Review

Penile size and penile enlargement surgery: a review

  • International Journal of Impotence Research volume 20, pages 519529 (2008)
  • doi:10.1038/ijir.2008.14
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Abstract

Penile size is a considerable concern for men of all ages. Herein, we review the data on penile size and conditions that will result in penile shortening. Penile augmentation procedures are discussed, including indications, procedures and complications of penile lengthening procedures, penile girth enhancement procedures and penile skin reconstruction.

Introduction

Throughout history, the penis has defined masculinity. Discussion of the penis has been deemed taboo, socially unacceptable; and at other times, it is the topic of lighthearted conversation and jokes. Length, girth and function, however, have been an issue for men throughout history. This is apparent in the first book of the Old Testament, Genesis, where Abraham is told, ‘Every male among you shall be circumcised. You shall be circumcised in the flesh of your foreskins, and it shall be a sign of the covenant between me and you.’1 The ancient Greeks were also fixated on the penis, as recorded by Kallixeinos of Rhodes in 275 BC, who described a ‘golden phallus, 180 feet long’. The phallus was topped with a golden start and was carried through the streets during a festival in Alexandria, all the while people sung to it and recited poems.1

Kelley and Eraklis2 performed the first recorded penile augmentation in 1971 for the treatment of microphallus in the pediatric population. Subsequently, the adult population began to show interest in the procedure for cosmetic and psychological reasons, similar to that seen with reconstructive breast surgery and augmentation. Penile augmentation procedures are not an American Urological Association sanctioned procedure, and typically both plastic surgeons and urologists perform penile enlargement procedures. The purpose of this paper is to summarize the available literature on penile size, discuss conditions that contribute to penile shortening, and to highlight the indications, procedures and complications of penile enlargement surgery.

Penile size

Paintings and writings by the ancient Greeks, as early as 200 BC suggest that they believed that a smaller penis was superior.1 However, over the course of time, with the various sexual revolutions this belief has changed and for most men, larger is better and comparisons to the rest of the general population matter. This is evident in the terms ‘phallic identity’ and ‘phallocentrism’. ‘Phallic identity’, as described by Vardi, is the concept of a man seeking identity in his penis, which a focus on bigger is better. Similarly, ‘phallocentrism’ is the concept that the penis is central to a man's identity.3

Penile size has been suggested to correlate to certain physical characteristics. There has been some data suggesting no correlation between shoe size and penile length by Shah and Christopher in a small 2002 study. They studied 104 men from 54 to 87 years of age. All penises were measured on full stretch and the foot size of each patient was recorded. After linear regression analysis, there was no statistical correlation between stretched penile length and shoe size.4

Specifics of measurement of penile size is important in comparing data in different papers. Although there is no standard technique for measuring penile size, there appears to be a consensus among researchers that penile length should be measured on the dorsum of the penis beginning from the pubopenile junction to the tip of the glans (Figure 1).5 This measurement applies to the flaccid, stretched and erect states. In addition, measurements of penile girth should be obtained from the middle of the penile shaft, in all three states. For the purpose of clarity of nomenclature, a flaccid penis is one that is unstimulated or not aroused, and would be seen when the man is in the normal anatomical position. Flaccid stretched is when the flaccid penis is pulled to its maximal distance. Lastly an erect penis is one that is maximally stimulated, either through visual, tactile or pharmaceutical manipulation.

Figure 1
Figure 1

Penile length from pubopenile skin to meatus and fat pad depth from pubic bone to pubopenile skin. Reprinted with permission from Journal of Urology.

To date, there have been few studies published on penile size. The first reported study was conducted by Loeb in 1899, where he examined 50 subjects, age ranging from 17 to 35 years. He measured the penis only in the flaccid state and found the average size to be 9.41 cm.6 It was not clearly stated how measurements were made. In 1942, Schonfeld and Bebe looked at the normal variability of penile size, both length and girth of the penis from birth to maturity. With respect to penile length, measurements were recorded only in the stretched state, however they looked at penile girth in both the erect and flaccid conditions. They found that the average stretched length was approximately 13.1 cm (13.26 for 61 men aged 17 years, 13.11 for 71 men aged 18–19 years and 13.02 for 54 men aged 20–25 years). In addition they found the average girth of the flaccid penis (location of measurement not mentioned) to be 8.5 cm, and the average girth of the erect penis to be 15.8 cm.7

