Sexual Functioning and Behavior of Men with Body Dysmorphic Disorder Concerning Penis Size Compared with Men Anxious about Penis Size and with Controls: A Cohort Study

#Penisenlargement on Instagram: a mixed-methods study

This study aims to analyze the reliability of #penisenlargement hashtag on Instagram and to investigate how young adult men perceive their penis size in real-world settings after being exposed to #penisenlargement Instagram postings. In the first phase, the credibility of the 100 most recent publicly accessible postings with the #penisenlargement hashtag was evaluated. Also, the last 1000 posts related to the same hashtag were evaluated to determine follower reach and engagement impacts. In the second phase, men were exposed to the #penisenlargement hashtag for 6 months and completed an online questionnaire examining their motives to undergo augmentation. Only a few (n = 6, 1%) posts had reliable information. At the time of questionnaire completion, participants reported a substantial drop in their genital self-image (22.3 ± 3.6 to 17.8 ± 3.0, p < 0.001) and a significant increase in their media exposure (1.24 ± 1.05 to 2.3 ± 0.74, p < 0.001) compared to their pre-Instagram exposure levels. The most prevalent reason for pursuing penis enlargement following Instagram exposure was to enhance self-perception and confidence. Our findings indicate that penis enlargement methods on Instagram are mostly unreliable. In addition, being exposed to posts pertaining to "penis enlargement" the hashtag can encourage men to seek penis augmentation surgery.

Defining Preferred Esthetics of the Ideal Phallus via Crowdsource Survey

OBJECTIVE

To describe phalloplasty subunits and determine the preferred crowdsourced esthetics. Esthetic ideals are often used to guide reconstruction, and there has been an increase in the number of gender-affirming surgeries and reconstructive phalloplasties performed. However, there is a paucity of literature describing ideal phalloplasty esthetics.

METHODS

Phallus esthetic subunits were defined, and a split testing-based survey was used. Subjects were solicited via Craigslist, Amazon Mechanical Turk, and Reddit and distributed among health care co-workers. Computer-generated images with variable ratios of glans, corona, and shaft were provided and respondents were asked to select the most esthetically pleasing photo. Demographic information was gathered. Univariate and multivariate regression were performed.

RESULTS

A total of 1029 people responded to the survey request and 909 people (88.3%) completed the entire survey. There were 440 respondents who self-identified as male, 334 female, 92 transgender male, and 25 transgender female. The health care field was the profession for 55.4%. Health care providers had 65.3% higher odds of preferring the longer shaft length-to-width ratio, 30.3% less odds of preferring a bilateral taper of the glans, and 48.4% less odds of preferring an angulated shaft compared to non-health care providers (P = .006, P = .021, P <.001, respectively). When compared to males, transgender females were more than 13 times likely to prefer an angulated glans corona junction (P = .008).

CONCLUSION

The ideal phallic esthetic varies by individual, and there were statistically significant preferences across age, education, health care status, gender, and sexual orientation. This study can serve as a guide on phalloplasties for patients and gender-affirming surgeons.

The Efficacy of Injection Penile Girth Enhancement as an Option for Small Penis Syndrome Management

BACKGROUND

In recent years aesthetic injection techniques with soft tissue fillers have become popular worldwide due to their effectiveness, safety, and low cost. There is no standard approach to the management and follow-up of patients seeking penile enlargement procedures described in the literature, and the surgical penile enlargement methods are controversial.

OBJECTIVES

The goals of this study were to assess the effect of injection penile girth enlargement on sexual relationship satisfaction, confidence, and self-esteem, and to evaluate the clinical efficacy and safety of this procedure for the management of men with small penis syndrome (SPS).

METHODS

This was a single-center, clinical case series study executed from January 2019 to February 2021, which involved 148 men who were unsatisfied with the shape of their normal-size penises and requested penis girth correction.

RESULTS

A total of 132 patients completed full treatment and follow-up. Mean girth enlargement was 1.7 ± 0.32 cm for the midshaft and 1.5 ± 0.32 cm for the glans of the penis. Satisfaction with sexual life improved. Mean scores increased by 17.9 ± 3.04 points for sexual relationship satisfaction and by 12.2 ± 3.17 points for confidence. The mean score for self-esteem increased by 8 ± 2.8 and by 4.3 ± 0.97 points for overall relationship satisfaction.

CONCLUSIONS

Penile enlargement with hyaluronic acid injection positively affects sexual relationship satisfaction, confidence, and self-esteem of men with SPS. The rate of psychosocial improvement does not correlate with penile size changes. It is a simple, safe, and effective technique that can be used in daily clinical practice.

