Article

Penile Enlargement: From Medication to Surgery

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Abstract

Penis lengthening pills, stretch apparatus, vacuum pumps, silicone injections, and lengthening and thickening operations are available for men who worry about their penis size. Surgery is thus far the only proven scientific method for penile enlargement. In this article, we consider patient selection, outcome evaluation, and techniques applied. In our view, sexological counseling and detailed explanation of risks and complications are mandatory before any operative intervention.

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... In terms of low tech treatments, trends such as the styling or removal of pubic hair for men signal the increased visibility of male genitals and a new, primarily visual genital aesthetic (Ramsey et al, 2009; for a comparable discussion about women's genitals and pubic hair, see Barcan, 2004). Equally a range of low-tech solutions exist which focus upon herbal remedies, penile lengthening pills, penile workout regimes, penile extenders or penile vacuum pumps (for review see Nugteren et al., 2010). A range of more traditional and pharmaceutical treatments now exist, through oral means as tablets (e.g., Viagra), also as gels (e.g., Cialis), alongside injected drugs (such as Caverject-"alprostadil") or injected liquid silicone. ...
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This paper explores contemporary understandings and representations of the penis. It presents an overview of recent trends which re-frame long-standing penile anxieties within a new hybrid world of health and aesthetics. It explores these apparent changes through the lens of biomedicalisation. By focusing on constructions of masculinities in crisis, changes in the representability of the penis and the effects of Viagra, it suggests that contemporary penile pathologies and anxieties are being constructed and commodified. In the past medical discourse has focused primarily upon the 'traditional' functionality of the penis, more recently it has focussed upon pharmaceutical innovations such as Viagra. However, we suggest that now there appears to be the emergence of a new penile discourse, a penile aesthetic that focuses upon penile appearance as much as function. This shift has been facilitated by the Internet, the deregulation of pornography and changes in sexual mores.
... It may be also of special importance in ED men who may be subjected for penile prosthesis insertion, which is frequently associated with a decrease in penile length (Deveci et al., 2007) or in need for condom catheters, particularly those with diabetes, whose size should fit the penis (Schneider et al., 2001). The VED is a common choice for men wishing to enhance their penis size (Nugteren et al., 2010). However, the vacuum would probably not affect the study findings if they are irreversible due to organic comorbidities like diabetes (Cho et al., 2012;Wang et al., 2014). ...
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This study aimed to report penile dimensions in diabetic and nondiabetic men with erectile dysfunction (ED) and correlate their dimensions with other study variables. A case-control study was designed through retrospective data analysis of diabetic and nondiabetic patients consulting for ED and a control group (n = 105, each group). Study data retrieved included history, clinical evaluation, and penile dimensions (pendulous length [PL], total length [TL], and circumference [CF]) at flaccid and erect states. Results identified that patients had lower values (mean, cm) for almost all penile dimensions. The diabetic patients identified significant differences in most dimensions, whether in flaccid (PL: 7.46 vs. 7.51 and 7.81, p = .11; TL: 11.8 vs. 12.77 and 12.88, p = .000; CF: 8.84 vs. 9.1 and 9.14, p = .016) or erect state (PL: 9.66 vs. 9.61 and 10, p = .092; TL: 13.96 vs. 14.88 and 15.04, p = .000; CF: 11.56 vs. 12.06 and 11.92, p = .018) as compared with the nondiabetic patients and controls, respectively. No significant correlation was detected between the dimensions and age, durations of diabetes and ED, or erectile function scores. In conclusion, diabetic and nondiabetic patients with ED presented, in varying degrees, significant decline in their penile dimensions, and this was more prevalent in diabetic patients. As changes in penile size could be a silent corollary of comorbidities, monitoring the changes in penile dimensions should be an important component of the clinical checkup of any patient with ED, especially a diabetic patient. © The Author(s) 2015.
... Primarily, the concern has been about men overreporting their penis size given that, in contemporary Western cultures, larger penises tend to be regarded more favorably than penises of smaller sizes [12,13]. Additionally, past research has demonstrated that men tend to underestimate their penis size (i.e., a greater proportion of men report that their penis is average or below average in size) and many men seek to increase the size of their penis through pills, exercise, devices, or surgeries [14][15][16]. ...
