Tolerability and efficacy of newly developed penile injection of cross-linked dextran and polymethylmethacrylate mixture on penile enhancement: 6 months follow-up

Multidisciplinary approach and management of patients who seek medical advice for penile size concerns: a narrative review

We aimed to provide an overview of the strategies available to manage patients concerned about their penile size and to provide useful surgical hints regarding the most common penile enlargement approaches, based on our surgical expertise in this field. A comprehensive research was carried out on MEDLINE/PubMed database to identify pertinent studies concerning penile enlargement issues. The search strategy included a range of keywords; e.g. penis, penile, enlargement, augmentation, lengthening, girth. Management of penile size-related concerns represents a real challenge for the urologist, especially when dealing with patients suffering from penile dysmorphophobic disorder (PDD). A multidisciplinary preoperative assessment, including a psychiatric/psychological evaluation, may help in discerning those patients who would benefit the most from counselling/conservative management from those who would benefit from surgery instead. Conservative approaches include the use of vacuum-based and penile-stretching devices, which have shown encouraging levels of efficacy and safety. Over the last decades, different surgical strategies have been developed, aimed at either increasing flaccid penile length or improving penile girth. Penile lengthening procedures are more established, and satisfactory results can be achieved by experienced, large referrals' volume, surgeons. To date, there is lack of consensus regarding the penile girth enhancing techniques, and therefore these should be regarded as experimental. A multidisciplinary approach is necessary to identify patients with PDD, who should not be offered surgical intervention and should be referred for psychiatric/psychological counselling instead. The surgical approach should be tailored to the subject's unique anatomy and underlying conditions.

Penile length augmentation surgical and non-surgical approaches for aesthetical purposes

The aim of this review is to describe reported techniques and to provide available scientific data on the success of penis length procedures for cosmetic purposes. Penis lengthening methods remain a controversial issue. Penis size is a matter of great interest among men who are affected by 'small penis anxiety'' or just believe themselves to have a small penis, even though the dimensions of the organ fall within the normal range. We performed a narrative review of the literature based on a comprehensive search in the MEDLINE database for original articles published until March 2021, referring to lengthening approaches exclusively for aesthetical reasons. Abstracts, opinion papers and case series ≤10 patients were not considered. We included the results of 14 papers in the review that gathered the experience obtained in a total of 1661 patients. Four of the studies referred to non-surgical procedures for penile length augmentation (PLA) and the remaining 10 analyzed the results of invasive (surgical) procedures. Both invasive and non-invasive techniques achieve similar improvements in penis length. These procedures vary in complexity and require specialized training and experience. However, the low scientific quality of the analyzed papers makes it difficult to establish recommendations to choose one technique over any other. However, it seems reasonable that, if possible, non-invasive techniques should be proposed as a first-line treatment. Before deciding the procedure, we must carry out a correct psychological evaluation of our patients, discuss with them the technique of choice, and adjust their expectations.

Focusing on sexual rehabilitation besides penile rehabilitation following radical prostatectomy is important

Erectile dysfunction is commonly reported after radical prostatectomy. Besides the loss of erections, sexual life after prostatectomy is impacted by urinary incontinence, orgasmic dysfunction, and psychological stress. In this review, we describe classical medical therapies used for erectile function rehabilitation such as PDE5 inhibitors and injection therapy. A vast amount of data support the idea of focusing on restoration of sexual function on top of erectile function after prostatectomy. The important strategies described to rehabilitate sexual function include pelvic floor muscle therapy, couple therapy, appropriate preoperative counseling, and focusing on non-penetrative alternatives. A multidisciplinary approach and including the partner is important. Erectile function alone is not sufficient for satisfactory sexual experience and may not be used as a proxy for sexual quality of life. Adding full-spectrum sexual rehabilitation to a standard penile rehabilitation regimen has the highest chances of obtaining satisfactory sexual outcomes in men and their partners after radical prostatectomy.

