Inconspicuous Penis

Inconspicuous penis: a conundrum

By Dr Japinder Khosa, Paediatric Urologist, Joondalup

The term ‘inconspicuous penis’ refers to a group of abnormalities in which the penis appears small for the age causing great concern and anxiety to both parents and the child.

Micropenis is usually defined as a normally formed penis with a stretched penile length (SPL) of at least 2.5 SD below the mean for the patient’s age. SPL is defined as the maximum length of the penis when stretched and is measured from the base of the penis under the pubis symphysis to the tip of the glans. It usually results from hormonal abnormality during gestation and can present in isolation or as part of disorder of sexual differentiation (DSD). An endocrinology referral and cultural circumcision should not be performed until assessed. Concealed penis This is where a penis of normal size is hidden below the surface of prepubic skin, and has various causes.

Congenital Megaprepuce is a condition characterised by poor fixation of the skin at the base of the penis, phimosis, deficiency of ventral shaft skin and a swollen large inner prepuce. This results in severe ballooning of the prepuce with inability to void completely. Parents are required to express urine manually from the foreskin of the baby, which is the clinch to the diagnosis. Visually the penis looks short, glans is located beneath the penoscrotal junction and the penis has a dome shaped appearance. This needs surgical correction. Webbed Penis results from a skin fold or a web that obscures the penoscrotal angle. Diagnosis is made by lifting the shaft of the penis and to see a cutaneous fold that extends from the ventral penile skin to the scrotal wall and sometimes there can be complete penoscrotal fusion, needing surgical correction.

Key messages

Inconspicuous penis can result in considerable concern for both parents and the child 9% of children presenting for circumcision have evidence of inconspicuous penis Differentiate true micropenis, which needs an endocrinology review, to a concealed penis, which needs a paediatric urology review.

Trapped penis is an acquired form where, following circumcision, the penile skin forms a circumferential scar distal to or at the level of the glans and traps the penis. It can happen after an overzealous neonatal circumcision or circumcision performed on a penis with moderate penoscrotal webbing. These boys can present with difficulty passing urine and UTI. It can be treated with topical steroids but if not responsive will need surgical correction. Excessive prepubic fat is more commonly seen in older and obese adolescents. Most of these boys will lose their fat pad with growth and puberty. However, in obese individuals who are post pubertal, surgical correction may be needed to ensure psychological confidence and, in some cases, help in voiding standing up. Inconspicuous penis is more common than is usually appreciated and a timely referral to a paediatric urologist or endocrinologist can alleviate parent and patient concerns.

Author competing interests – nil

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