Adult acquired buried penis and bariatric surgery: a mighty motivator

Introduction

Adult acquired buried penis (AABP) is a syndrome in which the penis becomes enclosed under skin and fat, often due to obesity. This can lead to issues with hygiene, sexual function and urination. As hygiene becomes more difficult, the surrounding skin is exposed to urine and undergoes breakdown and scarring. This worsens the problem and creates a viscous, self-perpetuating cycle. Amongst men with buried penis, there is data to suggest decline in quality of life, and it is common for patients to be depressed and experience feelings of hopelessness (1).

The incidence of AABP is not known. However, rates of obesity are rising, and 81% of American men are projected to be overweight by 2030 (2). With the increase in obesity, there will be an increased number of men suffering from this disease. In the early stages of AABP, it is unclear whether weight loss will ameliorate or exacerbate patient symptoms, and the effect may be variable between otherwise similar patients. Some studies report that losing weight will reverse the process and symptoms will improve (3), while others have found that weight loss worsened the condition (1). That said, there is consensus that as the disease progresses, surgical intervention is the mainstay of treatment (4). Considering the lingering questions regarding both the incidence of the disease and the effect that weight loss may have on disease symptoms, we aim to evaluate how bariatric surgery affects men with AABP. We present this article in accordance with the SURGE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-692/rc).

Methods

Patients who underwent bariatric surgery at a single academic institution between 2009 and 2021 were contacted for participation in a retrospective cross-sectional survey. Bariatric surgery was defined as any surgical intervention for weight loss. Initial contact was attempted over email. Those that did not respond were called at two separate points to gauge interest in participation. Interested participants were sent an online REDCap, sex-specific survey based on self-reported sex. We did not inquire if patients identified as transgender or nonbinary. The survey included questions on demographics, voiding and anatomic function, and sexual function. Binary “yes or no” questions were used to minimize recall bias and assess symptom change over time. The survey is included online at https://cdn.amegroups.cn/static/public/tau-2025-692-1.pdf. For this study, we only included completed surveys from male participants.

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study received approval from the Institutional Review Board of the University of California, San Francisco (IRB, No. 22-36207). All patients consented to participation.

Patients were not asked to provide pre- or post-surgery genital photos. Men were considered to have AABP if they answered “yes” to the question, “Have you ever had trouble exposing the penis to urinate or have sex?”. Men were also asked if they would be willing to view a series of 5 pictures depicting men with buried penis of progressively worse severity (available online: https://cdn.amegroups.cn/static/public/tau-2025-692-1.pdf). Of note this was done prior to the widespread implementation of a classification system for AABP. If they opted in, they were then asked to choose the photo that best represents how they looked before the surgery and how they currently look.

Statistical analysis

Baseline characteristics were compared between men with and without AABP using Fisher’s exact test. McNemar’s test was used to assess significant changes in symptoms within each group from pre-operative baseline to post-operative follow-up. To compare the efficacy of bariatric surgery between the two groups, the rate of symptom resolution was compared using Fisher’s exact test. Given the exploratory nature of this analysis, P values were not adjusted for multiple comparisons and statistical significance was set at P<0.05. Graphpad.com was used to perform Fisher’s exact test and McNemar’s test. Medcalc.org was used to calculate absolute difference and confidence intervals (CIs). Microsoft excel was used to perform t-tests on demographic data.

Results

Demographics

Eighty-nine men were contacted, of which 64 completed the survey (72% response rate). There were 11 with AABP, based on an answer of “yes” to the question, “Have you ever had trouble exposing the penis to urinate or have sex?”. The average and median time from surgery to survey was 51.6 and 45.5 months respectively, with a range of 5–140 months. There was no significant difference in age, pre-operative (prior to bariatric surgery) weight and pre-operative body mass index (BMI), average post-operative weight loss, and time from surgery to survey between the AABP and non-AABP groups (Table 1).

Voiding and anatomic function

Men were asked to recall pre-operative voiding and anatomic function including ability to urinate standing, ability to see their penis and difficulty with genital hygiene/infections. Amongst men with AABP, a vast majority (82%) could urinate standing, a minority (8%) were able to see their penis, and about half (45%) had issues with genital infections. Men without AABP reported significantly better pre-operative function: 100% could urinate standing (absolute difference 18%; 95% CI: 3.3% to 47.5%, P=0.03) and only 9% had issues with genital infections (absolute difference 36%, 95% CI: 9.6% to 63.1%, P=0.01). Regarding anatomy, 40% of men without AABP could see their penis compared to the 8% of men with AABP (absolute difference 32%, 95% CI: 1.1% to 47.1%, P=0.08) (Figure 1).

Figure 1 Baseline characteristics of men with and without AABP who underwent bariatric surgery. *, statistically significant difference between baseline values (P<0.05, Fisher’s exact test). AABP, adult acquired buried penis.