Article
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Genital aesthetic and penile enlargement surgeries are relatively new. Most results are anecdotal, but some surgeons are trying to generate meaningful data. Follow-up data are often difficult to obtain because many patients travel long distances for the surgery. Dermal-fat grafts have been successful, although some patients resist the operation primarily because of the large donor scar(s). Gluteal crease donor scars are less noticeable than groin scars. Physicians performing fat injections promise small scars and minimal morbidity but emphasize the frequent necessity for re-injections. Dermal-fat grafts do not need re-operations and appear to have good long-term results. A reasonable aesthetic proportion between the shaft and the glans should be maintained. Some men with massive fat injections, however, appreciate the greatly enlarged shaft despite the “grotesque” appearance resulting from the disproportion between the shaft and the glans. The limited size of the dermal-fat grafts does not allow for massive thickening of the shaft because circumference increase of 1 to 2 inches is reasonable even with a relatively small glans. No effective procedure for enlargement of the glans is known. Penile lengthening operations in the normal patient remain a major question. There is no satisfactory incision for skin advancement onto the penis, but a Z-plasty or double Z-plasty may be acceptable. Z-plasty is preferable owing to the high incidence of hypertrophic scars, wound disruption, and dorsal humps with V-Y advancement flaps. Moreover, exaggerated length claims of many physicians are unrealistic; a gain of 1 inch is considered a success. The patient with the 3-inch gain may be deformed with an extended escutcheon and a low-hanging penis, while achieving minimal or no real length gain. Malpractice is a major consideration in penis enlargement surgery. Most malpractice carriers will not insure penile fat injections. Depending on the physician and the insurance carrier, dermal-fat grafts may be covered. Liability largely depends on adequate informed consent. Patients should be advised that these operations are investigational and require an extensive consent form to be signed. They must understand that penis enhancement techniques are evolving and that results are still being compiled. Extensive physician consultation before surgery is imperative, and a “factory” approach is unethical. No two patients are anatomically alike, and thus, a “standard” approach to penile enhancement surgery is not in the best interest of the patient. Many referred patients present with persistent pain, bizarre-appearing V flaps, penile shortening, and massive fat injections with lumps. Some men have become emotional cripples, physically and psychologically unable to perform sexually. Obviously, a man seeking penile enlargement surgery has self-esteem issues, and therefore, a disastrous result may leave him further devastated. Dissatisfied male aesthetic patients have a greater propensity towards violence, so the physician must carefully screen these patients and perform good work for the protection of both the patient and himself. The male with the concealed penis definitely benefits from a suprapubic lipectomy, release of the suspensory ligament, and a possible Z-plasty of the penoscrotal junction. Such reconstructive cases to restore normal sexual functioning may be covered by insurance. The necessity for understanding plastic surgical principles to achieve satisfactory results cannot be overemphasized. Knowledge of the principles of flap design and surgical technique is necessary to prevent flap necrosis, wound disruption, “dog-ear” formation, unsightly genital distortion, and poor scar formation. Urologists should study these principles and techniques before performing such operations. Meticulous, time-consuming surgery will help prevent major problems and patient dissatisfaction. Penis enlargement surgery is effective with low morbidity and high patient satisfaction. As new techniques evolve, demand will continue to increase.
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Complications of the recent cosmetic technique of penile lengthening and girth enhancement are reviewed. During a 16-month period 12 men presented with complications of penile augmentation performed elsewhere. All 12 patients had undergone release of the suspensory ligament and 10 had received autologous fat injection. The chief complaint was poor cosmetic appearance (irregular residual fat nodules in 7 men, skin deformity and scarring in 4 and scrotalization in 4). Reoperation was necessary in 6 patients, wound complications occurred in 6 and sexual dysfunction was reported by 4. Only 1 patient reported a subjective increase in penile length. Although a verifiable complication rate may never be available, the morbidity of elective penile lengthening and girth enhancement is noteworthy. These cosmetic techniques should be regarded as experimental.
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More than 30 patients presented for reconstruction of penile deformities secondary to penile enlargement surgery performed by other physicians. Lengthening was performed by releasing the suspensory ligament of the penis and advancing pubic skin with a V-Y advancement flap. Girth was increased by injecting autologous fat. Specific complaints relating to the lengthening procedure involve hypertrophic and/or wide scars, a proximal penile hump from a thick, hair-bearing V-Y flap, and a low hanging penis. Complications relating to autologous fat injections include disappearance of fat, penile lumps and nodules, and shaft deformities. The repair of these deformities is described. From 1994 through October 1996, 19 men underwent 24 various combinations of reconstructive operations, such as scar revisions, V-Y advancement flap reversal, and removal of fat nodules and asymmetrical fat deposits. Penile appearance and function were improved. Complications include 1 hematoma requiring drainage, minor wound complications and 1 inadequately reversed V-Y flap. The methods of various repairs are discussed, including reconstructive limitations, timing and staging. Significant improvement can be achieved with proper reconstruction of penile deformities.
