Concerns over penile size and a desire for a longer penis are common in the male population. The number of male patients seeking an andrological consultation for the problem of 'short penis' is increasing. We looked at the numbers of patients presenting to a University andrology clinic over a 2-y period and correlated their perceived penis size with the accepted norms. Sixty-seven patients were evaluated with a median age of 27 (range 16-55) complaining of 'short penis' and requesting surgical correction. Clinical history, including the IIEF-5 questionnaire and an accurate physical examination were obtained. Data concerning measures of penile length and circumference were recorded in both the flaccid and fully stretched states and compared to the normal reference range as previously described in the nomogram we recently published (Eur Urol 2001; 39: 183-186.). All patients were also asked to estimate the length of a normal sized penis.
Fourty-four (65.7%) complained of a short penis only while flaccid, 22 patients (32.8%%) while both flaccid and erect, and only one patient (1.5%) was worried only by the erect length of the penis. Fifteen (22.4%) also complained about their penile circumference. Fifty-seven (85%) patients thought a 'normal' penile length should range from 10 to 17 cm (median value of 12 cm). Ten patients (15%) were not able to estimate 'normal' penile size. No patient was found to have a penile length under the 2.5 percentile according to our nomogram. Forty-two (62.7%) subjects recalled the problem starting in childhood, when they felt that their penis was smaller than their friends'. In 25 patients (37.3%) the problem started in the teenage years after seeing erotic images.
Our data show that most men who seek penile lengthening surgery overestimate 'normal' penile length. In our series, none of the patients could be classified as having a severely short penis according to our nomogram and none had any anatomical penile abnormality. Most found the use of a nomgram to show them how they compared with other men helpful. We suggest that documentation of such a demonstration should be made for any man seeking an opinion on penile lengthening surgery.
In recent years, penile size has become a matter of great debate, with an increasing number of patients seeking urological advice for a so-called ‘short penis’. In a clinical setting, the definition of ‘short penis’ is more often attributed to a condition termed ‘penile dysmorphophobia’, i.e. the perception of inadequacy of the penis even though the true dimensions of the organ fall within the normal range. A ‘clinically relevant’ short penis, definable as any length of < 4 cm [< 2"] for the flaccid penis and < 7 cm [< 3"] for the stretched penis, is quite unusual in men seeking medical treatment for inadequate penile size. Several augmentation phalloplasty procedures have been proposed with the aim of elongating the shaft or enlarging the penile girth but at present the drawbacks of these techniques are a lack of standardization, the potential risk of complications, and a high rate of patient dissatisfaction. Given these premises, methods to increase penile dimensions which are less invasive than surgery would be preferable.
It has been claimed that the penile extender, a nonsurgical device that used progressive mechanical traction to the penis, produces a significant improvement in penile length and circumference, both in the flaccid and the erect state. Little scientific evidence and no peer-reviewed clinical study supports the potential clinical utility of the penile extender in the treatment of patients complaining of inadequate penile size. In the present, they assessed a commonly marketed penile extender in a phase II single-arm study that was powered to detect significant changes in penile size.
Gontero P, Di Marco M, Giubilei G, et al. Use of penile extender device in the treatment of penile curvature as a result of Peyronie's disease. Results of a phase II prospective study. J Sex Med 2009;6(2):558-66.
INTRODUCTION: Pilot experiences have suggested that tension forces exerted by a penile extender may reduce penile curvature as a result of Peyronie's disease. AIM: To test this hypothesis in a Phase II study using a commonly marketed brand of penile extender.
METHODS: Peyronie's disease patients with a curvature not exceeding 50 degrees with mild or no erectile dysfunction (ED) were eligible. Fifteen patients were required to test the efficacy of the device assuming an effect size of >0.8, consistent with an "important" reduction in penile curvature. Changes in penile length over baseline and erectile function (EF) domain scores of the International Index of Erectile Function (IIEF) constituted secondary end points.
MAIN OUTCOME MEASURES: Patients were counselled on the use of the penile extender for at least 5 hours per day for 6 months. Photographic pictures of the erect penis and measurements were carried out at baseline, at 1, 3, 6, and 12 months (end of study). The IIEF-EF domain scores were administered at baseline and at the end of study. Treatment satisfaction was assessed at end of study using a nonvalidated institutional 5-item questionnaire.
RESULTS: Penile curvature decreased from an average of 31 degrees to 27 degrees at 6 months without reaching the effect size (P = 0.056). Mean stretched and flaccid penile length increased by 1.3 and 0.83 cm, respectively at 6 months. Results were maintained at 12 months. Overall treatment results were subjectively scored as acceptable in spite of curvature improvements, which varied from "no change" to "mild improvement."
CONCLUSIONS: In our study, the use of a penile extender device provided only minimal improvements in penile curvature but a reasonable level of patient satisfaction, probably attributable to increased penile length. The selection of patients with a stabilized disease, a penile curvature not exceeding 50 degrees, and no severe ED may have led to outcomes underestimating the potential efficacy of the treatment.
Gontero P, Di Marco M, Giubilei G, et al. A pilot phase-II prospective study to test the 'efficacy' and tolerability of a penile-extender device in the treatment of 'short penis'. BJU Int 2009;103(6):793-7.
OBJECTIVE: To assess a commonly marketed brand of penile extender, the Andro-Penis(R) (Andromedical, Madrid, Spain), widely used devices which aim to increase penile size, in a phase II single-arm study powered to detect significant changes in penile size, as despite their widespread use, there is little scientific evidence to support their potential clinical utility in the treatment of patients with inadequate penile dimensions.