LEVEL OF EVIDENCE: 4

Efficacy and complications of hyaluronic acid and polylactic acid for penile augmentation: a systematic review and meta-analysis

Background

Penile size is considered a symbol of manhood and is a subjective problem for men, especially those with small penis syndrome. Penile augmentation was introduced to correct penile size problems from a medical, psychological, or esthetic point of view. Hyaluronic acid (HA) and polylactic acid (PLA) are two types of augmentation agents that are popularly used today. However, no systematic studies and meta-analyses have compared these two modalities as penile augmentation agents. This study aimed to analyze the efficacy and safety of penile filler injections with HA compared to PLA.

Methods

This study was based on the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Articles examining the differences in efficacy and adverse events of the administration of HA and PLA in patients undergoing penile augmentation were systematically reviewed from the PubMed, Proquest, Web of Science, and Scopus databases. An odds ratio with a 95% CI was applied to measure the study outcome. The analysis was performed with RevMan 5.4 software. The risk of bias for each study was evaluated using the Risk of Bias v2 instrument from Cochrane. This research protocol is registered in the International Prospective Register of Systematic Reviews (PROSPERO) registry.

Result

Four articles consisting of 283 research subjects were included in this study. The meta-analysis for penile girth enhancement after penile augmentation found significant results in the HA group compared to the PLA group (P=0.01). There was no difference in the level of satisfaction with penile appearance 4 weeks after penile augmentation in the HA group compared to the PLA group (P=0.79). HA was significantly superior in sexual satisfaction 12 weeks postpenile augmentation (P=0.0004). There was no difference in the incidence of pain after penile augmentation in the HA group compared to the PLA group (P=0.33). In the postaugmentation penile inflammation, there was no difference (P=0.98) in the HA group compared to the PLA group.

Conclusion

There are differences in the efficacy of penile augmentation with the superiority of HA in increasing penile diameter and postaugmentation sexual satisfaction compared to PLA. There was no difference in the incidence of complications between using HA and PLA.

Psychological Autopsy in Small Penis Syndrome: Determining the Manner and Circumstance of Death Following a Vehicular Accident

Road traffic accidents and related deaths are on the rise, especially in developing countries. Even though uncommon and probably under-recognized, predisposing psychiatric states may be contributory, posing the question of whether these could be avoided. Psychological autopsy, despite not being performed routinely, might play a pivotal role in such instances, in reconstructing events leading to the catastrophe and determining the role played by the parties involved. The legal implications, such as the exoneration of the wrongly accused, might be substantial. This case report presents a death of a middle-aged South Asian male with strong history and evidence of small penis anxiety following a direct collision in a road traffic accident. It highlights the careful evaluation of the clinical history of the deceased by a psychological autopsy and reiterates the importance of the former in suspected cases.

The scrotum: A comparison of men's and women's aesthetic assessments

BACKGROUND

Cosmetic surgery is a growing trend. Opportunities for an individual to attain their personal aesthetic ideal via plastic surgery have now extended as far as the genital area. Adaptive surgery on intimate areas of the body may take place for physical complaints, but may instead be due to a desire to conform to a particular ideal. Breast operations, labia reductions, and penis lengthening are long-established interventions, the motives for which a number of previous studies have examined. Tightening of the scrotum, by contrast, is a new trend in the aesthetic surgery market. Notwithstanding its rapid increase, studies have yet to investigate aesthetic preferences as regards the scrotum.

AIMS

Accordingly, the aim of the present study is to compare men's and women's evaluation of various sizes of scrotum, to the end of assisting people opting to undergo this procedure in taking decisions on their visual preferences.

MATERIAL AND METHODS

The participants in this study rated a number of photographs of scrotums, in nine different lengths and widths, and completed a questionnaire whose aim was to determine whether assessments differed by gender. Further, we considered whether the variables of age, extraversion, openness to experience, and consumption of pornography influenced participants' evaluations.

RESULTS

We found no significant differences in evaluation of the aesthetic of scrotums in relation to any of these personality traits. The results show what sizes (lengths and widths) of scrotum the participants judged to be the most and least attractive.

DISCUSSION

The esthetics of the scrotum is little explored. In this study, only normal deviations were considered, i.e. within one standard adjustment. Further studies should consider extremes.

CONCLUSION

Ultimately, it was barely possible to identify a "beautiful" scrotum; we must instead speak of the least ugly.

Who seeks sex therapy? Sexual dysfunction prevalence and correlates, and help-seeking among clinical and community samples

Sexual dysfunctions (SD; e.g., female sexual interest/arousal disorder, erectile disorder, female orgasmic disorder, delayed ejaculation, genito-pelvic pain/penetration disorder, etc.) affect up to a third of individuals, impairing sexuality, intimate relationships, and mental health. This study aimed to compare the prevalence of SDs and their sexual, relational, and psychological correlates between a sample of adults consulting in sex therapy (n = 963) and a community-based sample (n = 1,891), as well as examine barriers to sexual health services for SD and the characteristics of individuals seeking such services. Participants completed an online survey. Analyses showed that participants in the clinical sample reported lower levels of sexual functioning and sexual satisfaction and higher levels of psychological distress than participants in the community-based sample. Moreover, higher SD rates were related to lower relational satisfaction and higher psychological distress in the community sample, and to lower sexual satisfaction in both samples. Among participants in the community sample who sought professional services for SD, 39.6% reported that they were unable to access services, and 58.7% reported at least one barrier to receiving help. This study provides important data regarding the prevalence of SD and the link between SD and psychosexual health in clinical and nonclinical samples, as well as barriers to treatment access.

