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Falcone M, Bettocchi C, Carvalho J, Ricou M, Boeri L, Capogrosso P, Cocci A, Corona G, Gül M, Hatzichristodoulou G, Jones TH, Kadioğlu A, Kalkanli A, Martinez-Salamanca JI, Milenkovic U, Morgado LA, Russo GI, Serefoğlu EC, Tharakan T, Verze P, Minhas S, Salonia A. European Association of Urology Guidelines on Penile Size Abnormalities and Dysmorphophobia: Summary of the 2023 Guidelines. Eur Urol Focus 2023:S2405-4569(23)00197-9. [PMID: 37709592 DOI: 10.1016/j.euf.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/10/2023] [Accepted: 08/31/2023] [Indexed: 09/16/2023]
Abstract
CONTEXT Recommendations regarding the management of penile size abnormalities and dysmorphophobia are important in guiding evidence-based clinical practice. OBJECTIVE To present a summary of the 2023 European Association of Urology sexual and reproductive health evidence-based recommendations for the management of penile size abnormalities and dysmorphophobia. EVIDENCE ACQUISITION A broad and comprehensive scoping exercise covering all areas of the guidelines was performed. Databases searched included Medline, EMBASE, and the Cochrane Libraries. A level of evidence and a strength of recommendation were assigned for each recommendation according to the evidence identified. The evidence cutoff date for the 2023 guidelines is June 1, 2022. EVIDENCE SYNTHESIS Well-structured studies reporting high level of evidence, with standardized PROMS were deficient on penile size abnormalities and dysmorphohobia. A shared definition for short penis/micropenis was also lacking. Categorisation of penile abnormalities according to congenital, acquired, and dysmorphophobic aetiology is deemed compulsory. A detailed medical and psychosexual history and precise measurements of penile size are essential in the diagnostic pathway. Patients with normal penile size who are seeking penile augmentation should be referred for psychological evaluation for potential dysmorphophobic disorders. Penile length and girth enhancements can be achieved via a multitude of treatments, but a personalised management plan is crucial for satisfactory results. Endocrinological therapies, when indicated, are effective in the prepubertal setting only. Vacuum therapy has a limited evidence base in treatment protocols, although acceptable outcomes have been reported for penile traction therapy. Surgical techniques to enhance penile length and girth have limited evidence and should only be proposed after extensive patient counselling. CONCLUSIONS Management of penile abnormalities and dysmorphophobia is a complex issue with considerable ethical concerns. The adoption of a structured diagnostic and therapeutic pathway is crucial, as recommended in the guidelines. PATIENT SUMMARY Requests for medical/surgical treatments to increase penis size have increased dramatically worldwide. Several conservative and surgical treatments are available. However, few patients receive clear information on the benefits and possible harms of these treatments. These guidelines aim to provide a structured path to guide both physicians and patients in the selection of appropriate treatment(s) to increase penis size.
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Affiliation(s)
- Marco Falcone
- Department of Urology, Molinette Hospital, A.O.U. Città della Salute e della Scienza, University of Turin, Turin, Italy.
| | - Carlo Bettocchi
- Department of Andrology and Male Genitalia Reconstructive Surgery, University of Foggia, Foggia, Italy
| | - Joana Carvalho
- William James Center for Research, Department of Education and Psychology, University of Aveiro, Aveiro, Portugal
| | - Miguel Ricou
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Luca Boeri
- Department of Urology, IRCCS Fondazione Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Capogrosso
- Department of Urology and Andrology, Ospedale di Circolo and Macchi Foundation, Varese, Italy
| | - Andrea Cocci
- Department of Minimally Invasive and Robotic Urologic Surgery and Kidney Transplantation, University of Florence, Florence, Italy
| | - Giovanni Corona
- Endocrinology Unit, Medical Department, Maggiore-Bellaria Hospital, Bologna, Italy
| | - Murat Gül
- Department of Urology, School of Medicine, Selcuk University, Konya, Turkey
| | | | - T Hugh Jones
- Centre for Diabetes and Endocrinology, Barnsley Hospital NHS Trust, Barnsley, UK
| | - Ates Kadioğlu
- Department of Urology, İstanbul University School of Medicine, İstanbul, Turkey
| | - Arif Kalkanli
- Department of Urology, Taksim Education and Research Hospital, Istanbul, Turkey
| | | | - Uros Milenkovic
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - L Afonso Morgado
- Urology Service, Centro Hospitalar Universitário São João, Porto, Portugal; Department of Biomedicine, Faculty of Medicine, Porto University, Porto, Portugal
| | - Giorgio I Russo
- Urology Section, Department of Surgery, University of Catania, Catania, Italy
| | - Ege Can Serefoğlu
- Department of Urology, Biruni University School of Medicine, Istanbul, Turkey
| | - Tharu Tharakan
- Department of Urology, Charing Cross Hospital, Imperial Healthcare NHS Trust, London, UK
| | - Paolo Verze
- Department of Medicine and Surgery, Scuola Medica Salernitana, University of Salerno, Fisciano, Italy
| | - Suks Minhas
- Department of Urology, Charing Cross Hospital, Imperial Healthcare NHS Trust, London, UK
| | - Andrea Salonia
- Division of Experimental Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
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Stancampiano MR, Suzuki K, O'Toole S, Russo G, Yamada G, Faisal Ahmed S. Congenital Micropenis: Etiology And Management. J Endocr Soc 2022; 6:bvab172. [PMID: 35036822 PMCID: PMC8754418 DOI: 10.1210/jendso/bvab172] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Indexed: 01/23/2023] Open
Abstract
In the newborn, penile length is determined by a number of androgen dependent and independent factors. The current literature suggests that there are interracial differences in stretched penile length in the newborn and although congenital micropenis should be defined as a stretched penile length of less than 2.5 SDS of the mean for the corresponding population and gestation, a pragmatic approach would be to evaluate all boys with a stretched penile length below 2 cm, as congenital micropenis can be a marker for a wide range of endocrine conditions. However, it remains unclear as to whether the state of micropenis, itself, is associated with any long-term consequences. There is a lack of systematic studies comparing the impact of different therapeutic options on long-term outcomes, in terms of genital appearance, quality of life, and sexual satisfaction. To date, research has been hampered by a small sample size and inclusion of a wide range of heterogeneous diagnoses; for these reasons, condition-specific outcomes have been difficult to compare between studies. Lastly, there is a need for a greater collaborative effort in collecting standardized data so that all real-world or experimental interventions performed at an early age can be studied systematically into adulthood.
