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Table of Contents
REVIEW ARTICLE
Year : 2020  |  Volume : 31  |  Issue : 5  |  Page : 200-205

Webbed penis: Etiology, symptoms, surgical treatments, and outcomes


1 Division of Urology, Department of Surgery, Taipei Tzu Chi General Hospital, Buddhist Tzu Chi Medical Foundation, Taipei; School of Medicine, Buddhist Tzu Chi University, Hualien, Taiwan
2 Division of Urology, Department of Surgery, Taipei Tzu Chi General Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan

Date of Submission21-Jan-2020
Date of Decision12-Mar-2020
Date of Acceptance05-Apr-2020
Date of Web Publication27-Oct-2020

Correspondence Address:
Chia-Da Lin
Division of Urology, Department of Surgery, Taipei Tzu Chi General Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Chienkuo Road, Xindian Dist., New Taipei City
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/UROS.UROS_5_20

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  Abstract 


Webbed penis may be congenital or acquired in etiology. Treatments are indicated for reasons such as cosmetic concerns and erection pain. This study aims at reviewing the etiology, symptoms, types of surgical correction, and outcomes of webbed penis. We searched Medline/PubMed for “webbed penis” and “inconspicuous penis” from 1956 through 2019. In this study, we discuss the advantages, drawbacks, and outcomes of each surgical method. We also explain the postoperative cosmetic outcomes and complications of the previously proposed surgical methods. Since the isolated congenital webbed penis is uncommon, there is a paucity of large-scale studies for the treatment of webbed penis. A variety of methods are proposed to correct webbed penis, including traditional transverse incision and vertical closure, Z-plasty, V-Y advancement technique, Byars preputial flap method, and other methods. Preoperative design is essential and is based on not only the degree of penoscrotal fusion but also the surgeon's experience and preference of the surgical methods. Some methods call for elaborate skin flaps that may be technically complicated. The immediate outcomes of surgical correction for webbed penis are good. However, studies on long-term cosmetic results and patient satisfaction remain scarce. Hence, surgical correction of the webbed penis generally yields good results. Long-term follow-up of postoperative cosmetic outcomes, patient satisfaction, and the impact of surgery on the psychological development of children are indicated.

Keywords: Surgical correction, penoscrotal web, webbed penis


How to cite this article:
Chao TC, Yang SS, Chang SJ, Lin CD. Webbed penis: Etiology, symptoms, surgical treatments, and outcomes. Urol Sci 2020;31:200-5

How to cite this URL:
Chao TC, Yang SS, Chang SJ, Lin CD. Webbed penis: Etiology, symptoms, surgical treatments, and outcomes. Urol Sci [serial online] 2020 [cited 2020 Nov 28];31:200-5. Available from: https://www.e-urol-sci.com/text.asp?2020/31/5/200/299262




  Introduction Top


The term “webbed penis” is used when the scrotal skin extends too high onto the ventrum of the penis forming a web between the penis and scrotum.[1] In 1953, Bisotti[2] first proposed the term “virga palmata” to describe the webbed penis in Italian literature. Other appellations such as penoscrotal web, penoscrotal fusion, penoscrotal pterygium, and penis palmatus were also employed to describe the condition.[3] The true incidence of webbed penis is unknown. Isolated congenital webbed penis is uncommon and it often coexists with other congenital anomalies such as hypospadias, chordee, or micropenis. A review of patients treated for hypospadias at Riverside Hospital in Newport News revealed that the incidence of webbed penis among these patients was 3.5%.[4] With an obscured penoscrotal angle, a webbed penis may appear small despite the normal size of penile phallus. Therefore, a webbed penis represents one type of concealed penis or inconspicuous penis. According to the classification system proposed by Maizels et al., inconspicuous penis includes the buried penis, webbed penis, trapped penis, and micropenis.[5] In a series of surgical corrections of concealed penis and inconspicuous penis, the isolated webbed penis was accounted for a minor part of the inconspicuous penis.[6],[7],[8],[9]

Webbed penis is usually asymptomatic. Due to the obscured penoscrotal angle by the web, the penis appears small and concealed. Usually, cosmetic concerns urge parents of young boys and older patients to seek medical help. After adolescence, pain associated with wearing condoms, erection, or coitus can also occur.


