Sexual Medicine Update - Archive

Surgical Skills Course May 2006

PENIS ENLARGEMENT SURGERY

Penile lengthening and augmentation surgery is attracting more and more men. Nevertheless, both its objective results and ethical implications are debated.

Indications and operative strategies, as well as an assessment of the results, seem to be poorly standardized, while many candidates for this type of surgery have a penis within the normal size range.

Rarely do men associate their virility to the size of their penis and its erectile capacity. The psychological trauma triggered by dissatisfaction about one’s penis size originates in many cases in childhood, from comparing one’s own penis with other children’s the same age or from parent’s anxiety with regards to their children’s genitalia. Penis hypoplasia, as a negative sign of sexual identity, can cause an important psychological impact.

What is observed in the physician’s daily office practice is that most patients complaining about a small penis have the sexual organ within the measurements deemed normal for an adult man. Some are obese individuals with their penis partially covered with prepubic fat; others are tall, with a proportionally small penis. The increasing information disclosed in the media on techniques for a possible penile enlargement causes an increasing number of men to seek doctors, wishing to enlarge their sexual organ.

PENILE MORPHOMETRY
Defining a normal penile size has become of increasing interest; especially in patients who wonder if their penis is small. To be able to evaluate whether the penile size is normal, correct diagnostic assessment needs to be carried out and - if the penile size is found to be small - adequate therapeutic choice needs to be made.

Papers in the literature show that an adult male’s penis in on average 8,5-9,4 cm long, in the flaccid state, and 12,9-14,1 cm long, in erection, depending on the anthropometrical techniques used. Some authors characterize an adult “micropenis” as being shorter than 4 cm in the flaccid state or 7,5cm in the erect state. Those patients could be offered some type of surgical correction. Penile measurement is taken from the pubis to the tip of the glans with the organ stretched. The patient should be examined both in the upright position ad lying down to better have his prepubic fat assessed.

SURGICAL INDICATIONS AND TECHNIQUES
Currently, the penile enlargement surgery may be indicated is some situations, in which the penis functional restoration is sought:

1. Bladder exstrophy
2. Significant shortening due to Peyronie´s disease
3. Severe epispadias and hypospadias
4. Partial sequels from surgical or trauma amputations
5. Micropenis
6. Sequels from penile infections

Perovic and Djordjevic developed a unique technique for real penile lengthening. They combined the penile disassembly technique with the interposition of rib cartilage in the space between the glans cap and the tips of the corpora cavernosa. This approach provides a genuine increase in penile length. Penile lengthening was moderate and ranged from 2 to 4 cm; this depended directly on the elasticity of the neurovascular bundle.

Montorsi et al. reported a new surgical procedure for penile deformity caused by severe cavernous fibrosis. This technique is based on multiple relaxing incisions of the tunica albuginea of the penile shaft, followed by the placement of a three-piece penile prosthesis. When compared with the length before surgery the average penile length was increased by 2.3 cm while flaccid and 3 cm while erect. Larger series are clearly needed to confirm the preliminary data of Montorsi's group. This technique is very promising regarding an increase in penile length in patients with erectile dysfunction who need a penile prosthesis.

Other enlargements techniques used:

1. Section of the suspensory ligament of the penis, forward extension of the organ and refixation
2. Lipectomy or liposuction of prepubic fat
3. Z-plasty or VY-plasty of the prepubic regions skin fold
4. Skin flap rotation from the lower abdomen to the penis
5. Muscle-cutaneus flaps for penile reconstructions

All the above-mentioned methods provide a 1-2 cm lengthening, however, only when the penis is in the flaccid state, and no gain in the erect state has been reported.
In the reconstruction surgeries this augmentation may be greater, not preserving the physiological erection, and they are usually performed in patients who have undergone amputation or mutilation. 

Lengthening surgeries are followed by a high rate of complications:

1. Following sectioning of the suspensory ligament, if not duly refixed, the penis may drop and, even if rigid, it points downwards, with loss of the erection angle.
2. Penile scar retractions following z-plasty or VY plasty
3. Penile “scrotalization” with an inadequate esthetic outcome, causing a “dog ears” shaped penis.
4. Hypostasis, infections, abscesses, fistulas and chronic edema.

