Penile Size and Penile Enlargement Surgery: A Review

B.E. Dillon; N.B. Chama; S.C. Honig

Disclosures

Int J Impot Res. 2008;20(5):519-529. 

In This Article

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]

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