Clinical Significance of Shortened Penile Length and Alterations in Penile Length Following Treatment for Peyronie's Disease

INTRODUCTION

Across many cultures, penis size has been associated with virility, and concerns about penile length are commonplace. Peyronie's disease (PD) is a known acquired cause of penile shortening.

OBJECTIVES

This paper describes the psychosocial impacts of penile length on men and their partners, both generally and in men with PD, and evaluates the effect of PD treatments (eg, collagenase clostridium histolyticum , surgery, mechanical therapy) on this outcome measure.

METHODS

A PubMed database search was performed for English language articles through July 2021. Main outcome measures were association of penile length with emotional well-being, selfesteem, and relationship satisfaction in men with PD, and change from baseline penile length after treatment.

RESULTS

Shortened penile length caused by PD can negatively impact patient and partner quality of life, including effects on body image, emotional well-being, sexual function, and interpersonal relationships. In men with PD, studies have demonstrated an association between loss of penile length and emotional problems, reduced satisfaction with sexual performance, poor self-esteem, depression, and relationship difficulties. Loss of penile length can frequently occur after surgery for PD (including plication, plaque incision/excision with grafting, and penile implant). Advanced surgical techniques may preserve/increase penile length, but the increased risks associated with these complex procedures must be carefully considered. Treatment with collagenase clostridium histolyticum does not appear to negatively impact penile length, and 5-year follow-up data suggest potential longterm posttreatment improvements in this outcome measure. Penile traction therapy, either alone or as adjunctive therapy, may increase penile length in men with PD, but nonadherence may limit improvement.

CONCLUSION

Changes in penile length are important to many men, particularly those with PD, and should be considered during PD treatment selection. Penile length should be measured objectively before and after treatment for PD and should be included as an outcome measure in future studies on treatment effectiveness. Goldstein I, Gelbard MK, Lipshultz LI. Clinical Significance of Shortened Penile Length and Alterations in Penile Length Following Treatment for Peyronie's Disease. Sex Med Rev 2022;10:409-420.

History and future perspectives of male aesthetic genital surgery

Since ancient times, men have tried to change the size and shape of their genitals. Bites from insects or poisonous snakes and weights were among the first methods used for this purpose. In the first half of the 1900s, the scientific push regarding male genital aesthetic surgery began. Scrotoplasty, penile suspensory ligament release, injection of hyaluronic acid as filler, use of several types of grafts, lipofilling, and liposuction are techniques currently used. The Penuma® implant has recently been described with promising results. We are living in the era of tailored surgery and regenerative medicine. Shortly the surgeons will have to know several surgical techniques and adapt them to the patient. New fillers with ideal characteristics, innovative prosthetic devices, and stem cells will probably be the protagonists of future aesthetic surgery. The main effort of the scientific community should be directed towards the design of new randomized controlled trials to increase the evidence on the efficacy and safety of the topic, with the ultimate aim of allowing clear recommendations from scientific societies.

Male esthetic genital surgery: recommendations and gaps to be filled

The reason behind the spread of penis enlargement practices over time is rooted in the virility that the appearance of the genitals can give a man, as well as an altered perception of his own body. The approach should be to modulate the interventions on the real needs of patients, carefully evaluating the history, the psychological picture, and possible surgical advantages. The aim of this study was to shed light on cosmetic surgery of male genitalia through minimally invasive and more radical techniques, with the purpose of laying the foundation for possible indications and recommendations for the future. A non-systematic literature review using the PubMed and Scopus databases was conducted to retrieve papers written in English on cosmetic surgery of the penis published over the past 15 years. Papers discussing cosmetic surgery in patients with concomitant pathologies associated with sexual dysfunction were excluded. The main outcomes recorded were change in penile dimensions in term of length and girth and surgical complications.

Revelations on Men Who Seek Penile Augmentation Surgery: A Review

INTRODUCTION

Men with normal penis size sometimes mistakenly believe they have below average penile dimensions and often seek out treatment. Many men suffer from significant anxiety regarding this perceived defect. In this review, we evaluate the current literature of psychological, medical, and surgical treatment options for men with a complaint of a small penis.

OBJECTIVE

To review the current practice for treatment of men presenting for penile augmentation surgery.

METHODS

A literature review was conducted, using PubMed to identify current studies regarding penile enhancement. Search terms included "penile enhancement," "small penis anxiety," "small penis syndrome," "body dysmorphic disorder," and "penile augmentation."

