Patient and Parent Satisfaction after Surgical Repair of Concealed Penis in Children

doi:10.21203/rs.3.rs-5383738/v1

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Patient and Parent Satisfaction after Surgical Repair of Concealed Penis in Children

https://doi.org/10.21203/rs.3.rs-5383738/v1

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published 03 Feb, 2025

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Background: Concealed penis in children is a morbid condition that needs special attention due to its negative psychological impact on both parents and patients. It represents a unique challenge due to the multifactorial nature of its etiology that requires different surgical approaches tailored to each case.

The aim of this study was to evaluate parents’ satisfaction after surgical repair of concealed penis in children.

Methods: The study was carried out on male patients, aged <18 years, diagnosed with concealed penis. All patients were subjected to repair of concealed penis. Adolescents and parents’ satisfaction were measured 3 months after concealed penis repair by 4 tools including a pre-validated questionnaire to evaluate outcome of the surgical treatment, the pediatric penile perception score for penile morphology, the patient’s global impressions of improvement scale, and rating the satisfaction with the final penile appearance by an expert independent urologist.

Results: There was a significant negative correlation between the age of children and the global impressions of improvement (r=-0.358; P=0.038) (better levels of parents’ satisfaction are associated with lower age group of children). The mean exposed penile length was significantly higher after surgical correction of concealed penis (P = <0.001). Postoperative satisfaction with penile morphology according to obesity and circumcision before surgical repair was significantly different between patients (P<0.05).

Conclusions: Surgical repair of concealed penis is generally safe and feasible with high rate of excellent surgical outcomes. It has good functional and cosmetic results with low rate of postoperative complications and achieve high grades of parents satisfaction.

Satisfaction Score

children

Concealed Penis

Concealed penis refers to a group of conditions that make the normal size penis looks small ^[1]. Concealed penis (CP) can be secondary to congenital conditions such as loose attachments of penile skin, megaprepuce, prepubic adiposity, or iatrogenic after penile surgeries ^[2]. The term was further classified by Maizels et al. ^[3] into; buried penis, penoscrotal webb and trapped penis. The condition is different from Micropenis which is less than two standard deviations below the mean stretched penile length ^{[2, 3]}. Parents bring their children mainly for anxiety caused by this appearance and for difficulty to maintain proper hygiene e.g. recurrent balanitis, ballooning of prepuce in megaprepuce and post void dribbling of urine ^[4]. The described urgical techniques aim at providing a normally looking penis with preserved penopubic and penoscrotal angels ^{[5, 6]}. Studies made to evaluate long-term outcome of these surgical interventions have been done in adult cases but they are quite few in children ^[7]. The aim of this study was to evaluate patients and parents’ satisfaction after surgical repair of CP in children.

Methods : The study was carried out from April 2023 to April 2024 after approval from the local ethical committee (IRB3624MS149/4/23).

Inclusion criteria included male < 18 years, diagnosed with concealed penis, and scheduled for surgical repair.

Exclusion criteria were patients with micropenis, buried penis repair with liposuction, penile skin deficiency, previous genital surgeries except for circumcision, other congenital anomalies such as hypospadias, epispadias and cryptorchidism and uncontrolled bleeding disorders.

Complete history taking, physical examination, laboratory investigations e.g. complete urine analysis, complete blood count, bleeding and coagulation times were performed before surgery.

Procedures: All patients underwent repair under general anesthesia. A supplemental caudal block was administered. The external genitalia were prepared and draped. A midline traction suture using a 5 − 0 proline was placed. Penoplasty was performed through circumcising skin incision 3–5 mm proximal to the corona, degloving of the penile skin was done by dissection in the plane between the Buck's fascia and dartos fascia dorsally down to the penopubic angle and ventrally down to the penoscrotal junction with dissection of any dysgenetic dartos fascia bands. Penile fixation sutures with nonabsorbable proline 5 − 0 sutures at 12 (dorsal midline), 5 and 7 (paraurethral) o’clock were done between the penile and the tunica albuginea. Excess prepuce was then excised, the proximal penile skin was sutured to the mucosal collar using absorbable vicryl 6 − 0 sutures. A dressing of gauze soaked with antibiotic ointment was applied for 5 days. The surgery was performed as an out patient procedure.

Follow up visits were scheduled weekly for the 1st month, then 3 months and one year later.