Penile girth augmentation by injectable fillers: a comprehensive review of imaging features and inflammatory complications

Despite the extensive controversy and debate of penile girth augmentation, high demands for such procedures are increasing. Penile inflammation is not common sequel after penile filler augmentation, but when it occurs, it has serious complications that sometimes necessitate emergency surgical intervention. Imaging with a variety of modalities, including ultrasonography, magnetic resonance imaging, and ascending urethrogrphy plays a paramount role in the detection and assessment of these conditions. Inflammatory conditions after penile girth augmentation using injectable fillers are ranging from local granuloma to penile abscess formation or diffuse cellulitis that may extend to the scrotum, perineum or deep pelvic organs. Rapid diagnosis and evaluation of extensions are important to avoid associated morbidity and permanent deformity. Our purpose is to provide a practical review of relevant penile anatomy, imaging appearance and injection technique of different types of subcutaneous fillers used in penile girth augmentation, and inflammatory complications that may occur after these procedures. Brief descriptions of patient clinical information and imaging features of inflammatory complications will be included and correlated in actual cases.

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.

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.

Efficacy and safety of newly developed cross-linked dextran gel injection for glans penis augmentation with a novel technique

There is no safe and effective standard method for glans penis augmentation. Furthermore, there has been scant research on glans penis augmentation due to a poor understanding of glans anatomy, technical difficulty, and a lack of suitable substances for augmentation. Cross-linked dextran gel is a newly developed filler for soft-tissue augmentation. We evaluated the efficacy and safety of using a novel technique to inject cross-linked dextran gel for glans penis augmentation during a 24-week follow-up study. This prospective, single-arm, multicenter study enrolled twenty healthy adult men who underwent glans penis augmentation between June and August 2013. Cross-linked dextran gel was injected into the glans penis using a simple and easy technique. The sizes of the glans penis and individual satisfaction were assessed. Any adverse event was also reported. A total of 18 individuals were analyzed; two of them were lost to follow-up. The mean procedure time and injected volume were about 30 min and 6.6 ± 0.9 ml, respectively. The mean surface areas of the glans at baseline and 24 weeks were 20.0 ± 3.5 cm² and 33.6 ± 5.4 cm², respectively, representing a mean increase of 68.7% ± 14.0% (P < 0.001). Sixteen individuals (88.9%) were satisfied with the outcomes, and none were dissatisfied. There were no serious adverse events during the study. Cross-linked dextran gel injection for glans penis augmentation was easy and showed a significant augmentative effect on the glans penis, good durability, and was well tolerated without serious adverse events. Therefore, cross-linked dextran gel injection may be an effective, new technique for glans penis augmentation.

A Comparison of the Efficacy and Safety Between Hyaluronic Acid and Polylactic Acid Filler Injection in Penile Augmentation: A Multicenter, Patient/Evaluator-Blinded, Randomized Trial

BACKGROUND

Studies about the clinical utility of fillers on penile augmentation (PA) are lacking. Furthermore, no randomized study has compared the utilities of fillers.

AIM

To compare the efficacy and safety between hyaluronic acid (HA) and polylactic acid (PLA) filler injection for PA.

METHODS

This prospective, randomized patient/evaluator-blind, comparative multicenter study consisted of an initial 2-week baseline period and 48-week patient/evaluator-blind post-injection period. 72 patients with small penis syndrome were enrolled from 3 institutions between March-July 2016. Patients were divided into 2 groups: the HA group, comprising 36 patients injected with HA, and the PLA group, comprising 36 patients injected with PLA.

MAIN OUTCOME MEASURES

Penile girth and satisfaction were assessed at baseline and at 4, 12, 24, and 48 weeks after injection.

RESULTS

Penile girth increases adequately lasted ≤48 weeks in both groups (16.95 ± 10.53 and 13.49 ± 9.98 mm of mean increase in the HA and PLA groups, respectively; P < .001). The mean penile girth increase in the HA group was significantly greater than that in the PLA group at 4 weeks (P < .001). Subsequently, it gradually decreased and was no longer significantly different at 48 weeks (P = .075). Satisfaction levels increased after injection and were maintained ≤48 weeks. No significant differences were observed in the overall satisfaction level between the groups (P > .05). Filler injection-related adverse events were mild and transient and occurred in 1 and 3 patients in the HA and PLA groups, respectively.

CLINICAL IMPLICATIONS

This study provides an overview of the efficacy and safety of HA and PLA fillers, which are the most commonly used soft tissue fillers for PA.

STRENGTH AND LIMITATIONS

This study, to our knowledge, is the first to compare the efficacy and safety between different filler injections for human PA. However, it was impossible to perform a researcher-blinded trial because of the unique properties of fillers, and 31 patients (43.1%) were dropped during the study period.