RESULTS

The literature consistently reveals that men who seek out penile augmentation surgery usually have normal penile dimensions. There are limited published data on the practice of penile lengthening surgery or procedures to increase penile girth. New techniques have expanded on suspensory ligament release, such as tissue grafting and flaps. Structured psychological counseling continues to be the recommended initial standard of care for these men.

CONCLUSION

Many social forces have increased the perception among men that their penis size is inadequate. This increases anxiety and can lead to psychological disorders such as Penile Dysmorphic Disorder and Small Penis Syndrome. Men who undergo penile enhancement are often not satisfied with the results and may develop complications. Soubra A, Natale C, Brimley S, et al. Revelations on Men Who Seek Penile Augmentation Surgery: A Review. Sex Med Rev 2021;XX:XXX-XXX.

A preliminary investigation of a novel method to manipulate penis length to measure female sexual satisfaction: a single-case experimental design

OBJECTIVES

To investigate a novel methodology and explore whether artificially reducing the depth of penetration during intercourse matters to women.

STUDY DESIGN AND METHODS

A study with a single-case experimental design ('n of 1'), in which a heterosexual couple act as their own control and the study is then replicated in subsequent couples, was conducted. Thirty-five couples were assessed for eligibility to participate. Twenty-nine couples without any sexual problems were randomized and 12 submitted sufficient data to analyse. As a proxy for reducing penis length, we artificially reduced the depth of penetration by using different sizes of silicone rings around the base of the man's erect penis. The main outcome measures were provided by the female partner on a scale of 0-100 and comprised: degree of (i) overall sexual pleasure; (ii) sexual pleasure from intercourse alone; and (iii) emotional connection to the male partner. The female partner was also asked before the experiment began to rate the degree of positive or negative change that would be personally meaningful for her.

RESULTS

On average, reducing the depth of penetration led to a statistically significant 18% reduction of overall sexual pleasure with an average 15% reduction in length of the penis. The longer the erect penis, the less likely the rings were to have an impact on sexual pleasure. There was a range of individual responses, however, with a minority of women reporting that reducing the depth of penetration was more pleasurable on some occasions.

CONCLUSIONS

Size may matter in women in a healthy stable relationship when there is penile shortening. Because of the small number of couples and the inclusion of men with an apparently long penis, our results are preliminary, and we welcome replication in a larger sample with a more diverse range of penile lengths. Our results should not be misinterpreted as meaning that increasing penile length will increase sexual pleasure in women.

Penile length and circumference dimensions: A large study in young Italian men

The aim of the present study was to evaluate the size of the penis in flaccidity and in erection of Italian men. A total of 4,685 men living in Italy and who have been visited at the Italian urology operating units were involved in the study between January 2019 and January 2020. Each patient was given details on how to measure their penis (erect length and circumference) in flaccidity and in erection, from the lower base to the distal penile tip. Mean (standard deviation [SD]) flaccid penis length was 9.47 (2.69), mean (SD) flaccid penis circumference was 9.59 (3.08), mean (SD) erect penis length was 16.78 (2.55) and mean (SD) erect penis circumference was 12.03 (3.82). At the linear regression analysis, height was associated with flaccid penis length (β = 0.04; p-value = .01), and erect penis length was (β = 0.05; p-value < .01) and erect penis circumference was (β = 0.06; p-value < .01). Height is proportional to the length of the penis in flaccidity and in erection, and to the circumference in erection. The increase in BMI leads to a reduction in the length of the erect penis, as well as weight gain reduces the length of the flaccid penis.

Nonsurgical Methods for Penile Augmentation: A Systematic Review

BACKGROUND

There is no standardized approach for nonsurgical techniques for penile augmentation despite the increase of demand for this intervention.

OBJECTIVE

To compare the efficacy and safety between different injection techniques.

MATERIALS AND METHODS

On October 8, 2019, a literature search was performed on PubMed, Embase, Ovid, and Cochrane database. All articles describing penile augmentation were included.

RESULTS

Thirteen studies were included in this article with a total of 1,311 patients. Five studies were prospective cohort. The most commonly described technique was hyaluronic acid fillers with a total of 4 articles and 205 patients. The mean injected volume ranged from 20 to 40 mL. In all included studies, a minority of patients had side effects, but some had disabling complications.

CONCLUSION

There are no defined clinical guidelines for penile augmentation techniques implemented yet. Hyaluronic acid seems to be safe, efficient, and with a high satisfaction score. Further randomized control trials are warranted.

EBM LEVEL OF EVIDENCEBASED MEDICINE

2a.