In 1948, Kinsey published his hallmark paper on penile length, which until 2001 was the largest published series. Kinsey examined men between the ages of 20 and 59 and measured subjects in both the flaccid and the stretched flaccid states. He found that the average flaccid length was 9.7 cm and the average stretched length was 16.74 cm.8

Nearly 50 years later in 1992, Bondil et al.9 studied 905 men from age 17 to 91 years, to examine the ‘extensibility’ of the penis. Penile length was recorded in three conditions; flaccid, maximal flaccid stretched and flaccid after stretch. The maximal flaccid stretched length was achieved by pulling on the glans three times, allowing for ‘tissue viscoelasticity.’ After the penis was measured at its maximal flaccid stretched length, it was then remeasured in its flaccid length, which they defined as ‘flaccid after stretch’. Lengths were found to be 10.7 and 16.74 cm in the flaccid and stretched states, respectively.9 They concluded that extensibility decreases with age.

In 1992, da Ros and colleagues published the first series examining the length of the erect penis. The study was conducted in a group of Caucasian men who were interested in penile lengthening. 150 men were enrolled in the study and were given an intracavernosal injection of papaverine and prostaglandin to achieve erection, after which measurements were obtained. Measurements of girth were taken both proximally and distally. The authors found that the average erect length in their 150 subjects was 14.5 cm, proximal girth 11.92 cm and distal girth 11.05 cm.10 After data were collected, and information was shared about the ‘normal’ ranges of penile length, men were no longer interested in penile lengthening surgery.

In 1999, Bogaert and Hershberger11 investigated the relationship between sexual orientation and penile size. The authors had two cohorts, of 935 homosexual men and 4187 heterosexual men with a mean age of 30 in both groups. Self-reported penile length was performed in five measurements; estimated erect size, flaccid penile length, erect penile length, flaccid girth and erect girth. The authors reported that there was a significant difference in both penile length and girth in this self-reported mailed questionnaire population. The average flaccid homosexual penis was 10.41 cm as compared to 9.83 cm for heterosexual men. The average erect penis was 16.40 and 15.60 cm for homosexual men and heterosexual men, respectively. Furthermore, flaccid penile girth measurements were 9.75 cm for homosexuals and 9.40 cm for heterosexuals. Lastly, erect girths measured 12.57 and 12.19 cm in homosexual men and heterosexual men, respectively.11 The validity of self reported measurements needs to be considered when evaluating these data.

Wessells et al.5 published their data regarding penile length and indications for penile augmentation. They examined penile lengths in 80 men with a mean age of 54 years. Patients were excluded if they had any penile abnormalities (that is, disease, history of urethroplasty or congenital deformities). Measurements were taken in the flaccid, stretched and erect conditions. Measurements of the erect penis were obtained by injections with prostaglandin E1, and in some cases of incomplete erection phentolamine/papaverine were added to achieve full erection. The average flaccid length was 8.85 cm (s.d.=2.38); average stretched length 12.45 cm (s.d.=2.71) and the average erect length 12.89 cm (s.d.=1.31). Girth was recorded midshaft in the flaccid condition and erect conditions at 9.71 cm (s.d.=1.17) and 12.30 cm (s.d.=1.31), respectfully.5

The largest study on penile length was published in 2001 by Ponchietti et al.,12 with a sample size of 3000 Italian men. The goal of their study was solely to determine the variability in penile size. Subjects ranged from age 17 to 19 years and measurements were recorded in the flaccid and flaccid stretched states. Flaccid circumference was recorded in the middle of the shaft. Mean flaccid length was 9.0 cm (s.d.=2.0), mean stretched length was 12.5 cm (s.d.=2.5) and mean circumference was 10.0 cm (s.d.=0.75).

Schneider et al.13 looked at the relationship between penile size and problems associated with condom use. Their experimental population consisted of 111 men aged 18–19 years. Measurements were carried out in the flaccid length, and subjects were given calipers to measure penile width, not circumference. The average self reported flaccid penis measured 8.60 cm (s.d.=1.50), whereas the average erect penis was 14.48 cm (s.d.=1.99).13

In 2005, Awwad et al.14 published his series of patients examining penile size in Jordanian men with and without erectile dysfunction. In the 271 ‘normal’ subjects aged 17–83 years, they found that flaccid length was 9.3 cm (s.d.=1.9), stretched length 13.5 cm (s.d.=2.3) and penile girth 8.9 cm (s.d.=1.5). Table 1 summarizes all the aforementioned studies12 (Table 1).

