
Micropenis secondary to congenital anatomical anomalies
of the surrounding and overlying structures also known
as concealed penis
1. Campbell Walsh Wein Urology - 12th Edition
2. Cimador, M., Catalano, P., Ortolano, R. et al. The inconspicuous penis in children. Nat Rev Urol 12, 205–215 (2015).
3. Srinivasan AK, Palmer LS, Palmer JS. Inconspicuous penis. ScientificWorldJournal. 2011;11:2559-64
• Normally formed penis
with a stretched penile
length (SPL) of at least 2.5
standard deviations (SD)
below the mean for the
patient's age.
True
Micropenis

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Approximately 9% of patients presenting for initial circumcision and 63% of
patients referred for circumcision revision
May develop depression and anxiety due to the fear of being ridiculed by their
peers, while parents may worry about their child's future sexual activity and
fertility
We should be able to differentiate between true micropenis and concealed penis,
providing reassurance to parents and patients to facilitate appropriate
management
1. Campbell Walsh Wein Urology - 12th Edition
2. Cimador, M., Catalano, P., Ortolano, R. et al. The inconspicuous penis in children. Nat Rev Urol 12, 205–215 (2015).
3. Srinivasan AK, Palmer LS, Palmer JS. Inconspicuous penis. ScientificWorldJournal. 2011;11:2559-64
Incidence and Psychological Impact

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1. Campbell Walsh Wein Urology - 12th Edition
2. Cimador, M., Catalano, P., Ortolano, R. et al. The inconspicuous penis in children. Nat Rev Urol 12, 205–215 (201
3. Srinivasan AK, Palmer LS, Palmer JS. Inconspicuous penis. ScientificWorldJournal. 2011;11:2559-64
Penile Development
7th weeks' gestation,
the human embryo
remains sexually
indifferent
8th week of gestation,
male and female
developmental paths
diverge
Leydig cells in males
produce testosterone
stimulated by maternal
chorionic
gonadotropins
Male external genital
development depends
on the conversion of
testosterone to
dihydrotestosterone
(DHT) by 5α-reductase
The genital tubercle
form penis, and the
urogenital folds fused
become the penile
urethra in males
The glanular segment
of the urethra forms by
invagination from the
tip of the glans, and the
labioscrotal folds fuse
to shape the scrotum
Penile differentiation is
achieved by the 13th
week of gestation
There is a significant
increase in penis size
between the 14th and
38th week of gestation
Development of the
penis is completed by
fetal androgens
Abnormality of the
hypothalamic-pituitary-
testicular axis after 12th
week of gestation can
result in an
underdeveloped penis

6. www.ugm.ac.id Locally Rooted, Globally Respected
1. Campbell Walsh Wein Urology - 12th Edition
2. Cimador, M., Catalano, P., Ortolano, R. et al. The inconspicuous penis in childre
3. Srinivasan AK, Palmer LS, Palmer JS. Inconspicuous penis.
Anatomy of Penis
Anomalies in the penile ligaments can contribute to a diminutive appearance of the
penis.
The fundiform ligament encircles the penile root and provides ventral support.
Camper's fascia is a fat layer over the inner layer of the superficial fascia, while
scarpa's fascia is adherent to the deep fascia.
The deep fascia (buck's fascia) attaches to the tunica albuginea and can be
involved in abscesses and necrotising fasciitis.
The superficial fascia (dartos fascia) forms a cylindrical sheath loosely attached to
the skin and deeper fascia.
Surrounding structures protect against bacterial infections but can contribute to
intracavernosal issues.
Penis is composed of corpora cavernosa, corpus spongiosum, areolar tissue, and
a layer of skin.

