What are the causes and treatments of a retractable penis (penile retraction)?

Causes and Treatment of Penile Retraction (Retractable Penis)

Penile retraction is primarily caused by anatomical abnormalities, trauma, or scar tissue formation, and treatment should be directed at the underlying cause, with surgical correction being the definitive management for most cases.

Causes of Penile Retraction

Anatomical Causes

• Congenital abnormalities:
  • Dysgenetic fibrous bands tethering the penis to prepubic subcutaneous tissue 1
  • Abnormal attachments of penile skin to deeper tissues

Traumatic Causes

• Pelvic trauma:
  • Pelvic fractures with symphysiolysis 2
  • Displaced pubic bone fractures pulling the penis via the suspensory ligament 3
  • Formation of adhesions between the penis and surrounding tissues

Post-surgical/Scarring Causes

• Scar tissue formation:
  • Previous genital surgeries or circumcisions 4
  • Peyronie's disease with significant scarring and retraction 5, 6

Other Contributing Factors

• Obesity:
  • Excessive prepubic fat engulfing the penile shaft 4
  • Massive weight loss with redundant skin covering the penis

Clinical Presentation and Diagnosis

Physical Examination

• Retracted penile skin with penis not visible in normal anatomical position
• Penile shaft may be palpable but hidden beneath skin/fat
• Urination may occur through an opening in prepubic skin 3
• Examination of genitalia should include checking for:
  • Abnormalities in testicular size
  • Fibrosis in shaft of penis
  • Retractable foreskin 7

Diagnostic Testing

• Imaging:
  • MRI can identify the location of the invaginated penis and its relationship to surrounding structures 3
  • Ultrasound has limited utility in diagnosing penile retraction 7

Classification of Adult Buried Penis

According to recent research, adult buried penis can be classified into three types 4:

1. Pseudo-buried penis: Penis covered under lax skin without retraction
2. Intermediate-type buried penis: Partial penile invagination
3. Classical buried penis: Complete penile retraction into prepubic fat

Treatment Approaches

Non-surgical Management

• Limited role in true penile retraction
• May be considered for temporary management or in patients unfit for surgery

Surgical Management

Based on the cause and classification:

For Trauma-Related Retraction

• Surgical exploration with:
  • V-Y plasty
  • Removal of fatty tissue
  • Dissection of entrapped corpora cavernosa
  • Ventral fixation of the penis 2
  • Release of fibrotic adhesions 3

For Obesity-Related Buried Penis

• Type 1 (Pseudo-buried penis):

  • Apronectomy and prepubic lift with tissue fixation 4

• Type 2 (Intermediate-type):

  • Prepubic apronectomy
  • Anchoring sutures to secure penile shaft 4

• Type 3 (Classical buried penis):

  • Scar excision
  • Reduction of prepubic fat
  • Extraction of penile shaft
  • Anchoring sutures
  • Reconstruction of penile envelope 4

For Peyronie's Disease with Retraction

• Intralesional therapy for stable disease with significant curvature:

  • Collagenase clostridium histolyticum (CCH) injections - first-line treatment 5
  • Interferon α-2b as second-line option 5

• Surgical options for severe cases:

  • Penile plication (for patients without erectile dysfunction)
  • Plaque incision/excision with grafting
  • Penile prosthesis implantation with modeling (for concurrent erectile dysfunction) 5
  • Intracavernous cylinder placement with tunical relaxing incisions and saphenous vein grafting 6

Post-Treatment Considerations

Follow-up Care

• Regular assessment of treatment efficacy
• Monitoring for complications
• Evaluation of sexual function and urinary symptoms

Potential Complications

• Recurrent retraction
• Erectile dysfunction
• Penile shortening
• Infection
• Preputial edema 6

Special Considerations

Psychological Impact

• Penile retraction can cause significant psychological distress
• Setting realistic expectations about treatment outcomes is important
• Psychological support may be beneficial

Erectile Function

• Erectile dysfunction may coexist with penile retraction
• For concurrent erectile dysfunction, PDE-5 inhibitors are appropriate first-line treatments 5
• Surgical correction of retraction may restore erectile function in some cases 3

Prevention

• Proper evaluation of genitalia in patients with pelvic trauma 3
• Early intervention to prevent progressive scarring and retraction
• Appropriate management of conditions that can lead to penile retraction (e.g., Peyronie's disease)

Penile retraction is a complex condition with multiple potential etiologies. Surgical intervention tailored to the specific cause and classification is the mainstay of treatment, with excellent outcomes reported in most cases when the appropriate technique is selected.