After surgery, both men with and without AABP saw a general improvement in voiding and anatomic function. In men with AABP, the ability to urinate standing increased from 82% to 100% (P=0.48), the ability to see the penis increased from 8% to 55% (P=0.07), and issues with genital hygiene/infection decreased from 45% to 36% (P>0.99). In men without AABP the ability to urinate standing decreased from 100% to 98% (P>0.99), the ability to see the penis increased from 40% to 91% (P<0.001), and issues with genital hygiene/infection decreased from 9% to 2% (P=0.22) (Figure 2).

Figure 2 Comparison of how bariatric surgery affected voiding, anatomic, and sexual symptoms in men with adult acquired buried penis vs. those without. *, in men without AABP, surgery resulted in significant improvement in ability to see penis (P<0.05, McNemar’s test); **, compared to men with AABP, men without AABP had significantly greater improvement in ability to see penis after surgery (P<0.05, Fisher’s Exact test). AABP, adult acquired buried penis.

When comparing voiding and anatomic symptom improvement after surgery, men without AABP had significant improvement in ability to see their penis (84% resolution vs. 50% resolution, absolute difference 34%, 95% CI: 3.4% to 62.1%, P=0.04). There were no other significant differences in anatomic and voiding symptom resolution.

Forty percent of men with AABP identified with a less-severe photo of buried penis after their surgery on the photo comparison evaluation. In men without AABP, 24% identified with a less-severe photo of buried penis after surgery. This difference was not significant (P=0.22).

Sexual function

Men were asked to recall pre-operative sexual function including whether they had issues with erectile function, issues with orgasm, and whether they were sexually active. Amongst men with AABP, 18% could not get an erection, 27% could not orgasm and 55% were not sexually active. Men without AABP were not significantly different: 11% could not get an erection (absolute difference 7%, 95% CI: −10.2% to 37.1%, P=0.62), 6% could not orgasm (absolute difference 21%, 95% CI: 0.9% to 50.6%, P=0.06), and 25% were not sexually active (absolute difference 30%, 95% CI: 0.3% to 56%, P=0.07) (Figure 1).

After surgery, both men with and without AABP saw a general improvement in sexual function. In the men with AABP, inability to achieve erection dropped from 18% to 9% (P>0.99), inability to orgasm was unchanged (27% vs. 27%), and sexual inactivity dropped from 55% to 27% (P=0.25). In men without ABBP, inability to achieve erection increased from 11% to 13% (P>0.99), inability to orgasm increased from 6% vs. 13% (P=0.48), and sexual inactivity increased from 25% to 30% (P=0.51).

There was no significant difference between men with and without AABP in terms of sexual symptom change after surgery.

Discussion

There is a paucity of data regarding AABP and weight loss management. A PubMed search of “(weight loss) AND (buried penis)” only yields 9 articles. We present novel data on how bariatric surgery affects perceived voiding, anatomic, and sexual function in obese men. This includes an approximation of the incidence of AABP amongst obese men seeking bariatric surgery—of the 64 men who underwent bariatric surgery and agreed to participate in our survey, 17% had AABP. To be clear, this number is higher than we would expect in the general population, as there will be a higher prevalence among men undergoing bariatric surgery. Data from this survey-based analysis suggest that bariatric surgery may lead to an improvement in many voiding, anatomic, and sexual health categories in patients with AABP, however statistical significance was not reached, likely due to low sample size.

Smith-Harrison et al. and Ho et al. note that some improvement in sexual symptoms is to be expected with weight loss, as obesity is associated with poorer sexual function in general (3,4). However, if AABP progresses to an inability to exposure the penis due to inflammation and scarring, weight loss alone is unlikely to be effective (5). Even in patients without scarring, there is some concern that weight loss will not “unbury” the penis because there is residual suprapubic fat or loose skin (6). Amend et al. performed semi-structured interviews with 20 men who had AABP to better understand the challenges these men face and their outcomes after surgical repair (1). They surprisingly found that weight loss did not result in urinary or sexual symptom improvement in any of the men, and one-fifth of them had worsening symptoms with weight loss.

In our study, we saw improvements in voiding and anatomic function across all men who underwent bariatric surgery. Although many of these changes did not reach statistical significance, likely due to limited sample size, the clinical trend is positive. Larger studies are required to substantiate these findings. The impact on sexual function was more complex. Stratified analysis showed divergent trends: men with AABP had improvements in their sexual function while men without AABP had decline in sexual function. Although these changes were not significant, they do challenge prior literature suggesting that weight loss may worsen symptoms in patients with AABP.

A potential explanation for this discrepancy lies in our classification method, which relied on patient reported difficulty exposing the penis. It is possible that some men in our study struggled with penis exposure due to a large abdominal pannus—a situation likely improved with weight loss—as opposed to true buried penis pathology. Our cohort was not approved for physical examination by the IRB so validation of AABP diagnosis with clinical examination was not possible and is a major limitation of this study. Another potential source of discrepancy lies in the study population. While other studies predominantly included urology patients, our study included patients undergoing bariatric surgery. It is likely that patients seeking urologic care have more advanced stages of AABP and a higher level of symptom burden. This hypothesis is supported by our photographic data, as no patient in our AABP cohort identified with the most severe grade of disease (photo 5 of the survey, shown online: https://cdn.amegroups.cn/static/public/tau-2025-692-1.pdf). However, as our photographic self-assessment tool has not been validated, and retrospective self-identification is subject to inherent recall bias, we interpret these findings with caution.