PATIENTS AND METHODS: Fifteen patients were required to test the efficacy of the device, assuming an effect size of >0.8. Eligible patients were counselled how to use the penile extender for at least 4 h/day for 6 months. Penile dimensions were measured at baseline and after 1, 3, 6 and 12 months (end of study). The erectile function (EF) domain of the International Index of EF was administered at baseline and at the end of the study. Treatment satisfaction was assessed using an institutional unvalidated five-item questionnaire.
RESULTS: After 6 months the mean gain in length was significant, meeting the goals of the effect size, at 2.3 and 1.7 cm for the flaccid and stretched penis, respectively. No significant changes in penile girth were detected. The EF domain scores improved significantly at the end of study. Treatment satisfaction scores were consistent with acceptable to good improvement in all items, except for penile girth, where the score was either 'no change' or 'mild improvement'.
CONCLUSIONS: Penile extenders should be regarded as a minimally invasive and effective treatment option to elongate the penile shaft in patients seeking treatment for a short penis.
The number of patients seeking penile contour improvement is constantly increasing. Most of these men have a normal-sized stretched penis (~13 cm or ~5-6"), but some are dissatisfied by the girth and wish to undergo augmentation. Penile girth augmentation is currently carried out by dermal grafts or by fat injections. The former requires surgery and the graft might lack sensation for several months postoperatively, whereas the final results of the latter are unpredictable because the procedure requires overcorrection due to fat reabsorption. Liquid injectable silicone has been used to augment soft tissue, but no investigation of its application for penile girth enhancement has been reported before. The following study describes the use of liquid injectable silicone for enhancing penile girth by augmenting penile volume and report our short-term results. [OUCH!!!]
Yacobi Y, Tsivian A, Grinberg R, Kessler O. Short-term results of incremental penile girth enhancement using liquid injectable silicone: words of praise for a change. Asian J Androl 2007;9(3):408-13.
AIM: To report our experience with penile girth augmentation using liquid injectable silicone.
METHODS: Between August 2003 and July 2006, 324 men (mean age 35 years, range 19-65 years) received a series of liquid silicone subcutaneous injections between the penile skin and the corpora cavernosa on the dorsal and lateral aspects of the penile shaft, under local anesthesia. Digital photographs taken pre- and post-procedure (n = 324), and penile contour measurements (n = 30) yielded objective results. Subjective results were derived from patient and partner testimony of satisfaction. Follow-up averaged 20 months (range 1-36 months).
RESULTS: Three hundred and twenty-four procedures were primary augmentations. Most men (61%) were married, 7% were accompanied by their partners, and 93% were circumcised. The mean measured penile circumference was 9.5 cm (7.5-11.5 cm) pretreatment and 12.1 cm (10.3-15.3 cm) post-treatment (mean increase of 27% in circumference and 0.84 cm in diameter). Patient and partner satisfaction was already expressed after the first two treatments. Sexual activity could be resumed after 8 h. Complications (mild bruising) were easily resolved.
CONCLUSION: Penile girth augmentation using liquid injectable silicone yields very satisfactory short-term results with no immediate or short-term complications.
Penile size has been a source of anxiety for men throughout history, and still today men often feel a need to enlarge their penises in order to improve their self-esteem or to satisfy or impress their partners. The fact that so many procedures have been performed in the past years is evidence of this phenomenon. Interestingly, the main concern of the majority of men undergoing this kind of surgery is the flaccid penile size, when men feel considerably inadequate to engage in sexual relationship, despite normal penile length and girth. Currently, even among modern men, there are a variety of social, cultural, and psychological aspects regarding the size of their genital organs. Men still tend to seek their identity in their symbolically powered penis, and believe that ‘bigger is better’. These stigmas of apparently small penises, and the increasing influence of the media on sexual issues, have created a demand for these procedures. The need to perform cosmetic surgery in order to enlarge the penis remains highly controversial, due to unsatisfactory surgical outcomes and high complication rates. Nevertheless, these procedures are commonly performed, generally in private settings.
The reported normal length and girth of an adult flaccid penis ranges between 7.6cm–13.0 cm in length and 8.5 cm–10.5 cm in circumference. The increase in length following surgery that is required to satisfy these patients is not well established and not adequately referred to in the medical literature.
It is important that a distinction be made between surgery for functional abnormalities such as a micropenis (whether congenital or due to oncologic/traumatic amputation), which requires high skilled reconstructive surgical expertise, and surgery for improving penile appearance, surgical procedures performed in patients with a normal penile size and shape. The new developments in this controversial field, mainly surgical procedures for penile enhancement, are discussed.
Vardi Y, Gruenwald I. The status of penile enhancement procedures. Curr Opin Urol 2009;19(6):601-5.
PURPOSE OF REVIEW: Most men who request surgical penile enhancement have a normal-sized and fully functional penis but visualize their penises as small (psychological dysmorphism). This fact by itself leads to controversy regarding the true indications for penile enhancement procedures in men without micropenis.
RECENT LITERATURE: One of the typical aspects of penile enhancement is the lack of true methodological evaluation of the more commonly performed procedures. Even recently, only few solid scientific studies are available which can shed some light on results and outcome of these controversial procedures.
SUMMARY: Although some additional data has emerged during the past year, there is still no consensus in regard to indications and surgical techniques used for penile augmentation or penile girth enhancement. There is further need for more studies to provide a better overview of the value and worthiness of these procedures.