Table 1: Summary of penile size articles

After reviewing these data, some conclusions can be drawn regarding penile length and girth. With respect to penile length, average penile size is 9.0–9.5 cm in the flaccid state, whereas the maximally stretched flaccid length is 14.5–15 cm. Average erect penile length ranges from 12.8 to 14.5 cm and the average penile girth is 10.0–10.5 cm. What is the significance of these findings? Most of the papers had standard deviations of 2 with respect to penile length and standard deviations of 1 when looking at penile girth. By applying these findings, one might be able to assess the patients who are 2 s.d. below the average size. This appears to be the patients who have a flaccid penile length <5 cm, or mid shaft penile girth <8.0 cm.

These data give reconstructive surgeons a starting point as to when penile augmentation might be deemed medically necessary or appropriate.

Conditions causing penile shortening

Penile shortening is a phenomenon that is associated with certain medical and surgical conditions. These conditions include prostate cancer patients treated with radical prostatectomy, Peyronie's disease and congenital anomalies. There is also some evidence that erectile dysfunction may be an independent risk factor for shortening.

There have been several studies that have evaluated penile length after radical retropubic prostatectomy (RRP). In 2001, Munding et al.15 examined penile length in 31 men who underwent RRP by a single surgeon. All men had erections that were sufficient for penetration preoperatively. Penile measurements were recorded in triplicate on all patients in the holding area prior to surgery. These were performed in the stretched flaccid condition only, from the tip of the glans to the pubopenile skin. The same measurements were taken again 3 months postoperatively. No erect measurements were recorded, nor was penile girth recorded. They demonstrated penile shortening in the stretched condition in 71% of patients; 23% of patients were found to have <1.0 cm decrease in length whereas 48% were seen to have a>1.0 cm decrease in stretched penile length.15

A second study published in 2003 by Savoie et al.,16 similarly examined post-RRP flaccid and flaccid stretched penile lengths. Penile lengths and girth of 63 men undergoing RRP were measured pre- and postoperatively. Measurements were recorded from the pubopenile skin to the meatus, in the flaccid and stretched flaccid conditions. Penile circumference was also measured midshaft. Measurements were taken preoperatively in the holding area and then 3 months postoperatively. About 68% of patients demonstrated a statistically significant reduction in penile length in both the flaccid and flaccid stretched conditions, but interestingly, an increase in penile girth was also seen.16 Etiology of penile shortening is unclear at the present time. Theories include early penile shortening related to urethral shortening due to RRP, or secondary corporal fibrosis from chronic hypoxia and fibrosis.

There is increasing evidence, however, that penile shortening is not limited to surgical treatments of prostate cancer. This was demonstrated by Haliloglu et al.17 in 2006, when they looked at penile length in men treated with a combination of androgen suppression and radiation therapy. All subjects received hormone deprivation therapy in the form of a luteinizing hormone releasing hormone (LH-RH) agonist, (either leuprolide or goserelin) every 3 months for a total of nine injections. Twenty days of bicalutamide (50 mg per day) was given ten days prior to the LHRH agonist. External beam radiation (70 Gy) was administered in a two-phase four-field approach. Penile measurements were recorded in the stretched flaccid condition from the pubopenile skin to the tip of the glans. They found that there was a statistically significant decrease in penile length in men treated with hormonal suppression plus radiation. More specifically the men who had a pretreatment stretched length of <14 cm had a lower percentage of penile shortening compared to men with pretreatment lengths >14 cm.17 Although the literature is limited, there is some evidence that external beam radiation can cause penile fibrosis and ultimately penile shortening.18 The effects of hormone deprivation alone on penile length is not known.

Awwad et al.14 examined penile size on normal adult Jordanian men and in men with erectile dysfunction. Their data on ‘normal’ subjects have already been outlined earlier. Awwad found that when comparing normal men to men with erectile dysfunction, there was a statistically significant reduction in both flaccid and stretched penile length. More specifically, the average flaccid penile length was 7.7 cm (potent patients 9.3 cm), whereas the average stretched penile length was 11.6 cm (potent patients 13.5 cm). Penile girth of the impotent men was not assessed. The authors cited loss of elasticity and lack of intermittent stretching of tunica albuginea as one explanation for the disparity in penile length between potent men and impotent men.14