Anxiousness and Distractibility Strengthen Mediated Associations Between Men's Penis Appearance Concerns, Spectatoring, and Sexual Difficulties: A Preregistered Study

Men with penis appearance concerns are more likely to experience sexual difficulties because they engage in spectatoring (i.e., negative self-critical attentional focus during sex). This preregistered study investigated whether anxious and distractible personality traits make men with penis appearance concerns more likely to engage in spectatoring and, in turn, experience sexual difficulties. In a sample of 858 sexually active men in predominantly mixed-gender relationships, we replicated previous findings that penis appearance concerns were associated with greater spectatoring, and in turn greater problems with erection and orgasm. Additionally, our novel hypotheses that anxiousness and distractibility would strengthen these associations were partially supported. Anxiousness strengthened associations between penis appearance concerns and sexual embarrassment, and in turn was associated with greater reports of erectile and orgasmic difficulties. However, anxiousness did not strengthen the mediated associations between penis appearance concerns, self-focus, and erectile and orgasmic difficulties. Distractibility strengthened associations between sexual embarrassment and erectile difficulties, and in turn strengthened the mediated associations between penis appearance concerns, sexual embarrassment, and erectile difficulties. However, distractibility did not strengthen associations between sexual embarrassment and orgasmic difficulties, between sexual self-focus and erectile difficulties, nor between sexual self-focus and orgasmic difficulties. Implications for therapeutic treatments are discussed.

Non-invasive and surgical penile enhancement interventions for aesthetic or therapeutic purposes: a systematic review

OBJECTIVE

To systematically review the literature in order to investigate the efficacy and safety of surgical and non-invasive penile enhancement procedures for aesthetic and therapeutic purposes.

METHODS

A systematic search for papers investigating penile enhancement procedures was performed using the MEDLINE database. Articles published from January 2010 to December 2019, written in English, including >10 cases, and reporting objective length and/or girth outcomes, were included. Studies without primary data and conference abstracts were excluded. The main outcome measure was objective length and/or girth improvement. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

RESULTS

Out of 220 unique records, a total of 57 were reviewed. Eighteen studies assessed interventions for penile enhancement in 1764 healthy men complaining of small penis. Thirty-nine studies investigated 2587 men with concomitant pathologies consisting mostly of Peyronie's disease and erectile dysfunction. Twenty-five studies evaluated non-invasive interventions and 32 studies assessed surgical interventions, for a total of 2192 and 2159 men, respectively. Non-invasive interventions, including traction therapies and injection of fillers, were safe and mostly efficacious, whereas surgical interventions were associated with minor complications and mostly increased penile dimensions and/or corrected penile curvature. Overall, the quality of studies was low, and standardized criteria to evaluate and report efficacy and safety of procedures, as well as patient satisfaction, were missing.

CONCLUSION

The quality of the studies on penile enhancement procedures published in the last decade is still low. This prevents us from establishing recommendations based on scientific evidence regarding the efficacy and safety of interventions that are performed to increase the penis size for aesthetic or therapeutic indications.

Genital manifestations of body dysmorphic disorder in men: a review

Body dysmorphic disorder (BDD) is a serious psychiatric condition that affects approximately 2.5% of the U.S. adult population. BDD occurs when a person develops a debilitating focus and sense of distress about a minor or imagined physical flaw. There is growing awareness that in some men with BDD, the physical preoccupation centers on the appearance of their genitals. This review explores existing research on genital manifestations of BDD in men. PubMed and PsychInfo searches with the key word's genital manifestations of BDD were conducted, which yielded a list of 48 unique articles. Articles that were included in the present review were published in English and focused on men with a formal diagnosis of BDD from a psychiatrist, psychologist, or structured clinical interview. Only five articles met these criteria, and all were conducted by the same research group. The articles are reviewed here, along with thoughts about directions for future research and implications for treatment.

Penile Size Dissatisfaction

BACKGROUND

Men concerned about their penis size often consult professionals working in urology, andrology, surgery, and sexual medicine.

AIM

To inform professionals in the sexual medicine field about small penis syndrome as a clinical syndrome and to provide recommendations for treatment.

METHODS

This was an overview of the existing literature combined with our extensive clinical experience.

RESULTS

Small penis syndrome is a syndrome with psychiatric comorbidities and social consequences that impair life. Men with these concerns tend to be susceptible for treatment that is not evidence based and potentially harmful.

CLINICAL IMPLICATIONS

Treatment of men with concerns about penis size should start with a thorough biopsychosocial assessment, followed by extensive psychoeducation, counselling, and psychological interventions, even if surgery is being considered.

STRENGTHS & LIMITATIONS

The strength of this study is the concise overview of the existing literature combined with clinical experience which leads to important recommendations. Limitation is that this is not a systematic review.

CONCLUSION

Complaints about penis size should be taken seriously, and a thorough biopsychosocial and multidisciplinary assessment is required.