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The suspensory system of the penis acquires clinical importance in reparative surgery, traumatology and through its role in erection. The aim of this study was to identify the different anatomic structures constituting the suspensory ligament by dissection and by magnetic resonance imaging (MRI). Ten unembalmed male subjects were used for dissection of the region of the base of the penis. Ten volunteer patients underwent MRI of the penis before and after the injection of prostaglandin (PGE1). The suspensory apparatus consisted of separate ligamentous structures: the fundiform ligament, which is lateral, superficial and not adherent to the tunica albuginea of the corpora cavernosa; the suspensory ligament properly so-called, further back, stretching between the pubis and the tunica albuginea of the corpora cavernosa and consisting of two lateral, circumferential, and one median bundles, which circumscribed the dorsal vein of the penis. These structures were identifiable in MRI and their supporting role was evidenced during tests of erection. The suspensory ligament seemed to maintain the base of the penis in front of the pubis and to behave as a major point of support for the mobile portion of the penis during erection.
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To describe a technique for penile lengthening and the results achieved. The penis is completely disassembled into its anatomical parts; the glans cap remains attached dorsally to the neurovascular bundle and ventrally to the urethra and corporal bodies. A space is created between glans cap and the tip of corpora cavernosa; this space is used to insert autologous cartilage previously harvested from the rib, the space being measured beforehand when the corpora cavernosa are erect. The anatomical entities and inserted cartilage are joined together to form a longer penis. The increased length of the penis depends directly on the elasticity of the urethra and especially of the neurovascular bundle. From June 1995 to March 1999 the technique was applied in 19 patients aged 18-52 years, who were followed for a mean (range) of 3.3 (1-4.5) years. The increase in penile length was moderate, at 2-4 cm; there were no injuries of the neurovascular bundle or urethra, and no erectile dysfunction. Fifteen patients reported painless sexual intercourse, the remaining four patients providing no data. During the follow-up the cartilage insert remained at about the same size as that at initial implantation. The penile disassembly technique combined with the interposition of rib cartilage in the space between the glans cap and tips of the corpora cavernosa provides a genuine increase in penile length, with satisfactory results.
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To report on the efficacy and safety of augmentation phalloplasty procedures in physically normal young men, to introduce a patient selection and outcome evaluation questionnaire as well as, to propose a surgical technique modification. Eleven (11) out of 28 psychosomatically normal men (25-35 years) who presented complaining of penile dysmorphophobia (subjective perception of small penis), were subjected to: (a) penile lengthening (suprapubic skin advancement--ligamentolysis): n=5, (b) penile lengthening and shaft thickening (free dermal-fat graft shaft coverage): n=3 and (c) panniculectomy--suprapubic lipectomy and penile lengthening: n=2. A self administered questionnaire was employed in order to facilitate selection of the patients qualifying for the operation as well as to evaluate the outcome. In addition, a technical modification regarding dermal-fat graft handling was applied. The postoperative course was uneventful with minor complications. The mean penile length gain (flaccid--stretched penis) was 1.6 cm (1-2.3 cm) [p=0.0014], the mean circumference gain was 2.3 cm [p=0.003] at the base and 2.6 cm [p=0.0012] subcoronaly. Significant (20%-53%) [p<0.0001] sexual self-esteem and functioning improvement was reported by the majority (91%) of patients. Although penile size alteration was not spectacular or satisfying the patients' "great" expectations, the substantially uneventful clinical course coupled with the significant improvement in sexual self-esteem and function and the highly accepted outcome by the patients, render augmentation phalloplasty reasonable treatment modality for the management of strictly selected and thoroughly informed young adults who suffer from penile dysmorphophobia.