  Etiology Top


The exact etiology of the webbed penis is unknown. During embryogenesis, the development of the penis is completed at 16 weeks of gestation.[5] A delay or disturbance in the development of the preputial skin could result in a deficiency of the ventral penile skin or abnormal dartos band attachment could explain the condition.[4],[10] In Glanz's[11] opinion, abnormal attachment of the skin due to an embryonic carry-over a vestigial cloacal veil may contribute to webbed penis. In patients with acquired webbed penis, the etiology was due to overt excision of the ventral penile skin during the circumcision that causes postoperative penile tightness during erection.[12]


  Treatments Top


Patients with acquired webbed penis that causes discomfort are in need of surgical correction to release the tightness of the penis. Nonetheless, the indications for surgical correction of isolated congenital webbed penis are unclear, since its natural history and the number of males with a webbed penis that spontaneously regressed are unclear. Maizels et al.[5] and Wollin et al.[13] emphasized early surgical correction of inconspicuous penis reduced negative psychological effects on boys.

It is important to identify other coexisting congenital anomalies before the surgical correction of the webbed penis. The ultimate goal of treating a webbed penis is to separate the penis from the scrotum, removing the web entirely and increasing the ventral penile skin length. In 2010, a new classification was proposed by Montasser and El Gohary. Webbed penis can be broadly categorized into primary and secondary types, according to their study. The primary is further subdivided into simple and compound. Subtypes of the simple webbed penis are based on the involved length of the web to the penile shaft. Compound types of webbed penis included three subtypes: (1) web with prepenile scrotum, (2) with penile curvature, and (3) broad web. A secondary webbed penis is defined as a postcircumcised penis in obese children or a concealed penis. The classification aims to streamline the proper operative procedures for children who were referred for circumcision.[14] However, the usefulness of the classification to the clinical practice has been questioned by other authors.

In our opinion, the degree of penoscrotal fusion can be simply classified into complete and partial fusion as shown in [Figure 1]. Penoscrotal web can be classified as partial and complete penoscrotal fusion. Partial penoscrotal fusion is defined as “the scrotal skin extends onto the ventrum of the penis but proximal to the midpoint of the penile shaft“, while complete penoscrotal fusion is defined as “the scrotal skin extends onto the ventrum of the penis but distal to the midpoint of the penile shaft.”
Figure 1: Classification of webbed penis: (a) partial penoscrotal fusion (b) complete penoscrotal fusion

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Historically, a variety of surgical techniques were advocated to correct the webbed penis. Because of the variability of the effectiveness of different lengthening methods, it is important to take the degree of penoscrotal fusion into consideration before choosing a surgical method. In our opinion, the ventral penile skin length to be increased or the length of discrepancy to remove the web was determined by the formula shown in [Figure 2]. Theoretically, the discrepancy (d) to be lengthened is calculated as the formula: D=a+b –c.
Figure 2: To measure the length of the discrepancy (d), the formula: D = a + bc was used

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Traditionally, the simplest and most commonly used method to correct the webbed penis is to incise the web transversely and close the wound vertically. Other methods include Byars preputial flaps, Z-plasty, V-Y plasty, and other flap methods.

V-Y plasty

We preferred the V-Y plasty to correct the webbed penis. The method of correction was well described previously.[15] A V-figured incision (with an open angle of 60° and each arm 1 cm in length) was made at the penoscrotal junction of the patient as shown in [Figure 3]. The triangular skin flap was cautiously undermined and mobilized, and the vessels underneath the flap were carefully preserved. The skin flap was pulled gently upwards and the penile skin both below and beside the incision was also undermined for a short distance. The wound was closed to create a Y-figured wound using a 4-0 chromic catgut. With the intent to correct the web completely, the V-Y advancement procedure was repeated at the site distal to the previous suture line.
Figure 3: V-Y plasty: after a V-shaped incision at the penoscrotal junction, the V-shaped flap was carefully dissected and mobilized. Then, the wound was closed in a Y-shaped closure