Probably the most common etiology of penile shortening is seen in patients with Peyronie's disease. It is important to note that both the natural history of disease and the scarring process after surgical repair with incision/excision of plaque with graft or a penile plication procedure for surgical correction may cause a reduction in penile length.19 When the disease is circumferential or bilateral, it prevents the tunica albuginea from expanding thereby causing penile shortening.20 Surgical procedures for correction can result in fibrosis that can result in further reduction in length when compared to preoperative measurements. Typically, 60–100% of patients undergoing penile plication procedures will have some degree of penile shortening. In addition, 0–50% of patients undergoing incision of plaque with graft may have penile shortening.21 This is likely the result of graft contraction. There is some early data suggesting that a penile extension device may increase length, prevent graft contraction and minimize postoperative penile shortening.22, 23

Lastly, congenital micropenis results from a number of biochemical etiologies, and it is lifelong. By definition, micropenis is ‘a normally formed penis that is at least 2.5 s.d. below the mean in size’.24, 25 The biological causes stem largely from defects in the hypothalamus, specifically when an inadequate amount of gonadotropin-releasing hormone is released. This may be a primary hypothalamic or an anterior pituitary problem. Lastly, the micropenis can result from embryonic testis failure causing insufficient masculinization.22 Bladder exstrophy and epispadias also can result in penile shortening, thought to be related to a congenitally shortened anterior corporal length.26

Penile augmentation procedures

When speaking of penile enhancement surgery, one must distinguish between those procedures that increase penile circumference, penile length and plastics procedures to change skin surrounding the penis.

The Sexual Medicine Society of North America has drafted a position statement on penile lengthening and girth enhancement surgery. It reads as follows:

‘The Society for the Study of Impotence has found no peer reviewed, objective or independently-monitored studies, or other data, which prove the safety or efficacy of penile lengthening and girth enhancement surgery.

Therefore, penile lengthening and girth enhancement surgery can only be regarded as experimental surgery.

The Society is aware of complications and adverse outcomes that should be clearly disclosed to patients considering such surgery.

The Society believes that those government agencies charged with the regulation of medical practice and the enforcement of laws prohibiting false or unsubstantiated advertising claims should give careful attention to claims made with regard to these surgical procedures.’ (www.smsna.org)

Penile girth enhancements

One of the earlier papers aimed at penile girth enhancement was reported in 2002, by Austoni et al. Thirty-nine patients underwent elective enhancement surgery for hypoplasia of the penis or functional penile dysmorphophobia. Penile dysmorphophobia is defined as a condition in those men whose penis are normal, but request an augmentation procedure as a result of an altered perception of the organ. Penile dysmorphophobia can be both a functional issue and an aesthetic issue.27, 28 The procedure was carried out by using a saphenous vein graft. Incisions were made in the tunica albuginea from apex of the corpora to the crura and saphenous vein patches were placed.27 At 9 months postoperatively, there was no statistically significant increase in flaccid penile circumference, but there was a statistically significant increase in erect circumference. Erect diameter (location on shaft not specified) preoperatively was 2.85 cm, whereas the average erect diameter postoperatively was 4.21 cm. The authors indicated that there were no ‘major complications’.27

Fat injection into the penis is the mainstay of girth enhancement procedures. The goal of fat injection into the dartos layer of the penis is uniform enhancement of penile circumference. In 2006, Panfilov29 described his method of injecting the penis with autologous fat. In his protocol, 200–250 cm3 of a physiologic solution containing adrenalin (1:800 000) and 0.02 xylocaine (50 ml xylocaine 1% per 1 l solution) was instilled into two 2–3 mm incisions on the upper inner thigh. After approximately 50 min, the fat was harvested. Fat was injected in four 1 mm incisions around the penis at the 1, 5, 7 and 11 o’clock positions. For each incision anywhere from 10 cm3 to 16 cm3 of fat is injected. After injections, the penis is ‘kneaded’ to even out the injections. At 1 year of follow up, 77 patients were highly satisfied, 8 patients were fairly satisfied and 3 patients were not satisfied. One patient had too much fat injected into his foreskin, and 2 patients had excessive loss of fat.29 Table 2 summarizes these studies.