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True Micropenis
The coexistence of SPL at least 2.5 SD below the mean and hypospadias is termed
"microphallus." This criterion helps differentiate micropenis from other conditions.
Formula [(0.16 × weeks of gestation) - 2.27] can be used to calculate normal SPL values for
Caucasian preterm infants born at 24-36 weeks of gestation
Micropenis confirmed at birth is often the result of a hormonal disorder during gestation. It can be
either an isolated condition or part of a disorder of sexual development (DSD)
Ethnicity may not significantly impact SPL values in newborns. Mean SPL values of newborns
from different ethnicities have been amalgamated and accepted as the standard
1. Campbell Walsh Wein Urology - 12th Edition
2. Cimador, M., Catalano, P., Ortolano, R. et al. The inconspicuous penis in children. Nat Rev Urol 12, 205–215 (2015).
3. Srinivasan AK, Palmer LS, Palmer JS. Inconspicuous penis. ScientificWorldJournal. 2011;11:2559-64

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Concealed Penis
Caused by prepubic tissues,
penoscrotal webbing, scar
caused by circumcision
trauma, or large hernia and
is often associated with
phimosis.
Should not get their prepuce
excised as it is the only
cutaneous coverage of the
penis and may be needed to
cover the penile shaft during
reconstructive management
Adequate fixation of penile
skin is necessary to prevent
a pole of narrowed skin on
the tip of the penis, which
can result in concealed
penis.
1. Campbell Walsh Wein Urology - 12th Edition
2. Cimador, M., Catalano, P., Ortolano, R. et al. The inconspicuous penis in children. Nat Rev Urol 12, 205–215 (2015).
3. Srinivasan AK, Palmer LS, Palmer JS. Inconspicuous penis. ScientificWorldJournal. 2011;11:2559-64

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Buried Penis
Buried penis caused by excessive prepubic fat or lack of anchoring of the superficial fascia and skin to the
deeper fascia at the base of penis.
Large scrotal masses (hernia and/or hydroceles) could bury the penis and excessive preputial skin,
known as megaprepuce, make the penis look relatively diminutive.
Diagnosis of buried penis due to excessive prepubic fat can be done by physical examination of the
genitalia.
In older children and obese adolescents, the excessive presence of prepubic fat is easily discernible
on inspection and seems to hang over the base of the penis.
In uncircumcised boys with megaprepuce, scrotal and ingiunal masses should be looked for, since these
sometimes could make the penis look relatively small due to distortion of the area.
1. Campbell Walsh Wein Urology - 12th Edition
2. Cimador, M., Catalano, P., Ortolano, R. et al. The inconspicuous penis in children. Nat Rev Urol 12, 205–215 (2015).
3. Srinivasan AK, Palmer LS, Palmer JS. Inconspicuous penis. ScientificWorldJournal. 2011;11:2559-64

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Webbed penis
1. Campbell Walsh Wein Urology - 12th Edition
2. Cimador, M., Catalano, P., Ortolano, R. et al. The inconspicuous penis in children. Nat Rev Urol 12, 205–215 (2015).
3. Srinivasan AK, Palmer LS, Palmer JS. Inconspicuous penis. ScientificWorldJournal. 2011;11:2559-64

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Trapped penis
Caused by inappropriate
circumcision and also occur after
circumcision in a child with
significant scrotal swelling
secondary to hydrocele or hernia.
Characterized by a secondary
phimosis, which can predispose
affected children to recurrent urinary
tract infections, ballooning during
urination, or even urinary retention.
Managements include topical
steroids, and surgical reconstruction
for complex cases (vascularized
flaps, split-thickness skin grafts, and
two stage repair)
1. Campbell Walsh Wein Urology - 12th Edition
2. Cimador, M., Catalano, P., Ortolano, R. et al. The inconspicuous penis in children. Nat Rev Urol 12, 205–215 (2015).
3. Srinivasan AK, Palmer LS, Palmer JS. Inconspicuous penis. ScientificWorldJournal. 2011;11:2559-64

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Novel Technique in Buried Penile Management
1. Campbell Walsh Wein Urology - 12th Edition
2. Cimador, M., Catalano, P., Ortolano, R. et al. The inconspicuous penis in children. Nat Rev Urol 12, 205–215 (2015).
3. Srinivasan AK, Palmer LS, Palmer JS. Inconspicuous penis. ScientificWorldJournal. 2011;11:2559-64
Penoscrotal Flap Combination

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Novel Technique in Buried Penile Management
Penoscrotal Flap Combination
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Take Home Message

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