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This V-Y plasty avoids lateral rotation and can be easily designed preoperatively. Since the blood supply of the triangular flap can be well preserved, postoperative flap failure or wound contracture rarely occurs. The length gain from the V-Y plasty procedure, when applied to the forearm, is about 0.4 times the length of the straight limb of the Y.[16] Theoretically, when V-Y advancement is applied on innately loose penile and scrotal skin, more skin length gain can be gained. In our opinion, when performing the V-Y plasty, the optimal open angle of the V should be about 60° and the length of the arms should be about 1 cm. If the open angle is too large, the skin length gain will be restricted. On the other hand, if the open angle is too small, the blood supply to the tip of the triangular flap may be compromised. The length of the arms is also crucial for a successful correction. They have to be long enough to facilitate a satisfactory increase of skin length, yet not too long to crumple the triangular skin flap hindering suturing the V-shaped arms of the Y. The major drawback of the V-Y plasty is its inability to lengthen as effectively as the Z-plasty method.[16] In patients with complete fusion of the penis and scrotum, the V-Y advancement technique will not provide adequate skin lengthening of penile ventrum.

Transverse incision with vertical closure

Traditionally, the incision was placed at the midpoint of the penoscrotal web [Figure 4].[1] Vertical closure of the transverse wound was performed with interrupted catgut sutures, with good immediate cosmetic results. However, redundancy of the ventral penile skin, like a dog-ear, and narrowing of the transverse circumferential penile skin occurred after surgery. Besides, narrowing of transverse circumferential penile skin after the operation and postoperative wound contracture remain major concerns by other authors.[3]
Figure 4: Transverse incision with vertical closure: the web was incised transversely and the wound was closed vertically

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Parapenile incision

In correction complete penoscrotal web, Perlmutter and Chamberlain[10] used a parapenile incision to separate the penis from the scrotum in six boys with webbed penises in 1972. The incision line was placed parallel to the penile shaft at the parapenile area as [Figure 5] shown and left the major part of the penoscrotal web for the scrotum. The incision should not extend too close to the penoscrotal junction since constriction of the penoscrotal junction can occur after wound closure and cause discomfort during erection. Then, the wound was closed in a vertical fashion. Perlmutter believed that the method was simple and that wound contracture was not likely to occur postoperatively. However, postoperative skin redundancy that needs careful tailoring to avoid the dog-ear deformity is the major concern.
Figure 5: Parapenile incision: the incision line was placed at the junction of the penis and the web. Then, the wound was closed vertically

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Z-plasty

Z-plasty was first introduced by Glanz[11] in 1968 to correct the congenital webbed penis in a 56-year-old patient. Z-plasty is an effective method to increase the length along a selected axis. Z-plasty is composed of three equal limbs with two equal angles of 60°. The central limb of the Z-plasty is placed parallel to the line of the penile raphe [Figure 6]. After a Z-figure incision is made at the penoscrotal junction, the skin flaps are cautiously undermined and mobilized. The two skin flaps were transposed gently upwards and downwards. The wound was then sutured with 4-0 catgut sutures in an inverted Z-figure.
Figure 6: Z-plasty: after a Z-shaped incision at the penoscrotal junction, the flaps were carefully dissected and the two flaps were then transposed and closed as shown

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In planning a Z-plasty to correct webbed penis, one must consider limb length, size of open angles, and vesicoelasticity of the skin. Theoretically, a Z-plasty would result in a gain in length of 75% of the central limb when the open angle is 60°.[16] The usual open angles of the Z should be about 60°. If the open angles are larger, the skin length gain will be greater, but it may result in constriction of the transverse skin length. On the other hand, if the open angles are too small, the ability of skin lengthening is limited. Additionally, the narrow-angle of the skin flap may compromise the blood supply to the flaps. As needed, multiple Z-plasties may be used to facilitate lengthening without overt shortening of the transverse length that can cause the tightness of the penis.

