What are the potential causes and treatments for a retracting penis?

Retracting Penis: Causes and Management

Immediate Diagnostic Approach

The first priority when evaluating a complaint of "retracting penis" is to distinguish between physiologic retractile testis (which involves testicular position, not penile retraction), true penile concealment/retraction, traumatic penile dislocation, psychiatric delusion (Koro syndrome), or paraphimosis from genital piercing.

Key Clinical Distinctions

Retractile Testis (Most Common Misunderstanding)

• A retractile testis represents a hyperactive cremasteric reflex pulling the testis upward into the inguinal canal, not actual penile retraction 1
• The testis can be easily manipulated into the scrotum and remains there without traction, distinguishing it from true cryptorchidism 1
• Annual monitoring is mandatory because retractile testes carry a risk of becoming truly undescended during childhood, with reported incidence of secondary ascent ranging from 2-45% 2, 1
• Assess testicular position at least annually at well-child visits 2, 1
• Imaging studies are not recommended as they rarely assist in decision-making 1

True Penile Retraction/Concealment

• Retractile concealed penis is caused by dysgenetic fibrous bands tethering the penis to the prepubic subcutaneous tissue 3
• The retractile nature can be confirmed by flexion of the hips 3
• Physical examination reveals a buried penile shaft with only the glans visible 4

Traumatic Penile Dislocation

• Extremely rare but critical to identify: occurs following pelvic fracture with displaced pubic bone 5
• The retraction of the pubic bone pulls the penis by its suspensory ligament, leading to penile dislocation 5
• Penis may not be visible or palpable in expected position; micturition occurs by dripping from prepubic skin opening 5
• MRI shows invaginated penis located in anterior pelvic wall 5

Paraphimosis from Genital Piercing

• Paraphimosis (inability to replace a retracted foreskin) has been associated with urethral and glans piercings in uncircumcised men 2
• The foreskin may be reduced manually after a penile nerve block 2
• If manual reduction fails, inject the prepuce with hyaluronidase to allow edematous fluid to dissipate 2

Koro Syndrome (Psychiatric)

• A psychiatric syndrome where the patient is convinced his penis is retracting despite no physical evidence 6
• Requires psychiatric evaluation and management 6

Treatment Algorithms

For Retractile Testis

• No surgical intervention is required for true retractile testis 1
• Monitor annually for secondary ascent (acquired cryptorchidism) 2, 1
• If secondary ascent occurs (testis can no longer be manipulated into scrotum), refer to surgical specialist 2
• Boys with acquired cryptorchidism should be referred to appropriate surgical specialist, as the same adverse histologic features (loss of germ cells) found in primary undescended testes are also found in acquired cryptorchid testes 2

For Adult Acquired Retractile/Concealed Penis

Surgical correction is the definitive treatment for symptomatic retractile concealed penis 4, 3

• Surgical technique involves releasing dysgenetic fibrous bands tethering the penis to prepubic tissue 3
• For patients with significant prepubic fat pad, combined removal of suprapubic fat pad with insertion of subcutaneous soft silicone penile implant provides excellent cosmetic and functional outcomes 4
• This approach increases self-confidence, self-esteem, and sexual confidence with natural appearance at one year follow-up 4
• Proper selection of technique based on understanding of pathophysiology is critical to successful outcome 3

For Traumatic Penile Dislocation

Immediate surgical exploration and repair is required 5

• Perform inverted "V" suprapubic incision to explore pubic area 5
• Identify and isolate degloved penile shaft from fibrotic adhesions 5
• Sharply resect adhesions where subcutaneous tissue and skin are attached to fractured pubic bone spike 5
• Restore penis and skin to anatomical position 5
• Simulate erection with saline injection into corpora cavernosa to exclude penile curvature 5

For Paraphimosis from Piercing

• Attempt manual reduction after penile nerve block 2
• If unsuccessful, inject prepuce with hyaluronidase 2
• Remove all genital jewelry to prevent recurrence 2

Critical Pitfalls to Avoid

• Do not confuse retractile testis with penile retraction—these are entirely different anatomical conditions requiring different management 2, 1
• Do not dismiss complaints of penile retraction in trauma patients—delayed presentation of traumatic penile dislocation can occur months after pelvic fracture 5
• Do not order imaging for simple retractile testis—it is not indicated and does not assist in decision-making 1
• Do not perform orchidopexy for true retractile testis—only monitor annually for secondary ascent 2, 1
• Always evaluate genitalia in patients with pelvic trauma to identify occult penile dislocation 5