Table 2: Penile circumference enhancement studies

Alter has written extensively regarding his experience with penile enhancement surgery.29, 30, 31 In particular he has described the use of dermal fat grafts for penile girth enhancement. According to the author, dermal fat grafts are superior to autologous fat injections because less than 50% of fat survives in autologous fat injections whereas, dermal fat grafts had been used with success in plastic surgery.30 Dermal fat grafts are taken from the groin area below the swimsuit line, or from the gluteal creases. Alter states that circumferential placement of a dermal fat graft is the preferred technique, with the size of the dermal fat graft based on the measurement of the penis on full stretch from the pubopenile junction to the distal corona. The urethra is usually left uncovered. Penile weights are used after approximately 1 month, postoperatively, to prevent shrinkage and graft contraction.30

It is reported that circumference is increased between 1 and 2 inches, using the aforementioned procedure. The procedure is rather lengthy (several hours), but results in a uniform increase in girth, without nodularity. Edema resolves with 6 weeks, whereas normal texture is regained in 4–6 months. It should be noted, however, that there can be severe complications that include, but are not limited penile shortening, asymmetry and curvature due to fibrosis if the graft does not take uniformly.30, 31

With the advent of tissue engineering, there are a number of new mechanisms to perform circumferential enhancement. In 2006, Perovic et al.32 reported their series of 84 patients who had penile circumferential enhancement using a biodegradable scaffold. Age ranges of their subjects were 19–54 years, and indications for augmentation were penile dysmorphic disorder or failed penile enhancement surgery. After fibroblast cells were harvested from scrotal biopsies, they were grown to a volume of 2 × 107, and then seeded on a tube-shaped polylacti-co-glycolic-acid scaffold. After 24 h of incubation, the penis was degloved and scaffold was transplanted between dartos and Buck's fascia.32 At 24 months median follow up, mean increase in girth was 3.15 cm (1.9–4.1 cm) in the flaccid state and 2.47 cm (1.8–3.0 cm) in the erect state. Complications included infection in three patients, penile skin necrosis in two patients and seroma in five patients. All patients were able to be treated conservatively.32

A more novel technique used in penile girth enhancement has been the use of AlloDerm. AlloDerm is ‘an acellular dermal matrix derived from donated human skin’, which is available in sheets. Although most of the data for AlloDerm are anecdotal, recently, they have been widely used in penile girth enhancement. The AlloDerm sheets are placed above Buck's fascia. The reported minimal scar is one advantage of this technique for penile girth enhancement.33

Penile lengthening

The mainstay of penile lengthening procedures are a combination of release of the suspensory ligament of the penis with an inverted V–Y penopubic skin advancement (Figure 2).34 Most surgeons recommend cutting the suspensory and fundiform ligament in combination with the use of postoperative penile weights. There is minimal evidence-based data in the literature documenting pre- and postoperative lengths.

Figure 2
Figure 2

(a) Location of incision. (b) Post operative schematic showing cut ligament and skin realignment. Inverted V–Y skin plasty at penile base with release of suspensory ligament. Reprinted with permission from British Journal of Urology.

Shirong et al.35 performed penile elongation surgeries in patients who had congenital microphallus. They defined microphallus as an erect length of less than 8 cm, or in men with traumatic injuries. They performed 52 procedures over a 7-year period, in men aged 23–52 years. The procedure consisted of cutting the suspensory ligaments, beginning with the superficial ligaments and if more length was needed, the deep suspensory ligaments were partially cut. A scrotal flap was used to cover the exposed corpora, and in some cases a V–Y suture was used on the ventral side to avoid traction and allow better cosmesis.35 Only 20 patients were followed postoperatively, and increase in length was seen from 3.5–6.5 cm. There was an average decrease in length of 0.5–1.5 cm within the first 6 months of the procedure.

It is often standard protocol that after transection of the fundiform and suspensory ligaments, penile weights (at least 10 pounds) are used. Penile weights are hung from the corporal ridge, once the patient has recovered from the initial procedure. The weights prevent reattachment of the suspensory ligament and should be worn intermittently throughout the day. Some men opt to use progressively heavier weights for anywhere from months to years, which act as tissue expanders.30, 31 In addition, Alter has suggested the placement of fat (dissected off the spermatic cord) between the suspensory ligaments and bone to prevent adherence to the pubic bone resulting in penile shortening.29, 30

Recently, Shaeer et al.36 reported a variation on the skin reconstruction and fat placement to prevent postoperation shortening. They recommend placing a pubic fat flap between the penis and the pubic bone after the suspensory ligament is released. In addition, they report a combination of a ‘T closure’ in addition to the V–Y advancement.36