Comparison of Clinical Outcomes between Hyaluronic and Polylactic Acid Filler Injections for Penile Augmentation in Men Reporting a Small Penis: A Multicenter, Patient-Blinded/Evaluator-Blinded, Non-Inferiority, Randomized Comparative Trial with 18 Months of Follow-up

Although several types of penile augmentation (PA) fillers have been recently introduced, no long-term follow-up studies have compared them. This study aimed to compare the long-term clinical outcomes of hyaluronic acid (HA) and polylactic acid (PLA) filler injections for PA. Our multicenter, patient-blinded/evaluator-blinded, randomized comparative trial was performed for 18 months after the single injection of fillers. Sixty-seven healthy men reporting a small penis were administered an injection between November 2016 and May 2017. Subjects were divided into the HA group (n = 33) and PLA group (n = 34). At 18 months, the mean penile girths had significantly increased in both groups (each p < 0.001). Changes in the mean penile girth of both groups were not significantly different during the study period. Satisfaction levels at 18 months were significantly higher than those at baseline in both groups (each p < 0.01). Changes in satisfaction levels did not differ significantly during the study period. Injection-associated adverse events (AEs) occurred in three (9.1%) patients in the HA group and in two (5.9%) patients in the PLA group; no serious AEs occurred. In conclusion, HA and PLA filler injections for PA led to significant augmentation and increased satisfaction. Clinical efficacy and safety were comparable between groups.

Body image, cosmetic surgery, and minimally invasive treatments

Over the past 60 years, a growing body of research has investigated the psychological aspects of cosmetic surgery and related minimally-invasive treatments. While the earliest studies were influenced by psychoanalytic thinking, much of the work over the past several decades has been influenced by Thomas Cash's cognitive-behavioral theory of body image and has focused on the appearance concerns of patients who seek these procedures. The majority of individuals interested in the procedures report heightened dissatisfaction typically focused on the feature being considered for treatment. Studies from around the world also have suggested that between 5-15% of patients who present for cosmetic procedures meet diagnostic criteria for body dysmorphic disorder (BDD). While individuals with BDD typically do not report a reduction in their BDD symptoms following a cosmetic procedure, the great majority of patients without the disorder do report improvement in body image. The paper reviews this literature and also discusses the role of body image in three newer areas of plastic surgery-body contouring after massive weight loss, genital procedures (either for cosmetic purposes or as part of gender reassignment), and vascularized composite allotransplantation, including face and hand transplantation.

Towards clinical application of tissue engineering for erectile penile regeneration

Penile wounds after traumatic and surgical amputation require reconstruction in the form of autologous tissue transfers. However, currently used techniques are associated with high infection rates, implant erosion and donor site morbidity. The use of tissue-engineered neocorpora provides an alternative treatment option. Contemporary tissue-engineering strategies enable the seeding of a biomaterial scaffold and subsequent implantation to construct a neocorpus. Tissue engineering of penile tissue should focus on two main strategies: first, correcting the volume deficit for structural integrity in order to enable urinary voiding in the standing position and second, achieving erectile function for sexual activity. The functional outcomes of the neocorpus can be addressed by optimizing the use of stem cells and scaffolds, or alternatively, the use of gene therapy. Current research in penile tissue engineering is largely restricted to rodent and rabbit models, but the use of larger animal models should be considered as a better representation of the anatomical and physiological function in humans. The development of a cell-seeded scaffold to achieve and maintain erection continues to be a considerable challenge in humans. However, advances in penile tissue engineering show great promise and, in combination with gene therapy and surgical techniques, have the potential to substantially improve patient outcomes.

Systematic Review of Surgical and Nonsurgical Interventions in Normal Men Complaining of Small Penis Size

INTRODUCTION

Evidence on penile enhancement interventions is lacking. Nonetheless, many non-evidence-based solutions are readily available.

AIM

To investigate enhancement and nonenhancement interventions in men without penile abnormalities seeking to increase penis size.

METHODS

We performed a systematic review with no time restrictions adhering to the PRISMA guidelines. Studies with fewer than 10 cases or including men with organic penile pathologies or previous penile surgeries were excluded.

MAIN OUTCOME MEASURES

When available, treatment efficacy was evaluated based on patient satisfaction, penile size increase, and complications.

RESULTS

We included 17 studies, assessing a total of 21 interventions in 1,192 men screened, with 773 followed up after nonsurgical (n = 248) or surgical (n = 525) treatment. The quality of the studies was poor in terms of methodology for patient selection and outcomes assessment. The vast majority of series reported normal penile size. Among nonsurgical treatments, extenders increased flaccid length (but by <2 cm), injectables increased girth but were associated with a high complication rate, and vacuum devices did not increase size. Surgical interventions included suspensory ligament incision (the most used method; n = 12), tissue grafting (autologous, n = 2; dermal fat, n = 3, ex vivo, n = 2), flaps (n = 2), and penile disassembly (n = 1). Some men reported a significant size increase; however, complications were not infrequent, and none of the techniques was externally validated. When provided, counseling was effective, with the majority of men coming to understand that their penis was normal and unwilling to undergo any further treatment.