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Affiliation(s)
| | - Kentaro Suzuki
- Department of Developmental Genetics, Institute of Advanced Medicine, Wakayama Medical University, Wakayama 641-8509, Japan
| | - Stuart O'Toole
- Department of Paediatric Surgery and Urology, Royal Hospital for Children, Glasgow G51 4TF, UK
| | - Gianni Russo
- Department of Pediatrics, Endocrine Unit, Scientific Institute San Raffaele, Milan 20132, Italy
| | - Gen Yamada
- Department of Developmental Genetics, Institute of Advanced Medicine, Wakayama Medical University, Wakayama 641-8509, Japan
| | - Syed Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow G51 4TF, UK
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Callens N, De Cuypere G, T’Sjoen G, Monstrey S, Lumen N, Van Laecke E, Hoebeke P, Cools M. Sexual quality of life after total phalloplasty in men with penile deficiency: an exploratory study. World J Urol 2014; 33:137-43. [DOI: 10.1007/s00345-014-1283-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 03/17/2014] [Indexed: 11/29/2022] Open
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Callens N, De Cuypere G, Van Hoecke E, T'Sjoen G, Monstrey S, Cools M, Hoebeke P. Sexual Quality of Life after Hormonal and Surgical Treatment, Including Phalloplasty, in Men with Micropenis: A Review. J Sex Med 2013; 10:2890-903. [DOI: 10.1111/jsm.12298] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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van der Zwan YG, Callens N, van Kuppenveld J, Kwak K, Drop SLS, Kortmann B, Dessens AB, Wolffenbuttel KP. Long-term outcomes in males with disorders of sex development. J Urol 2013; 190:1038-42. [PMID: 23507395 DOI: 10.1016/j.juro.2013.03.029] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2013] [Indexed: 11/26/2022]
Abstract
PURPOSE Indications that the prenatal action of testosterone in the brain is an important determinant of gender development and improved reconstructive techniques have caused a shift in male gender assignments in patients with 46XY disorders of sex development. We report long-term outcome data on psychosexual development and sexual function of these individuals in a cross-sectional study. MATERIALS AND METHODS Physical status of 14 men with a mean age of 25 years with disorders of sex development was assessed by structured interview and physical examination. Psychosexual outcome was evaluated by questionnaires and compared to a control group of 46 healthy, age matched men. RESULTS A total of 13 men underwent 1 to 6 (mean 2) genital surgeries. Mean age at first surgery was 2.7 years. Mean penile length was 6.6 cm. All men reported erections and were able to experience orgasms. Ejaculatory dysfunction was reported by 7 men. Mean penile length was 7.9 cm in patients who were able to achieve penetrative intercourse and 4.9 cm in those who were not. Meatus was glanular in 5 patients, coronal in 7 and at the distal shaft in 1. Compared to controls, men with disorders of sex development were less satisfied with the appearance of the penis and scrotum but not with total body image. These patients reported decreased sexual desire and activities. CONCLUSIONS Outcome in this group of men with disorders of sex development was poor regarding penile length, ejaculation, satisfaction with external genitalia and frequency of sexual activity. Other aspects, such as overall body image and psychosexual functioning, showed no difference from controls.
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Affiliation(s)
- Yvonne G van der Zwan
- Department of Pediatrics, Division of Pediatric Endocrinology, Erasmus MC-Sophia, Rotterdam, The Netherlands.