In 2000, Perovic described his technique for penile elongation. Nineteen patients, aged 18–52 years were included in the study. Inclusion criteria were limited to patients who ‘thought their penis was too short for sexual satisfaction’. All patients had anatomically normal penis, but short erect lengths between 6 and 10 cm. Patients who had a penile length greater than 10 cm, were excluded. Perovic's procedure involved completely disassembling the penis into two components: the glans cap with the urethra attached on the ventral aspect and the neurovascular bundle on the dorsal aspect, and the corpora. An autologous piece of rib cartilage was then shaped and sutured in a place inserted between the corpora and the glans. Thirteen patients noted an increase in length between 2 and 3 cm, whereas the remaining six had an increase between 3 and 4 cm. No infections or erosions were noted, and the cartilage remained roughly the same size as at the time of implantation. Fifteen patients reported painless intercourse at 3 months. Five patients noted a dorsal curvature that was corrected with a vacuum device.37

Paniflov29 described his technique for penile elongation in 2006. He described incomplete cutting of the fundiform ligament of the penis. This allowed for the elongation of the extracorporeal part of the penis. Then, a ‘V–Y plasty’ was used to elongate the penile skin at the base.29 The average penile length preoperatively was 8.75 cm (6.5–10 cm), which was increased to a mean of 11.14 cm at 12 months postoperatively. Few objective outcome data were reported and no complications were reported.

Complications of penile lengthening procedures may be significant. There is minimal short- and long-term patient satisfaction data. Penile shortening is the major complication, usually resulting from the freely hanging penis reattaching to the pubic bone higher on the corporal bodies. This complication may be minimized by the placement of fat as described previously. Other complications include loss of sensation, angling of the penis downward (due to lack of support) and hypertropic scarring of wounds.

A discussion of penile lengthening would be incomplete without the mention of penile reconstruction for bladder exstrophy epispadias. After the exstrophy is repaired these patients are often left with deformities of their penis, mainly a shortened penis or an upward-tethered penis. This is thought to be a result of a congenitally shortened anterior corpus cavernosum.26 These deformities can lead to significant psychological and social issues in adulthood. A number of techniques have been described on how to reconstruct the epispadic penis. Cantwell was one of the first to describe the repair of epispadias in his 1895 article in the Annals of Surgery.38 Since then many others have developed their own novel techniques as well as modified Cantwell's procedure. In 1971, Kelley and Eraklis2 separated the corpora from the ischiopubic ramus in a patient with exstrophy of the bladder to gain length. One of the more common techniques used to correct exstrophy epispadias is the modified Cantwell–Ransley repair, a staged repair. This repair emphasizes penile chordee correction, urethral reconstruction, glandular reconstruction and penile skin closure. In 2000, Surer et al.39 reported their 10-year experience using this technique in 93 patients. Of the subjects, 79 had classic exstrophy and 14 had complete epispadias. A primary repair was performed in 65 of the patients who had classic bladder exstropy and 12 who had epispadias. A secondary repair was done in 14 patients who had classic bladder exstrophy and 2 who had complete epispadias. The authors found that more than 90% of the patients had a functionally usable penis (at 68 months of followup). Complications from the procedure included urethrocutaneous fistula in 19–23%, urethral strictures in 9% and minor skin separation in 6%. They ultimately concluded that the modified Cantwell–Ramsley procedure yields excellent results both cosmetically and functionally.39

Penile skin reconstruction (hidden penis and penoscrotal web)

A ‘hidden’ penis usually occurs secondary to overlying skin or abdominal fat. As described by Alter, this may result from ‘aging, obesity, overly aggressive circumcision, abdominoplasty with aggressive release of dartos fascia attachments to Scarpa's fascia or penile lengthening using an ill-advised large pubic V–Y advancement flap’.40 This is compared to a ‘buried’ penis where the penile shaft is underneath the surface of the prepubic skin. Buried penis often results from obesity and/or radical circumcision. In 1999, Alter and Ehrlich described a novel technique for correction of the hidden penis in adults. The authors stressed, that prior to embarking on the procedure, the etiology of the concealment must be identified correctly to fix the condition properly.

The amount of penile skin must be assessed to assure that there is sufficient amount to perform the procedure. When concealment is due to overhanging suprapubic skin, the skin is excised in an elliptical fashion, which will allow for visibility of the penis. It is important to taper the fat cephalad and laterally, which will prevent an unsightly appearance. The subdermal tissue of the suprapubic skin is then tacked to the rectus fascia which maintains the upward position of the resected skin (Figure 3).40

Figure 3
Figure 3

Technique of tacking subdermal penopubic junction to rectus fascia with multiple rows of polyester sutures. Reprinted with permission from Journal of Urology.