Evaluation

The primary outcome was to have a normal looking penis without recurrence of buried penis. To evaluate the outcome of our surgical intervention, we used 4 tools to measure patients and parents’ satisfaction after CP repair. These tools were offered to parents and adolescent patients (older than 12 years) at follow up visits 3 months after surgery. The first tool was a validated questionnaire designed by Herndon in 2003 to evaluate outcome of the surgical treatment of CP ^[7]. The second tool was pediatric penile perception score (PPPS) that allowed us to assess patient and parent satisfaction with postoperative penile morphology regarding penile length, shape of penile skin and general appearance of the penis ^[7]. The third tool was the patient’s global impressions of improvement (PGI-I) scale, which was simple and easy-to-use questionnaire that included asking parents to rate the perceived change in their sons’ condition in response to surgical intervention by grading it from 1 (very much better) to 7 (very much worse) ^[7]. The fourth tool was rating the satisfaction with the final penile appearance by an expert independent urologist who was asked to examine the cases 3 months after surgery and compare the findings with the preoperative images of the same children, then rating his satisfaction with the final penile appearance as (very satisfied, satisfied, unsatisfied or very unsatisfied). The study variables were compared based on age, obesity and circumcision state of patients.

Statistical analysis: Results were collected and statistical analysis was done by SPSS v26 (IBM Inc., Chicago, IL, USA). The Shapiro-Wilks test and histograms were used to evaluate the normality of the distribution of data. Quantitative parametric variables were presented as mean and standard deviation (SD) and compared utilizing unpaired Student's t- test. Qualitative variables were presented as frequency and percentage (%) and were analyzed utilizing the Chi-square test or Fisher's exact test when appropriate. Pearson correlation coefficient was used to investigate the correlation between Patient Global Impression of Improvement and age of patients. A two tailed P value < 0.05 was considered statistically significant.

The study included 71 male children with mean age 6 ± 5.5 years. Patients’ characteristics, state of circumcision, causes of CP and prevalence of obesity before surgical repair, operative time (66.6 ± 11.7 minutes) and postoperative complications are presented (Table 1). The mean exposed penile length was significantly higher after surgical correction (0.9 ± 0.7 vs 3.4 ± 0.69 respectively) (P < 0.001). Postoperative parent satisfaction with penile morphology was significantly different (P < 0.05) with higher levels of satisfaction among parents of younger age, non-obese, and uncircumcised groups (Table 2). Evaluation of surgical outcome regarding penile infections and hygiene using buried penis questionnaire and PGI-I scale were presented (Table 3). Parent and adolescent satisfaction regarding penile morphology and urologist satisfaction after surgical repair were presented in (Table 4). There was a significant negative correlation between the age of children and PGI-I (pearson correlation=-0.358; P = 0.038) (better levels of parents’ satisfaction are associated with lower age group of children).

Table 1

Patients characteristics, state of circumcision, causes, operative time and postoperative complications of the studied groups
Variables	n = 71 (%)
Age (year)
Mean ± SD	6.15 ± 5.5
≤ 2 years	33 (46.4%)
> 2 years	38 (53.6%)
Reasons for referral • Cosmetic concerns regarding small sized penis	60 (84.5%)
• Troubles with hygiene	42 (59.2%)
• Urine pooling behind skin	37 (52.1%)
• Recurrent infections	29 (40.8)
State of circumcision • Not circumcised	21 (29.5%)
• Circumcised	44 (61.8%)
Obesity	37 (52.1%)
Operative time (min) (Mean ± SD)	66.6 ± 11.7
Complications
Penile edema	5 (7.04%)
Ecchymosis	3 (4.2%)

Table 2

Postoperative parent satisfaction with penile morphology
Postoperative Parent satisfaction				P
		Obese group (n = 37)	Non-obese group (n = 34)
Penile length	Very satisfied	7 (20.5)	31 (91.17)	0.003*
	Satisfied	21 (61.76)	2 (5.8)
	Unsatisfied	9 (24.32)	1 (2.94)
Shape of the penile skin	Very satisfied	25 (67.56)	30 (88.2)	0.026*
	Satisfied	10 (27.02)	4 (11.7)
	Unsatisfied	1 (5.9)	0 (0.0)
Penile appearance	Very satisfied	25 (67.56)	30 (88.2)	0.026*
	Satisfied	10 (27.02)	4 (11.7)
	Unsatisfied	1 (5.9)	0 (0.0)
		Circumcised group (n = 44)	Uncircumcised group (n = 27)
Penile length	Very satisfied	15 (34.1)	23 (85.2)	0.011*
	Satisfied	19 (43.2)	4 (14.8)
	Unsatisfied	10 (22.7)	0 (0.0)
Shape of penile skin	Very satisfied	31 (70.4)	24 (88.9)	0.039*
	Satisfied	11 (25.0)	3 (11.1)
	Unsatisfied	2 (4.5)	0 (0.0)
Penile appearance	Very satisfied	31 (70.4)	24 (88.9)	0.039*
	Satisfied	11 (25.0)	3 (11.1)
	Unsatisfied	2 (4.5)	0 (0.0)
P value < 0.05 was considered statistically significant