Of note, classification systems for AABP have been adopted since the implementation of our survey. One example is the Wisconsin Classification System which stratifies patients based on preoperative history and physical exam and aims to guide surgical treatment (7). The system defines types of AABP as follows: Type I—abnormal penile skin, recommend peri-penile skin excision or split-thickness skin grafting; Type II—excess abdominal/suprapubic fat/lymphedema, sparing penile skin deterioration, recommend panniculectomy/escutcheonectomy and/or mons debulking monsplasty; Type III—excess abdominal/suprapubic fat/lymphedema with penile skin deterioration, recommend panniculectomy/escutcheonectomy and/or mons debulking monsplasty, as well as penis exhumation, peri-penile skin excision, and split thickness skin grafting; Type IV—severe scrotal edema, often associated with excess abdominal/suprapubic fat, penile skin deterioration, recommend scrotectomy, translocation of the testes, penis exhumation, peri-penile skin excision, split thickness skin grafting, and panniculectomy/escutcheonectomy. Using this framework, our study population likely had AABP type II, which theoretically could improve with weight loss as skin deterioration has not developed.

Our study did not use standardized validated questionaries like the IIEF and IPSS, as they are not validated for retrospective collection and would be prone to recall bias. Additionally, these questionnaires have not been validated in the AABP population. Currently, there is no validated patient reported outcome measure for men with AABP. Thornton et al. assessed 19 studies that implemented patient reported outcome measures in men undergoing AABP surgery and found significant heterogeneity, with no single instrument being used consistently (8). In our study, we used binary “yes or no” questions as opposed to a Likert scale, as we believed they would be less prone to recall bias.

Our population likely represents a cohort of highly motivated and compliant individuals with early stage AABP which may be reversed with weight loss (surgically assisted) monotherapy. Our findings have significant behavioral and motivational implications. Sexual health has long been intertwined with motivating patients to lead healthier lives. For instance, urologists often leverage the potential for improved erectile function to motivate diabetic patients toward stricter glycemic control. This same technique could be applied in bariatric medicine, where it is currently underutilized. Obesity rates in America are rising, and people are struggling to lose the weight. Yet, only 1% of patients who are eligible for bariatric surgery undergo treatment (9). While the reason for this is complex and likely multifactorial, it is in part due to the intangibility of its benefits i.e., prevented future illnesses. Our findings offer providers a different motivational approach, one that focuses on potential improvements to voiding, anatomic, and sexual function. Additionally, as patients see improvements in their day-to-day life, they may maintain their motivation and keep the weight off.

While these implications are promising, it is important to note several limitations of our study. First, we asked patients who had undergone bariatric surgery to recall a pre-op function which can suffer from recall bias. As previously mentioned, we used binary “yes or no” questions to mitigate this risk. Second, patients undergoing different types of bariatric surgery were analyzed as a single cohort. While this maximized statistical power, it limited our ability to distinguish effects due to bariatric surgery type. We hypothesize that changes in genitourinary symptoms are primarily mediated by the magnitude of weight loss, as opposed to type of surgery. Third, sexual function is temporal and changes in a patient’s libido or erectile function may be due to aging over the course of the study and development of comorbidities (i.e., diabetes, vascular disease) as opposed to bariatric surgery and weight loss. This confounding is compounded by the pooling of participants across postoperative intervals, which may mask time dependent changes in symptom resolution/ bother. Fourth, as mentioned above, is the inability to obtain approval to examine patients and clinically verify buried penis. Additionally, at time of patient survey, a classification system for AABP had not been agreed upon. Lastly, patients in our bariatric surgery cohort likely had less severe AABP than the typical urology patient, thereby limiting the generalizability of our findings. A strength of our analysis is the length of time from surgery that patients were surveyed, which demonstrates the persistent benefits of weight loss in this population.

Future directions of this work will be to validate these findings in a larger cohort. This will likely require a multi-institution study to get a larger sample size. Additionally, it would be interesting to look at patients undergoing non-surgical weight loss methods i.e., exercise and diet vs. medical therapies like semaglutide injections. This would allow us to explore if findings are generalizable across all forms of weight loss or are only specific to bariatric surgery.

Conclusions

AABP prevalence is likely increasing as obesity rates continue to rise and was found in 1 in 6 men undergoing bariatric surgery. Our data may suggest that bariatric surgery can improve voiding and anatomical function amongst all obese men. Additionally, sexual function improvement may be most notable in men with AABP. Improvements seen in this cohort of men may motivate more to undertake surgical treatment for weight loss.

Acknowledgments

During the preparation of this work, the authors used Gemini (Google) in order to improve grammar and readability. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.

Footnote

Reporting Checklist: The authors have completed the SURGE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-692/rc

Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-692/dss

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-692/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-692/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study received approval from the Institutional Review Board of the University of California, San Francisco (IRB, No. 22-36207). All patients consented to participation.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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