The major drawback of Z-plasty is the transference of hair-bearing skin to a nonhair-bearing area during Z-plasty, causing “local hirsutism” that may need laser fulguration of the hair follicles.[8] Z-plasty can also cause reduction of the circumferential penile skin when the ventral penile skin is inadvertently over-resected.[12]

Byars preputial skin flaps

Redman[17] first used preputial skin flaps to correct webbed penises in 1984. The Byars preputial flap method is usually applied to patients with hypospadias with a shortage of ventral penile skin.[18] A circumferential incision is made 5 mm to 10 mm below the coronal edge and the urethral meatus. Then, the penile skin is degloved to the penile base. After the excision of the redundant prepuce, a longitudinal incision was made at an avascular area on the dorsal prepuce. Then, the skin flap was transferred to the ventral site to help the scrotal skin regress more downwardly. The wound is closed with chromic catgut sutures [Figure 7]. Byars method is useful when the ventral penile skin is too short to use other flap methods. It also avoids transfer of hair-bearing skin to the ventral penile skin. However, the method is technically complicated and rotation of the skin flaps is required. Redundant skin flaps require careful tailoring to avoid the dog-ear deformity. This method is limited only with long enough dorsal penile skin and may not apply to patients with acquired webbed due to shortage of the foreskin.
Figure 7: Byars preputial flap method: after the circumcision was performed, a dorsal midline incision was made at dorsal prepuce. The skin flap was then resurfaced to the penile ventrum to help the scrotal skin regress downwardly

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Diamond-shaped skin flap

Dilley[3] proposed a flap method to correct the webbed penis as shown in [Figure 8]. A diamond-shaped area was placed at the penoscrotal junction. The diamond-shaped skin was then divided into four triangular areas. The two dashed triangular areas of skin were excised and the two other triangular areas of skin flaps were cautiously dissected and pulled to the opposite side and sutured in a Z-figure with chromic catgut sutures. This method slightly lengthens the ventral penile skin, but the authors do not mention its effectiveness in lengthening. This method greatly narrows the circumferential diameter of the penile base.
Figure 8: A diamond-shaped marking was placed at the penoscrotal junction and the area was divided into four triangular areas: The dashed areas of skin were excised and the two triangular skin flaps were then carefully dissected and mobilized

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Oblique skin incision followed by penis shaft skin physical therapy

Maizels et al.[19] used an oblique skin incision followed by penis shaft skin physical therapy to correct the penoscrotal web. An alternate circumcision incision was planned oblique, slant up, to the corona ridge. The oblique incision plan retained more ventral shaft skin than the skin of the dorsal site. After the circumcision, parents were educated to apply penile shaft skin physical therapy at diaper change for 6 months. Parental compliance plays a crucial role in the success of circumcision. The authors claim that surgical reconstruction could be avoided by this method.


  Outcome Analysis Top


Proper treatment of webbed penis depends on the surgeon's experience and preference of the surgical method, and the selection criteria for patient enrollment. We searched Medline/PubMed for “webbed penis” and “inconspicuous penis” from 1956 through 2019. Most case series reported good short-term postoperative cosmetic results. The case numbers, methods of surgical correction and outcomes were listed in [Table 1]. Regardless of the used correction method, there are few reports of complications associated with the surgery. Bonitz and Hanna had compared short-term outcomes of parapenile incision and vertical closure, V-Y plasty, and Z plasty in 2016. All of the procedures had a similar success rate at 6 months of follow up.[20] In our opinion, we suggest that parapenile incision and vertical closure are useful in correcting the complete penoscrotal web. Byars preputial flap method may be of great help in synchronous hypospadias and complete penoscrotal web with redundant dorsal penile skin. When correcting partial penoscrotal web, V-Y plasty, Z-plasty and oblique skin incision followed by physical therapy are preferred.
Table 1: Historical review of surgical methods of correcting webbed penis

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  Conclusion Top


When properly performed, the webbed penis can be corrected with a variety of surgical methods. Despite generally good postoperative results, the surgeon's experience with the method and the surgical design determine the postoperative cosmetic results. Since the degree of penoscrotal fusion runs the spectrum from complete fusion to a small web connecting the penis and scrotum, the method and design of correction may differ from one boy to another. Studies of long-term follow-up of cosmetic results and patient satisfaction are indicated.