Article
To evaluate in a multicenter, prospective study preliminary aesthetic and functional results of autologous ex-vivo tissue engineering for penile girth enhancement. From July 1999 to January 2004, 204 men of mean age 26.77 (range 19-54 years) underwent this procedure. Indications for penile girth enhancement were penile dysmorphic disorder and previous failed surgery for penile girth enhancement. Fibroblast cells harvested from 1 cc of biopsied scrotal dermal tissue were expanded in culture until the total cell number of at least 2x10(7) was reached. Suspended cells in culture medium were then seeded on pretreated tube-shaped PLGA scaffolds and incubated for 24 hours. After penile degloving, scaffolds were shape adjusted and transplanted between dartos and Buck's fascia when the skin was compliant or under the neurovascular bundle when the skin was not compliant. A total of 84 randomly selected patients were followed 1 to 5 years postoperatively (median 24 months). The gain in girth ranged from 1.9 to 4.1cm (mean 3.15 cm). Postoperative complications occurred as infection in three, penile skin pressure necrosis in two and seroma formation in five patients and were all treated conservatively. Surgical intervention was appraised by patients on a scale from 1 to 5 as follows: the best mark (5) was given by 44.05%, very good (4) by 36.90%, good (3) by 19.05% and only one patient gave the mark 2 judging general penile appearance as dissatisfactory; mean score was 4.25. Autologous tissue engineering by using biodegradable scaffolds as a carrier is a new and safe therapeutic approach for penile girth enhancement. The outcome of this study points out the necessity for its expanded clinical applicability in the future.
Article
This study assessed the management of patients requesting penile length enhancement by division of the penile suspensory ligament. From September 1998 to January 2005, 42 patients with a variety of etiologies were included; all underwent division of the penile suspensory ligament. The outcome was assessed objectively based on increase in flaccid stretched penile length (SPL) and subjectively using the rates of patient satisfaction. The mean increase in SPL was 1.3+/-0.9 cm (range, -1 to +3 cm), with the addition of a silicone spacer placed between the pubis and penis giving a better outcome (p<0.05). The overall patient satisfaction rate was 35% but lower in the group with penile dysmorphic disorder at 27%. Division of the penile suspensory ligament or other augmentation techniques may increase penile length but usually not to a degree that satisfies the patient. Men with penile dysmorphic disorder often have unrealistic expectations regarding the outcome of surgical intervention and should be encouraged to seek psychological help primarily, with surgery reserved as the last resort.
Article
Until 20 years ago, penis size (either nonerected or erected) was not mentioned, discussed, or defined even in serious books of human anatomy. The need of some men to enlarge and elongate their penile size is equivalent to the need of some women to ask for breast augmentation. The same method of transferring autologous fat into other parts of the body can be used in male patients for augmentative phalloplasty. The circumference of the penis increases 2 to 3 cm, and before of a heavier penis, the length increases 1 to 2 cm. If more lengthening is desired, subtotal dissection of the ligament fundiforme penis below the symphysis could be done, pull the corpus cavernosus out, and fix the tunica albuginea at the periost. At the root of the phallus, the skin can be elongated by V-Y-plasty, and the scrotal skin can be released by 1 or 2 Z-plasties. Combining both autologous fat transfer and ligament release allows for penis elongation of 3 to 5 cm. The authors have performed augentative phalloplasty on 88 patients since 1996. They have transplanted 40 to 68 ml of pure fat. Of the 88 patients, 57 underwent autologous fat transfer only, and 31 received additional ligament release. Penis length increased 1.5 to 4.8 cm (average, 2.42 cm), and circumference increased 1.4 to 4.0 cm (average, 2.65 cm). The initial penis lengths were 6.5 to 10.0 cm (average, 8.72 cm), and the circumference were 8.0 to 10.1 cm (average, 9.18 cm) not erected. This article details a simple operative procedure to enlarge the penis and simple postoperative bandages. Patients are advised to obstain from sexual activity for 5 weeks after the surgery. Two patients who disregarded this advice had an unsatisfactory result. In one patient too, much of the grafted fat had to be removed from the preputium. No other serious complications were observed.
Article
The male is often troubled by concerns that his penis is not large enough to satisfy his partner or himself. He is ashamed to have others view his penis, especially in the flaccid state. Such concerns might be unfounded in reality and might be a presentation of social anxiety or some other clinical problem, such as erectile dysfunction. Concern over the size of the penis, when such concern becomes excessive, might present as the 'small penis syndrome', an obsessive rumination with compulsive checking rituals, body dysmorphic disorder, or as part of a psychosis. However, it is often a worry that can be described as within the normal experience of many men. Various potential causal factors are considered. A thorough assessment, normalizing the worry and then exploring the treatment options in detail with the man, is essential to allow the matter to be consolidated satisfactorily within the male ego.
Article
To report our experience with penile girth augmentation using liquid injectable silicone. 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). 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. Penile girth augmentation using liquid injectable silicone yields very satisfactory short-term results with no immediate or short-term complications.