Phimosis, Buried Penis and Megaprepuce

1）Phimosis

Introduction

Phimosis is when the foreskin cannot be pulled back (retracted) over the glans penis. This is very common in boys and is often a normal finding in infants and young children, usually resolving naturally as the child grows older. By puberty most boys achieve full foreskin retractability.

Signs and Symptoms

• The foreskin cannot be pulled back over the glans.
• Ballooning (“puffing out”) of the foreskin during urination.
• Redness, soreness, or swelling around the tip of the penis.
• Recurrent infections under the foreskin or tip of the penis (Balanoposthitis).
• Pain, difficulty urinating, or a weak stream in severe cases.

Treatment and Management

• Conservative management is often appropriate for physiological (normal) phimosis in young children.
• Gentle daily retraction and good hygiene can help prevent infection.
• If phimosis causes symptoms or problems, a steroid cream may be prescribed. It is usually applied to the foreskin up to twice daily usually for 8 weeks. This usually improves the phimosis without the need for surgery. Steroid cream is a safe and common treatment and applied like lotion to soften the tip of the foreskin.
• Rarely, if symptoms persist or are severe, surgery such as circumcision may be considered.

Indications for Surgery

• Failure of medical management with steroid cream for problematic phimosis.
• Recurrent balanoposthitis or persistent painful symptoms.
• Associated urinary tract infections with underlying structural issues.
• Scarring or suspicion of balanitis xerotica obliterans (BXO), a special form of scarring.

2）Buried penis and megaprepuce

Introduction

Buried penis is a condition where the penis appears hidden beneath the skin of the lower abdomen, pubic area, or scrotum, even though the penile shaft itself is of normal size. Congenital megaprepuce is a rare type of buried penis characterized by excessive foreskin that inwardly folds, covering the penile shaft and making it appear shortened or sunken. Both conditions may cause difficulties with hygiene, urination, and psychological concerns.

Signs and Symptoms

• Penis appears small or "sunken" and may be difficult to see or retract the foreskin properly.
• Difficulty urinating due to urine trapped under the foreskin or skin folds, sometimes causing urine spraying or dribbling.
• Accumulation of urine and debris under the foreskin leading to foul odor, redness, swelling, foreskin infections, or urinary tract infections.
• Possible psychological impact from the penis's abnormal appearance.

Diagnosis

Buried penis and megaprepuce are diagnosed clinically. True buried penis is usually a congenital condition where the penile shaft is “buried” due to laxity of the ligaments attaching the penis to the pubic bone and abnormal attachment of skin to the penile shaft. Partial buried penis occurs usually due to excessive fat pad over the pubic area covering and hiding the penis, making it look shortened. Thus, a proper clinical evaluation is required for proper diagnosis and to determine the severity.

Treatment and Management

• Conservative management may include hygiene education and monitoring; in some cases, use of steroid creams for inflammation or skin adhesions.
• True buried penis usually requires surgery, especially for those with congenital megaprepuce. The key principle is to unbury the penis and re-create the penopubic angle by fixing the penile shaft to the pre-pubic fascia and re-fashioning of the foreskin.
• Partial buried penis usually does not require surgery. Weight management is advised as it is often associated with obesity.

What to expect during your first visit?

During the first visit to the paediatric surgeon for phimosis or buried penis, you can expect the following:

•  The surgeon will take a detailed history, asking about symptoms such as pain, difficulty urinating, or infections related to the foreskin.
•  An examination of the genital area will be performed to assess the degree of foreskin tightness, presence of inflammation, redness, scarring, or other abnormalities such as buried penis.
•  The condition of phimosis will be explained clearly, including the difference between physiological (normal in young boys) and pathological phimosis, and what to expect going forward.
•  The surgeon will demonstrate and teach gentle foreskin retraction exercises, instructing on how and when to perform them safely to avoid causing pain or injury.
•  Based on the examination, a topical steroid cream may be prescribed to help reduce tightness and promote foreskin flexibility, along with guidance on proper application.
•  If the phimosis is severe and causes significant problems, or if medical treatment is unlikely to be sufficient, surgery such as circumcision might be considered.
•  If true buried penis is diagnosed, surgery will usually be discussed and arranged.

References

• Royal Children's Hospital Melbourne. Clinical practice guidelines: the penis and foreskin [Internet]. Royal Children's Hospital Melbourne. Clinical practice guidelines: the penis and foreskin [Internet]. Melbourne: Royal Children's Hospital Melbourne; [cited 2026 May 27]. Available from: https://www.rch.org.au/clinicalguide/guideline_index/the_penis_and_foreskin/
• Moreno G, Corbalán J, Peñaloza B, Pantoja T. Topical corticosteroids for treating phimosis in boys. Cochrane Database Syst Rev. 2024;1(1):CD008973.
• Werner Z, Hajiran A, Al-Omar O. Congenital megaprepuce: literature review and surgical correction. Case Rep Urol. 2019;2019:4584609. doi:10.1155/2019/4584609.

Acknowledgement

Principal author: Dr Felix Yam on behalf of Department of Paediatric Surgery, HKCH

Initial posting: Oct 2026

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