Financial support and sponsorship

This work was supported by grants from Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation (TCRD-TPE-106-RT-6 and TCRD-TPE-107-51).

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Wein AJ. Campbell-Walsh Urology. Philadelphia: Saunders; 2016.  Back to cited text no. 1
    
2.
Bisotti P. Case of virga palmata. Rass Int Clin Ter 1953;33:452-6.  Back to cited text no. 2
    
3.
Dilley AV, Currie BG. Webbed penis. Pediatr Surg Int 1999;15:447-8.  Back to cited text no. 3
    
4.
Shepard GH, Wilson CS, Sallade RL. Webbed penis. Plast Reconstr Surg 1980;66:453-4.  Back to cited text no. 4
    
5.
Maizels M, Zaontz M, Donovan J, Bushnick PN, Firlit CF. Surgical correction of the buried penis: Description of a classification system and a technique to correct the disorder. J Urol 1986;136:268-71.  Back to cited text no. 5
    
6.
Bergeson PS, Hopkin RJ, Bailey RB Jr., McGill LC, Piatt JP. The inconspicuous penis. Pediatrics 1993;92:794-9.  Back to cited text no. 6
    
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Radhakrishnan JR, Manickam K. Concealed penis. Pediatr Surg Int 2002;18:668-72.  Back to cited text no. 7
    
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Borsellino A, Spagnoli A, Vallasciani S, Martini L, Ferro F. Surgical approach to concealed penis: Technical refinements and outcome. Urology 2007;69:1195-8.  Back to cited text no. 8
    
9.
Cimador M, Catalano P, Ortolano R, Giuffrè M. The inconspicuous penis in children. Nat Rev Urol 2015;12:205-15.  Back to cited text no. 9
    
10.
Perlmutter AD, Chamberlain JW. Webbed penis without chordee. J Urol 1972;107:320-1.  Back to cited text no. 10
    
11.
Glanz S. Adult congenital penile deformity. Case report. Plast Reconstr Surg 1968;41:579-80.  Back to cited text no. 11
    
12.
Alter GJ. Correction of penoscrotal web. J Sex Med 2007;4:844-7.  Back to cited text no. 12
    
13.
Wollin M, Duffy PG, Malone PS, Ransley PG. Buried penis. A novel approach. Br J Urol 1990;65:97-100.  Back to cited text no. 13
    
14.
El-Koutby M, Amin el G. Webbed penis: A new classification. J Indian Assoc Pediatr Surg 2010;15:50-2.  Back to cited text no. 14
[PUBMED]  [Full text]  
15.
Chang SJ, Liu SP, Hsieh JT. Correcting penoscrotal web with the V-Y advancement technique. J Sex Med 2008;5:249-50.  Back to cited text no. 15
    
16.
Cohen M. Mastery of Plastic and Reconstructive Surgery. 1st ed. Boston: Little Brown & Company; 1993.  Back to cited text no. 16
    
17.
Redman JF. A technique for the correction of penoscrotal fusion. J Urol 1985;133:432-3.  Back to cited text no. 17
    
18.
Byars LT. A technique for consistently satisfactory repair of hypospadias. Surg Gynecol Obstet 1955;100:184-90.  Back to cited text no. 18
    
19.
Maizels M, Meade P, Rosoklija I, Mitchell M, Liu D. Outcome of circumcision for newborns with penoscrotal web: Oblique skin incision followed by penis shaft skin physical therapy shows success. J Pediatr Urol 2019;15:404.e1.  Back to cited text no. 19
    
20.
Bonitz RP, Hanna MK. Correction of congenital penoscrotal webbing in children: A retrospective review of three surgical techniques. J Pediatr Urol 2016;12:161.e1-5.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

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Abstract
Introduction
Etiology
Treatments
Outcome Analysis
Conclusion
References
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