CONCLUSIONS

Both HA and PLA filler injections for PA led to a significant augmentative effect without serious adverse events and had clinically comparable efficacy and safety. Yang DY, Ko K, Lee SH, et al. A Comparison of the Efficacy and Safety Between Hyaluronic Acid and Polylactic Acid Filler Injection in Penile Augmentation: A Multicenter, Patient/Evaluator-Blinded, Randomized Trial. J Sex Med 2019;16:577-585.

Nonsurgical Medical Penile Girth Augmentation: A Retrospective Study of Psychological and Psychosexual Outcomes

BACKGROUND

Although interest in penile augmentation procedures is increasing, there is a significant lack of research into the psychological and psychosexual outcomes of these procedures.

OBJECTIVES

To investigate the psychological and psychosexual outcomes of nonsurgical medical penile girth augmentation.

METHODS

This retrospective study involved a mixed method approach. Twenty-five men who had undergone a nonsurgical medical penile girth augmentation between 1 and 12 months prior (mean, 6.6 months) completed an online questionnaire containing measures of procedure motivation, procedure satisfaction, genital self-image, penile-focused body dysmorphic disorder symptoms, self-esteem, and sexual relationship satisfaction. Six of these men elected to complete in-depth one-to-one semi-structured phone interviews to further explore the psychological impacts of the procedure.

RESULTS

In the online questionnaire, most men were satisfied with their penile size, appearance, and function after penile girth augmentation. The men also reported statistically significant improvements in their genital self-image (P < 0.001) and self-esteem (P = 0.008), and a reduction in penile-focused body dysmorphic disorder symptoms (P = 0.002) at the time of completing the questionnaire compared to recalled pre-procedural levels. The in-depth interviews yielded 3 themes surrounding penile augmentation outcomes: (1) high satisfaction with increased penis girth; (2) increased self-confidence, particularly in situations in which the penis would be seen, such as a locker room; and (3) increased sexual confidence, but some mixed impacts on sexual relationships.

CONCLUSIONS

Most men appear to be satisfied with their nonsurgical medical penile girth augmentation results, and they also seem to experience improvements in their overall self-esteem.

LEVEL OF EVIDENCE: 4

Complications of glans penis augmentation

Despite the controversy regarding penile augmentation (PA), glans penis augmentation (GPA) is used in penile reconstructive surgery in selected patients with small glans penis. Since 2003, injectable hyaluronic acid (HA) gel has been used for GPA. The attractiveness of HA gel fillers and interest in this technique have led to the use of other fillers for GPA, particularly irreversible fillers that improve the longevity of HA gels. Conversely, indirect glans augmentation via implantation of dermofat grafts or scaffolds between the corpus spongiosum and the distal tip of the corpus cavernosum is used to overcome poor longevity of the gel and glans surface undulation, which are the primary limitations of GPA using HA gel. Unfortunately, these implants form hard painful lumps over time in most patients and are difficult to remove. Blunt dissection is an invasive procedure that may cause vascular compromise and consequent glans necrosis in a few patients. We present our review regarding the current status of GPA for a more comprehensive understanding of this subject. Additionally, we have discussed a few complicated cases that were referred to us.

New bulking agent for the treatment of vesicoureteral reflux: Polymethylmethacrylate/dextranomer

Purpose

The aim of this study was to report preliminary results of endoscopic treatment of vesicoureteral reflux in children with a single injection of a new bulking agent, cross-linked dextran and polymethylmethacrylate mixture.

Materials and Methods

We performed a single-center, single surgeon, prospective, off-label study using polymethylmethacrylate/dextranomer to treat vesicoureteral reflux. All patients underwent endoscopic injection, followed by renal ultrasound and voiding cystourethrogram at 3 months postoperatively to identify de novo or worsening hydronephrosis and vesicoureteral reflux correction (to Grade 0 or I).

Results

Eighteen patients underwent injection of polymethylmethacrylate/dextranomer at our institution between April 2013 and December 2013. Ten were males and eight were females, with a median age of 58 months (range, 6 months to 5 years). Vesicoureteral reflux was unilateral in three patients and bilateral in 15, for a total of 33 renal refluxing units. Vesicoureteral reflux was Grade I in one renal refluxing unit, Grade II in 12, Grade III in 16, and Grade IV in four. Mean injected volume was 0.86 mL. Reflux was corrected in 23 renal refluxing units (69.7%) according to the 3-month voiding cystourethrogram. Complications included urinary retention in one patient. Mild pyelectasis was noted in one patient at 3 months, which spontaneously resolved 3 months later.