CONCLUSION

Treatment of small penis in normal men is supported by scant, low-quality evidence. Structured counseling should be always performed, with extenders eventually used by those still seeking enhancement. Injectables and surgery should remain a last option, considered unethical outside of clinical trials. Marra G, Drury A, Tran L, et al. Systematic Review of Surgical and Nonsurgical Interventions in Normal Men Complaining of Small Penis Size. Sex Med Rev 2020;8:158-180.

Penile Girth Enlargement Strategies: What's the Evidence?

INTRODUCTION

Most men seeking penile girth augmentation have physiologically normal penises but may suffer from severe preoccupation with penis size known as penile dysmorphophobic disorder.

AIM

To describe the medical, procedural, and reconstructive techniques available for penile girth enhancement and to review the success and complications of each modality.

METHODS

A comprehensive review of peer-reviewed publications on the topic was performed through a PubMed search. Key search terms included penis, enhancement, enlargement, phalloplasty, reconstruction, girth, and augmentation.

MAIN OUTCOME MEASURE

We wanted to summarize the motivations behind penile girth enhancement and review the outcomes for girth augmentation treatments.

RESULTS

Various medical, traction, injection, prosthetic, and reconstructive modalities have been studied for penile girth enhancement, with increases in girth ranging from 0-4.9 cm. Complications were reported in a minority of patients, but they may be devastating and include penile fibrosis, sexual dysfunction, device infection, and death.

CONCLUSION

A variety of penile girth augmentation techniques have been studied. Clinical guidelines are lacking, and complications of penile girth enhancement are likely underreported. Until more rigorous investigation with accurate reporting of complications is achieved, penile girth augmentation procedures should be considered experimental. Hehemann MC, Towe M, Huynh LM, et al. Penile Girth Enlargement Strategies: What's the Evidence? Sex Med 2019;7:535-547.

Spectatoring Mediates the Association Between Penis Appearance Concerns and Sexual Dysfunction

Men with penis appearance concerns are more likely to experience sexual dysfunction, but the processes underlying this association are unknown. This study investigated whether spectatoring (i.e., negative self-directed attentional focus during sex) mediates the association between penis appearance concerns and sexual dysfunction. Men in romantic relationships (N = 512, in predominantly mixed-gender relationships) reported on sex they had with their partner in the previous month. Indirect effects indicated that penis appearance concerns predicted greater spectatoring, and in turn predicted greater erectile and orgasmic dysfunction. Results suggest that spectatoring is a conduit through which penis appearance concerns impede sexual function.

Does underestimated penile size impact erectile function in healthy men?

The aim of this study is to assess the impact of objective (stretched) and subjective penile size in the erectile function in a urological check-up program on a cross-sectional study including 689 men aged 35-70 years. IIEF-5 questionnaire, physical examination (penile length, prostate volume, blood pressure, body mass index-BMI), metabolic syndrome (MS), comorbidities, habits (sexual intercourse frequency, physical activity, alcohol, and tobacco use), level of education, serum glucose, total testosterone, estradiol, PSA, lipid profile, and self-perceptions (ejaculation time and subjective penile size) were examined in multivariate models using logistic and linear regressions. Penile objective mean length was 13.08 cm ± 2.32 and 67 (9.72%) patients referred small penis self-perception. Seventy-six (11.03%) participants had severe erectile dysfunction (ED), 75 (10.88%) had mild to moderate and moderate ED, 112 (16.25%) had mild ED and 426 (61.83%) had no ED. Risk factors for ED that held statistical significance were self-perceived small penis (OR = 2.23, 95% CI 1.35-3.69, p = .0017), sexual intercourse frequency (per week) (OR = 0.45, 95% CI 0.38-0.52, p < .0001), satisfactory ejaculation time (no vs. yes, OR = 2.06, 95% CI 1.46-2.92, p < .0001), comorbidity (yes vs. no, OR = 2.01, 95% CI 1.46-2.76, p < .0001), age >65 years (OR = 2.93, 95% CI 1.53-5.61, p < .0001), tobacco use (yes vs. no, OR = 1.41, 95% CI 1.02-1.96, p < .0375), regular physical activity (no vs. yes, OR = 1.59, 95% CI 1.13-2.23, p < .0083), serum total testosterone < 200 ng/dl (OR = 3.48, 95% CI 1.69-7.16, p = 0.0009), serum glucose > 100 mg/dl (OR = 1.69, 95% CI 1.18-2.43, p = 0.0044) and systolic blood pressure > 130 mmHg (OR = 1.60, 95% CI 1.16-2.19, p = 0.0037). Results suggest that in addition to previously reported risk factors, patient's subjective impressions of penile size negatively impacts sexual life in about 10% of men considered healthy, while objective penile length does not play significant role in erectile function.