Sometimes a suprapubic lipectomy or liposuction is performed if a large suprapubic fat pad is present. On occasion, release of the penile suspensory ligaments may be performed to allow for additional penile length. Even after the suprapubic fat issues are addressed, there is still a tendency of the corpora to retract into the scrotum. In order to prevent the retraction, a midline incision is made at the penoscrotal junction, and dissection carried down to the spongiosum and tunica albuginea. Two tacking sutures are placed on either side of the urethra from the tunica albuginea to the ventral penoscrotal subdermal tissue (Figure 4). These sutures prevent retraction of the penis into the scrotum.40

Figure 4
Figure 4

Technique of bilateral tacking of subdermal penoscrotal junction to periuretheral tunica albuginea. Reprinted with permission from Journal of Urology.

As implantation of a penile prosthesis has been perceived by some as resulting in penile shortening,41, 42 Miranda-Sousa et al.43 developed a novel technique of releasing the penoscrotal web to give the appearance of a longer penis. The procedure was done in patients undergoing penile prosthesis implant for erectile dysfunction. Ninety patients, with a mean age of 62 years, underwent placement of a penile prosthesis. Group 1 consisted of 43 patients who had penile prosthesis placement (39 received Coloplast inflatable penile prosthesis and 4 received semi-rigid penile prosthesis) along with ventral phalloplasty with takedown of penoscrotal web. Group 2 contained 37 men who had Mentor Titan inflatable prosthesis placed through a standard penoscrotal incision. After the degree of penoscrotal webbing is determined by placing the penis on traction and distracting the scrotum in the midline, an asymmetric ‘V’ incision is made on each side of the web. A diamond shaped piece of scrotal skin is removed and closed in a modified Heineke–Michulz type fashion. In Group 1, 42 of 43 (98%) men reported good overall satisfaction; 84% reported an overall increase in their perception of penile length, whereas 12% reported no change and 4% reported decrease in penile length. The authors reported that the difference in patients reporting an increase in length vs those reporting a decrease in length reached statistical significance. In group 2, 31 of 37 (84%) patients reported penile shortening, which also reached statistical significance. Complications associated with the procedure were uncommon and minor (two wound hematomas and three superficial infections in group 1, and one wound separation in group 2). Operative time in group 1 was roughly 12 min longer than that in group 2. Most importantly, there were no prosthetic infections in either group.43

In 2007, Alter44 published his surgical technique for the correction of penoscrotal web, in which he defines the penoscrotal web as ‘an obtuse attachment of scrotal skin onto the ventral shaft, which shortens the functional and visual ventral penile length.’ He attributes most penoscrotal webs to aggressive circumcision in which too much ventral penile skin is excised, however the penoscrotal web can also be congenital. Alter uses the ‘Z-plasty’ technique to correct penoscrotal web. Using this technique, the midline raphe is used for the central limb of the Z plasty, and then a 60° angle Z-plasty is performed. According to Alter, 60° allows for a theoretical gain in length of 75%. Skin incisions are made along the Z-plasty through skin and superficial dartos fascia, and skin closed with a 4–0 or 5–0 moncryl. He does caution that closing the Z-Plasty can cause circumferential narrowing of the penis.44 More recently Chang and Liu published their technique for the correction of the penoscrotal web. Chang and Liu45 reported that despite being effective, Z-plasty can be technically difficult. The authors offer a V–Y advancement flap technique for the correction of penoscrotal web. They described making a V incision at the penoscrotal junction, and this flap is then mobilized, using caution to preserve blood supply so as to not devascularize the flap. This flap was then advanced upwards and closed in a Y configuration using 4–0 chromic suture. This same technique was repeated 1.5 cm below the previous suture line to completely correct the web. The authors added that the ideal angle of ‘V’ should be approximately 60° with a length of 1 cm to gain maximum length. Using an angle greater than 60° can restrict length, however, an angle too small can compromise blood supply.45

Complications

Many of the previously quoted studies do not discuss complications. Penile enhancement surgery is a highly risky procedure. There is no standard surgical technique, and much of the performed procedures are experimental with minimal objective pre- and postoperative data. In patients who have autologous fat transfer for girth enhancement, complications include loss of injected fat and irregularity at the injection site, scar thickening with keloid formation and scrotalization.46, 47 These complications are usually seen when the V–Y flap techniques is employed.46, 47 Sexual dysfunction and further penile shortening are also reported complications of these penile enhancement procedures.