Conclusions

Our short-term data show that polymethylmethacrylate/dextranomer injection can be used to treat vesicoureteral reflux with comparable efficacy to other substances currently used and a low rate of complications. Long-term follow-up is required to confirm the usefulness of this material in treating vesicoureteral reflux.

Nonsurgical Medical Penile Girth Augmentation: Experience-Based Recommendations

Penile augmentation is increasingly sought by men who are dissatisfied with the size and/or appearance of their penis. However, augmentation procedures are still considered to be highly controversial with no standardized recommendations reported in the medical literature and limited outcome data. Nevertheless, these procedures continue to be performed in increasing numbers in private settings. Therefore, there is a need for safe, effective, and minimally invasive procedures to be developed, evaluated, and reported in the research literature. In this article, we focus particularly on girth enhancement procedures rather than lengthening procedures as penile girth appears to be particularly important for sexual satisfaction. We discuss the advantages and disadvantages of the common techniques to date, with a focus on the minimally invasive injectable girth augmentation techniques. Based on considerable operative experience, we offer our own suggestions for patient screening, technique selection, and perioperative care.

Penile Girth Enhancement With Polymethylmethacrylate-Based Soft Tissue Fillers

INTRODUCTION

An unknown percentage of men will take every risk to develop a larger penis. Thus far, most injectables have caused serious problems. Polymethylmethacrylate (PMMA) microspheres have been injected as a wrinkle filler and volumizer with increasing safety since 1989.

AIM

To report on a safe and permanently effective method to enhance penile girth and length with an approved dermal filler (ie, PMMA).

METHODS

Since 2007, the senior author has performed penile augmentation in 752 men mainly with Metacrill, a suspension of PMMA microspheres in carboxymethyl-cellulose.

MAIN OUTCOME MEASURES

The data of 729 patients and 203 completed questionnaires were evaluated statistically.

RESULTS

The overall satisfaction rate was 8.7 on a scale of 1 to 10. After one to three injection sessions, average girth increased by 3.5 cm, or 134% (10.2 to 13.7 cm = 134.31%). Penile length also increased by weight and stretching force of the implant from an average of 9.8 to 10.5 cm. Approximately half the patients perceived some irregularities of the implant, which caused no problems. Complications occurred in 0.4%, when PMMA nodules had to be surgically removed in three of the 24% of patients who had a non-circumcised penis.

CONCLUSION

After 5 years of development, penile augmentation with PMMA microspheres appears to be a natural, safe, and permanently effective method. The only complication of nodule formation and other irregularities can be overcome by an improved injection technique and better postimplantation care.

Long-Term Safety and Longevity of a Mixture of Polymethyl Methacrylate and Cross-Linked Dextran (Lipen-10®) after Penile Augmentation: Extension Study from Six to 18 Months of Follow-Up

Purpose

The goal of this study was to investigate the long-term efficacy and safety of a mixture of polymethyl methacrylate (PMMA) and cross-linked dextran Lipen-10® used for penile augmentation under the physical impact generated during sexual intercourse.

Materials and Methods

From March 2010 to October 2011, a total of 20 patients with a mean age of 44 years (interquartile range, 20~70 years) who requested penile augmentation participated in this study. Lipen-10® filler is a mixture of 75% cross-linked dextran, 15% PMMA, and 10% hypromellose solution. With the patient in the supine position, Lipen-10® was injected into the subcutaneous tissue between the dartos fascia and Buck's fascia of the penis using a fanning technique. Penile length and circumference were measured before the procedure and six, 12, and 18 months after the procedure. Values were compared using the Student's t-test and the paired t-test.

Results

A total of 15 patients completed this study. The increases in circumference and length observed six months after the procedure were found to have been maintained without change at 12 and 18 months of follow-up. At 12 and 18 months of follow-up, no abnormal findings were observed. Pelvic magnetic resonance imaging conducted at 18 months of follow-up showed no trace of the injected filler having migrated to other sites, and the volume was well maintained.

Conclusions

Lipen-10®, a mixture of PMMA and cross-linked dextran, showed good durability and tolerability over 18 months of follow-up during which the participants were sexually active.