Table 3

Evaluation of surgical outcome regarding penile infections and hygiene using buried penis questionnaire and PGI-I scale of the studied children
Variables		n = 71 (%)
Variables		Yes	No
Buried penis questionnaire
Was the penis completely hidden behind skin prior to surgery?		44 (61.8)	27 (38.2)
Is the penis hidden after surgery?		4 (5.6)	67 (94.4)
Did you have negative concerns about the appearance of your son’s penis prior to surgery?		65 (91.5)	6 (8.5)
Do you think the surgery increased the length of your child’s penis?		66 (92.9)	5 (7.04)
Do you think surgery was helpful in alleviating those negative concerns?		66 (92.9)	5 (7.04)
Would you want this surgery again or recommend it to a friend whose child had the same condition as your son?		67 (94.4)	4 (5.6)
Did surgery make your son’s penis more assessable?		66 (92.9)	5 (7.0)
Did your child have infections prior to surgery for buried penis?		29 (40.8)	32 (59.1)
Did he develop an infection after surgery?		8 (11.2)	63 (88.7)
Did urine pool behind skin prior to surgery for buried penis?		37 (52.1)	34 (47.9)
Does urine pool behind skin after surgery?		6 (8.5)	65 (91.5)
Did you have trouble keeping your son’s penis clean prior to surgery?		42 (59.2)	29 (40.8)
Do you have trouble keeping your son’s penis clean now?		6 (8.5)	65 (91.5)
PGI-I
PGI-I	Very much better	48 (67.6)
	Much better	10 (14.08)
	A little better	11 (15.5)
	No change	2 (2.8)
Data are presented as frequency (%). PGI-I: patient’s global impressions of improvement.

Table 4

Parent and adolescent satisfaction regarding penile morphology and urologist satisfaction after surgical repair of concealed penis
Variables		n (%)
Parent satisfaction (n = 71)
Penile length	Very satisfied	38 (53.5)
	Satisfied	23 (32.4)
	Unsatisfied	10 (14.1)
Shape of the penile skin	Very satisfied	55 (77.5)
	Satisfied	14 (19.7)
	Unsatisfied	2 (2.8)
Penile appearance	Very satisfied	55 (77.5)
	Satisfied	14 (19.7)
	Unsatisfied	2 (2.8)
Adolescent patient satisfaction (n = 18)
Penile length	Very satisfied	12 (66.7)
	Satisfied	4 (22.2)
	Unsatisfied	2 (11.1)
Shape of the penile skin	Very satisfied	13 (72.2)
	Satisfied	3 (16.7)
	Unsatisfied	2 (11.1)
Penile appearance	Very satisfied	13 (72.2)
	Satisfied	3 (16.7)
	Unsatisfied	2 (11.1)
Urologist satisfaction (n = 71)
Penile appearance	Very satisfied	55 (77.5)
	Satisfied	10 (14.1)
	Unsatisfied	6 (8.4)
Data are presented as frequency (%).