A few penile enlargement-oriented devices are available on the market. There is no scientific evidence on the efficacy or safety of those techniques.

CONCLUSIONS
New techniques and modifications of old procedures continue to improve penile reconstruction. Such advancements have the potential to offer many patients a better quality of life and a better psychosexual outlook. We await the long-term results of these techniques and their wider utilization in clinical practice. Penile enlargement presents a great challenge and is still in the stage of investigation.

REFERENCES
1.Da Ross C et al. Caucasian penis: what is normal size? J Urol 1994, 151:323A (abstract 381).
2.Wessells H, Lue TF, McAninch JW. Penile length in the flaccid and erect states: guidelines for penile augmentation. J Urol 1996, 156: 995-7.
3.Bondil P,  Costa P,  Daures JP,  Louis JF, Navratil H. Clinical study of the longitudinal deformation of the flaccid penis and of its variations with aging. Eur Urol 1992, 21:284-6.
4.Torres LQ, Guilhermino DA. Comparative study between the length of the stretched penis and in erection state. J Urol 1999, 161:273 (abstract 1056).
5.Long DC. Elongation of the penis. Chin J Plast Surg Burns 1990, 6:17-9.
6.Ross H, Lissoos L. Penis lengthening. Int J Aesthetic Restorative Surg 1994,  2:89.
7.Santucci RA, Berger RE. ‘Finger trap’ penile lengthening after partial penectomy by multiple incisions in the tunica albuginea. J Urol 1995, 154:530-2.
8.Alter GJ. Augmentation phalloplasty. Urol Clin N Am 1995, 22:887–902.
9.Alter GJ. Penile enhancement. In: Advances in Urology. Mosby-Year Book: Chicago, 1996, pp. 225–254.
10.Alter GJ. Reconstruction of deformities resulting from penile enlargement surgery. J Urol 1997, 158:2153–7.
11.Hinderer UT, Espinosa JF. New technique of penis lengthening with girth augmentation in constitutional penile hypoplasia or in hypospadias. Cir Plast Ibero-Am 1997; v XXIII:151–160.
12.Perovic S, Djordjevic M. Penile lengthening. BJU Int 2000, 86:1028-33.
13.Montorsi F, Salonia A, Maga T, et al. Reconfiguration of the severely fibrotic penis with a penile implant. J Urol 2001, 166:1782-6

Questions

Question 1

Which is penis average normal size, in flaccid state?

a. 7.5 cm
b. 11 cm
c. 6.5 cm
d. 8 cm
e. 8.9 cm

Correct answer: E
Papers in the literature show that an adult male’s penis in on average 8,5-9,4 cm long, in the flaccid state.

Question 2
Which is penis average normal size, in erection?

a. 15 cm
b. 11 cm
c. 13 cm
d. 14.5 cm
e. 10 cm

Correct answer: C
Papers in the literature show that an adult male’s penis in on average 12,9-14,1 cm long, in erection.

Question 3
Give adult “micropenis” definition.

a. A penis shorter than 4 cm (flaccid) or 7.5 cm (erected).
b. A penis that does not permit sexual intercourse
c. A penis which size does not meet patient’s wishes
d. A penis shorter than 6 cm (flaccid) or 9 cm (erected)
e. A penis shorter than 7 cm (flaccid) or 10 cm (erected)

Correct answer: A
Some authors characterize an adult “micropenis” as being shorter than 4 cm in the flaccid state or 7,5cm in the erect state

Question 4
Mark which of the following is not an accepted indication for penis enlargement surgery.

a. Micropenis
b. Significant shortening due to Peyronie´s disease
c. Severe epispadias and hypospadias
d. Partial sequels from surgical or trauma amputations
e. A penis which is small according to patient´s expectations

Correct answer: E
Currently, the penile enlargement surgery may be indicated is some situations, in which the penis functional restoration is sought:

1. Bladder extrophy
2. Significant shortening due to Peyronie´s disease
3. Severe epispadias and hypospadias
4. Partial sequels from surgical or trauma amputations
5. Micropenis
6. Sequels from penile infections

Question 5
Which is (in cm) the standard lengthening that surgical techniques may provide?

a. 0.5 – 0.8 cm
b. 1 – 2 cm
c. 1.5 – 2.5 cm
d. 1.6 – 2.3 cm
e. 1.8 – 2.5 cm

Correct answer: B
Standard enlargements techniques include:

1. Section of the suspensory ligament of the penis, forward extension of the organ and refixation
2. Lipectomy or liposuction of prepubic fat
3. Zetaplasty or VY plasty of the prepubian regions skin fold
4. Skin flap rotation from the lower abdomen to the penis
5. Muscle-cutaneus flaps for penile reconstructions

All the above-mentioned methods provide a 1-2 cm lengthening, however, only when the penis is in the flaccid state, and no gain in the erect state has been reported.

References

• Secin FP,  Karanikolas N,  Kuroiwa K,  Vickers A,  Touijer K, Guillonneau B. Positive surgical margins and accessory pudendal artery preservation during laparoscopic radical prostatectomy. Eur Urol 2005, 48:786-92.
• Secin FP,  Karanikolas N,  Touijer AK,  Salamanca JI,  Vickers AJ, Guillonneau B. Anatomy of accessory pudendal arteries in laparoscopic radical prostatectomy. J Urol 2005, 174:523-6.
• Rogers CG,  Trock BP, Walsh PC. Preservation of accessory pudendal arteries during radical retropubic prostatectomy: surgical technique and results. Urology 2004, 64:148-51.
• Polascik TJ, Walsh PC. Radical retropubic prostatectomy: the influence of accessory pudendal arteries on the recovery of sexual function. J Urol 1995, 154:150-2.
• Benoit G,  Droupy S,  Quillard J,  Paradis V, Giuliano F. Supra and infralevator neurovascular pathways to the penile corpora cavernosa. J Anat 1999, 195:605-15.
• Breza J,  Aboseif SR,  Orvis BR,  Lue TF, Tanagho EA. Detailed anatomy of penile neurovascular structures: surgical significance. J Urol 1989, 141:437-43.
• Rosen MP,  Greenfield AJ,  Walker TG,  Grant P,  Guben JK,  Dubrow J et al. Arteriogenic impotence: findings in 195 impotent men examined with selective internal pudendal angiography. Young Investigator's Award. Radiology 1990, 174:1043-8.
• Gray RR,  Keresteci AG,  St Louis EL,  Grosman H,  Jewett MA,  Rankin JT et al. Investigation of impotence by internal pudendal angiography: experience with 73 cases. Radiology 1982, 144:773-80.
• Bahren W,  Gall H,  Scherb W,  Stief C, Thon W. Arterial anatomy and arteriographic diagnosis of arteriogenic impotence. Cardiovasc Intervent Radiol 1988, 11:195-210.
• Aboseif SR,  Breza J,  Orvis BR,  Lue TF, Tanagho EA. Erectile response to acute and chronic occlusion of the internal pudendal and penile arteries. J Urol 1989, 141:398-402.
• Mulhall JP, Graydon RJ. The hemodynamics of erectile dysfunction following nerve-sparing radical retropubic prostatectomy. Int J Impot Res 1996, 8:91-4.
• Mulhall JP,  Slovick R,  Hotaling J,  Aviv N,  Valenzuela R,  Waters WB et al. Erectile dysfunction after radical prostatectomy: hemodynamic profiles and their correlation with the recovery of erectile function. J Urol 2002, 167:1371-5.
• Droupy S,  Hessel A,  Benoit G,  Blanchet P,  Jardin A, Giuliano F. Assessment of the functional role of accessory pudendal arteries in erection by transrectal color Doppler ultrasound. J Urol 1999, 162:1987-91.