In 1997, Alter46 nicely reviewed the complications from penile enhancement surgery. Alter reoperated on 19 men over a 2-year interval, all of whom had penile enlargement surgeries by other physicians. In all 19 men, cutting the suspensory ligaments and advancing the skin in the V–Y advancement flap was performed in an attempt to achieve penile lengthening. Penile girth enhancement was accomplished by autologous fat injections. Patients presented various complaints such as hypertrophic scars, low hanging penis and penile lumps. In 12 of 19 patients, either complete or total reversal of the V–Y advancement flap was performed. In addition, 12 of the men had removal of subcutaneous fat nodules. Alter attributed most of the poor results to flap viability secondary to vascular supply, or to a thick V–Y flap. Often a complete reversal of the V–Y flap was either impossible, or undesirable. Elevation of the V flap was performed, aligning hair-bearing skin on the flap to the scrotum to maintain blood supply and scrotal dog ears were excised.46

Discussion

This review gives an overview of studies that examine the average length of the penis, conditions that result in penile shortening and penile enhancement procedures.

Variability arises between standardization of penile measurements. Objective standardization is required to make comparison of data more accurate. Penile length should be measured from the base of the penis, or the pubopenile junction at the most proximal point to the tip of the glans as the most distant point of measurement. Penile length should be evaluated in three states: flaccid, flaccid stretched and erect, whereas penile girth or circumference should be measured as flaccid and erect. In order to accurately reflect penile size, both length and girth measurements should be taken in all states. These measurements should be made by a single health professional, not with self-reported questionnaire data. With the exception of Wessells’ data,5 no study performed measurements under all conditions. Rather, measurements were recorded in either the flaccid state or the erect state, but never in both. Given the tremendous variability in penile size and the unpredictable penile extensibility, it would appear that penile measurement should be performed in all states in order to arrive at a consensus statement regarding penile size.

Why perform penile enlargement surgery? Is the motivation of the patient purely for cosmetic and psychological reasons or is there a bona fide medical need/condition to warrant or justify penile enlargement? With respect to those patients seeking enlargement for the former reason, there is no medical necessity to perform the surgery. This is usually true with cosmetic plastic surgery for women for breast augmentation when not associated with breast cancer. Is this type of surgery reasonable in men with respect to penis length? Should the surgeon consider psychiatric clearance prior to consideration of penile augmentation surgery? Should this be the standard of care?

There are medical conditions that result in legitimate penile shortening. There is evidence that some of the current treatments for prostate cancer, can lead to penile shortening. Specifically, men who undergo radical prostatectomy and possibly radiation therapy and hormonal treatment are susceptible to penile shortening.15, 16, 17 Although penile shortening has been documented, there is no quality of life data to support or refute the overall importance of this effect on male sexuality. Along similar lines, patients who have peyronie's disease are also subject to penile shortening, but much like those treated for prostate cancer, penile shortening is not usually significant enough to warrant enlargement surgery.

Surgeons who consider performing this type of surgery must be able to justify why enlargement surgery should be performed. This discussion should first include the distinction between those procedures that increase penile girth and those that are aimed at increasing penile length. Regardless of which type of procedure is being sought, the patient should be aware that there is no universally accepted protocol for either type of surgery. Most of the reported case studies have been in a small experimental population with short followups. They should also be informed of the numerous complications that can result from such procedures, which included but are not limited to poor cosmesis, further shortening and sexual dysfunction.

Plastic surgical procedures on the skin of the penis holds more optimism. It appears that the overall risks of these procedures are minimal. Quality of life data collection will be necessary to determine if the value of these procedures approach that of breast augmentation for women.

Conclusions

The issue of penile size is one that will forever be an area of controversy for most men. This review sheds some light on the objective data regarding penile size. To reach a true consensus of penile size, a study comparing men from different races and nationalities would need to be performed. Standard measuring techniques are necessary to determine the results of penile lengthening procedures. We have sufficiently demonstrated medical and surgical conditions in which penile shortening occurs. In addition, we have highlighted the procedures that are currently being performed for penile lengthening, girth enhancement and plastics skin reconstruction, and their associated complications.

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Affiliations

  1. Mount Sinai School of Medicine, New York, NY, USA

    • B E Dillon
    •  & N B Chama
  2. Urology Center, New Haven, CT, USA

    • S C Honig
  3. Division of Urology, University of Connecticut, Farmington, CT, USA

    • S C Honig

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Corresponding author

Correspondence to S C Honig.