Concealed penis in children is a morbid condition that needs special attention due to its negative psychological impact on parents and patients. It represents a unique challenge due to the multifactorial nature of its etiology that requires different surgical approaches tailored to each case. ^{[8, 9, 10]} Studies on the outcome of these surgical interventions have been done in adult cases but they are lacking in children ^[7]. We aimed at evaluation of parents’, adolescents and surgeon satisfaction after repair of concealed penis. In our study, the mean preoperative exposed penile length of our children was 0.9 ± 0.7 cm and ranged from 0-2.5 cm. On the other hand, the mean preoperative stretched penile length was 6.5 ± 2.04 cm and ranged from 3.1–9.8 cm. These findings are consistent with normal penile length for age as reported by Feldman et al. ^{[11, 12]} and Schonfeld et al. ^{[11, 12]} and meeting the criteria of CP as a normally sized penis distinctive from the actual small size penis in cases of micropenis. Regarding penile fixation, Alter and Ehrlich ^[13] used ventral penile skin fixation sutures only. Frenkl et al. ^[14] used only 2 fixation sutures at 9 and 3 o’clock and suggested that number of fixation sutures don’t affect rate of recurrence, although they had ahigh rate of recurrence(11.5%). Al Hadidi ^[15] used 4 fixation sutures at 12, 3, 6 and 9 o’clock. We reaaly do not know what did he meant with 6 o’clock suture, which anatomically will be at the site of the urethra ventrally. We used penile skin fixation sutures, but sutures were placed at 12 o’clock dorsally at the attachement of suspensory ligament to the penis away from neurovascular bundle and 5, 7 o’clock ventrally away from the urethra. These three sutures aim at having two anatomic angels, the penoscrotal angle and the penopubic angle. These sutures reconstruct penopubic and penoscrotal angles with better cosmetic results as proposed by Negm et al for reconstruction of penoscrotal angle in webbed penis ^[9]. We modified the 12 o’clock suture to be away from both the dorsal vein of the penis and the neurovascular bundle. In this study, penile edema, which lasted more than a week, occured in 5 cases (7.04%) and resolved spontaneously within 3 weeks. Other complications included ecchymosis in 3 cases (4.2%) and also, resolved spontaneously. Perger et al. ^[4], Cui et al. ^[16] and Kim et al. ^[17] reported that all postoperative complication after surgical repair of CP were minor, transient and required no readmission or further intervention. The most frequent complication was penile edema, Chen et al. ^[18] reported that 52 children of 96 children (54.1%) included in their study developed postoperative penile edema. This is different from our results which can be explained by that all our procedures were performed by an expert pediatric urologist who has a good experience in such procedure. In addition, we defined penile edema as the persistent edema after one week of surgery as defined by Negm and Nagla ^[8]. Regarding penile morphology, our surgery achieved high postoperative satisfaction among patients and parents with more than 90% satisfaction. This result is in accord to Ge et al. ^[19] who showed significant improvement in patient satisfaction about penile morphology. In our article, satisfaction after the surgery was higher among parents of younger children. There was a significant negative correlation between age of children and patient global impression of improvement (r=-0.358; P = 0.038). This was in accord to the results of a study by Herndon et al.^[18] who stated that the procedure was successful in toddlers and less often successful in adolescent. Regarding the time of surgery, for uncircumcised children brought by their parents seeking circumcision or referred by a primary health care provider, we scheduled them for penoplasty rather than routine circumcision. We suggest that it shouldn’t be performed before the first 6 months of age to allow for further penile growth during mini puberty and to have a safe anasthesia for the infant as proposed for other genital surgeries. While for circumcised or older children, Shenoy et al. ^[20] suggest that it should be done at school age or as soon as the diagnosis is made if older, to ensure that the patient doesn’t suffer any negative psychological impact during development. We realy explain the hazards of surgey in addition to pro and cons to the parents and let them decide to operate or not. Penile skin deficiency usually complicate circumcision of buried penis without correcting the pathology. In our study, we excluded cases of buried penis with penile skin deficiency that needed skin augmentation by flaps or grafts.^[10] We think these cases are of other category, the cimplicated buried penis, and should have satisfaction score in future studies.

The main limitation of this study was the short term follow-up. So, we are planning to extend our study to include a large number patients with long term follow up for better evaluation of

the functional and cosmetic outcomes especially urinary stream and sexual function after puberty.

Surgical repair of CP is generally safe and feasible with a high rate of excellent surgical outcomes. It has good functional and cosmetic results with low rate of postoperative complications and achieve high grades of parents and patients’ satisfaction.

CP (concealed penis)

PPPS (pediatric penile perception score)

SD (standard deviation)

PGI-I (patient’s global impressions of improvement)

Ethical approval and consnt to participate: Ethical approval was obtained from our university local ethical committee (IRB3624MS149/4/23). We strictly adhered to the principles of the Declaration of Helsinki, taking into account any updates since its conception.

Consent to participate:An informed written consent was obtained from the parents of the patients.patients and their guardians approved this submission. Manuscript does not contain personal data from any individual person.

Availability of data and material: available when asked from the corresponding author after approval from our institute.

Competing interests: we have no competing interests.

Funding: we are self-funded

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Patient and Parent Satisfaction after Surgical Repair of Concealed Penis in Children

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