The relationship between penile deformity, age, psychological bother, and erectile dysfunction in a sample of men with Peyronie's Disease (PD)

The aim of the present study was to investigate which PD specific factors (e.g., degree of penile curvature, levels of pain) cause most distress and to further explore whether there are specific subgroups of patients that report particularly high levels of psychological distress. Data were available for N = 119 men with a clinical diagnosis of PD presenting at a private Uro-Andrology in Germany. The strongest complaint of men with PD was being bothered by the look of the penis as opposed to being distressed by the pain (3.48 vs. 2.11). 75.4% reported having significantly less intercourse due to PD and for 61.4% this was very bothersome. Plaque size correlated positively with the level of symptom bother (r = 0.73, p < 0.05). Furthermore, men with a stronger curvature reported more concerns regarding size and form of the penis (r = 0.18, p < 0.05), more overall sexual dissatisfaction (r = -0.38, p < 0.001), and more PD related psychological and physiological symptoms (r = 0.58, p < 0.001). 44.4% of patients had a concurrent ED. Highest level of symptom bother was reported by men with a a strong curvature and a comorbid ED. Clinicians should pay special attention to patients presenting with extreme penile deformity and impaired sexual functioning, as they show the highest levels of psychological distress. Here, additional psychosexual support might be necessary.

Anthropometric study of penile length in self-declared Brazilians regarding the color of the skin as white or black: The study of a Myth

This is an observational transversal cohort study in which we aim to analyze the Brazilian penis length and compare the penis size of the men self-declared as white (SDW) or black (SDB) skin color. Subjects were asked for self-declare according to their skin color, after that they have been invited to participate in a semi-structured interview so as to have their perception evaluated regarding their penis size and their self-esteem as well. Eventually, their penis length was measured with an anthropometric ruler. The men´s mean penis length who declared themselves as black skin color was 16.5 ± 1.7 cm (penis length in real fully-stretched flaccid length) and the men´s mean penis length who declared themselves as white skin color was 15.8 ± 1.6 cm (p < 0.001).The majority of either SDB (94.0%) or SDW (89.4%) are satisfied with their penis size (p = 0.464). We have shown that the man´s mean penis length who identifies himself as black is just a little bit bigger than the one who identifies himself as white. However, there were no significant difference between groups regarding self-assessment of genital body image.

Characterization of Genital Dissatisfaction in a National Sample of U.S. Men

Male genital satisfaction is an important aspect of psychosocial and sexual health. The Index of Male Genital Image (IMGI) is a new scale that measures perceptions of male genitalia. We aim to characterize genital satisfaction using the IMGI and correlate dissatisfaction with sexual activity. We conducted a nationally representative survey of non-institutionalized adults aged 18-65 years residing in the U.S. In total, 4198 men completed the survey and 3996 (95.2 %) completed the IMGI. Men reported highest satisfaction with the shape of their glans (64 %), lowest satisfaction with the length of their flaccid penis size (27 %), and neutrality with the scent of their genitals (44 %). No demographic characteristics (age, race, sexual orientation, education, location, and income) were significantly associated with genital dissatisfaction. Men who were dissatisfied with their genitals were less likely to report being sexually active (73.5 %) than those who were satisfied (86.3 %). Penetrative vaginal sex (85.2 vs. 89.5 %) and receptive oral intercourse (61.0 vs. 66.2 %) were reported less by dissatisfied men. Overall, most U.S. men were satisfied with their genitals; however, a subset (14 %) report low genital satisfaction, which included men of all ages, races, and socioeconomic groups. Low genital satisfaction is associated with a decrease in sexual activity. These results provide clinicians and health educators a baseline of genital satisfaction to provide education and reassurance.

A review of penile elongation surgery

Penile elongation surgery is less commonly performed in the public sector, but involves a collaborative approach between urology and plastic surgery. Congenital and acquired micropenis are the classic surgical indications for penile elongation surgery. The goal of intervention in these patients is to restore a functional penis size in order to allow normal standing micturition, enable satisfying sexual intercourse and improve patient quality of life. Many men seeking elongation actually have normal length penises, but perceive themselves to be small, a psychologic condition termed 'penile dysmorphophobia'. This paper will review the anatomy and embryology of congenital micropenis and discuss both conservative and surgical management options for men seeking penile elongation therapy.

Relationship between self-discrepancy and worries about penis size in men with body dysmorphic disorder

We explored self-discrepancy in men with body dysmorphic disorder (BDD) concerned about penis size, men without BDD but anxious about penis size, and controls. Men with BDD (n=26) were compared to those with small penis anxiety (SPA; n=31) and controls (n=33), objectively (by measuring) and investigating self-discrepancy: actual size, ideal size, and size they felt they should be according to self and other. Most men under-estimated their penis size, with the BDD group showing the greatest discrepancy between perceived and ideal size. The SPA group showed a larger discrepancy than controls. This was replicated for the perceptions of others, suggesting the BDD group internalised the belief that they should have a larger penis size. There was a significant correlation between symptoms of BDD and this discrepancy. This self-actual and self-ideal/self-should discrepancy and the role of comparing could be targeted in therapy.