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Therapeutic strategies for patients with micropenis or penile dysmorphic disorder. Nat Rev Urol 2012; 9:499-507. [DOI: 10.1038/nrurol.2012.150] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Woodhouse CRJ, Lipshultz L, Hwang K, Mouriquand P, Creighton S. Adult care of children from pediatric urology: part 2. J Urol 2012; 188:717-23. [PMID: 22818132 DOI: 10.1016/j.juro.2012.05.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Indexed: 01/03/2023]
Abstract
PURPOSE We describe the outcomes of undescended testes and sex development disorders in adolescence and young adulthood. We reviewed the requirements for the long-term care of children born with these and other major congenital anomalies of the genitourinary system. MATERIALS AND METHODS The current English language literature was retrieved with a PubMed® search for articles on these subjects. Only articles covering outcomes at ages past puberty were included in analysis. The material was supplemented from the database of the clinic for adults with sex development disorders at University College London Hospitals. RESULTS An undescended testis has impaired spermatogenesis. In men in whom a unilateral undescended testis was corrected before puberty the incidence of paternity is normal at around 90% of those who attempt it. The equivalent rate for those with bilateral undescended testes is about 65%. If surgery for bilateral undescended testes is delayed until after puberty, fertility is unlikely. The risk of testicular neoplasms is overestimated and the relative risk is between 2.5 and 8. Children born with a sex development disorder receive multidisciplinary treatment throughout childhood and require the same care as adults. Males who are under virilized likely have a micropenis (greater than 2 SD below the mean stretched length) but they may have normal sexual function. Fertility depends on the underlying condition. Virilized females, who most commonly have congenital adrenal hyperplasia, currently present to adult clinics with an inadequate vagina after infantile surgery. Reconstruction is required to allow intercourse. CONCLUSIONS The care of adults born with abnormalities of the genitalia is complex. Early management may define upbringing in childhood but requirements for sexuality and fertility in adult life are different. Multidisciplinary care is essential and a case can be made to establish a subspecialty of urology to coordinate it.
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Blanc T, Ayedi A, El-Ghoneimi A, Abdoul H, Aigrain Y, Paris F, Sultan C, Carel JC, Léger J. Testicular function and physical outcome in young adult males diagnosed with idiopathic 46 XY disorders of sex development during childhood. Eur J Endocrinol 2011; 165:907-15. [PMID: 21964959 DOI: 10.1530/eje-11-0588] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE There are few studies of outcome in male patients with undefined 46 XY disorder of sex development (DSD). We aimed to assess testicular function and clinical characteristics after puberty in men with idiopathic 46 XY DSD. Design We conducted a University Hospital-based observational follow-up study. METHODS Nineteen patients with severe hypospadias associated with other signs of defective virilization, such as microphallus, cryptorchidism, and/or bifid scrotum, who were initially managed during childhood between 1988 and 1994, were evaluated at a median age of 17.6 (16.3; 17.8) years. Outcome measures included clinical findings and serum testosterone, FSH, LH, and inhibin B concentrations. RESULTS Testicular function was normal in only five (26%) patients. Impaired testicular function was observed in 14 (74%) patients and was partial (n=6; 32%) or total (n=8; 42%), requiring testosterone treatment for the initial (n=2) or secondary (n=6) induction of puberty. Undescended testis (unilateral n=3, bilateral n=2) was found and surgically managed only in the 14 patients with testicular impairment. Testosterone treatment in early childhood greatly increased penis length in all patients, but persistent microphallus following surgical treatment was observed at the end of puberty in most patients, with no difference between patients with and without testicular dysfunction (penis length of 68 (60; 75) vs 65 (60; 65) mm; P=0.42). Half the patients presented an adult height more than 5 cm below their target height. CONCLUSION Men diagnosed with idiopathic 46 XY DSD during childhood are at high risk of testicular insufficiency and persistent micropenis, and this should be taken into account during the follow-up.
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Affiliation(s)
- Thomas Blanc
- Pediatric Surgery and Urology Department, Centre de Référence Maladies Endocriniennes Rares de la Croissance, Hôpital Robert Debré Assistance Publique-Hôpitaux de Paris and Univ Paris Diderot, Sorbonne Paris Cité, Paris, France
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When size matters: a clinical review of pathological micropenis. J Pediatr Health Care 2010; 24:231-40. [PMID: 20620849 DOI: 10.1016/j.pedhc.2009.05.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2009] [Revised: 05/03/2009] [Accepted: 05/16/2009] [Indexed: 11/20/2022]
Abstract
Micropenis is a significantly small penis with normal internal male genitalia. Micropenis is usually diagnosed shortly after birth, and the cause should be established; in addition, it should be differentiated from other associated syndromes. The role of the pediatric nurse practitioner is to diagnose the micropenis, guide the parents through the options of management, and support all involved through the selected treatment, whether hormonal or surgical. Patients affected with micropenis will need long-term management from their pediatric nurse practitioners, as well as follow-up by endocrinologists, urologists, pediatric surgeons (if surgery is chosen as the treatment), psychologists, and social workers. The need of more long-term research on patients with micropenis also is discussed.
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Welsh M, MacLeod DJ, Walker M, Smith LB, Sharpe RM. Critical androgen-sensitive periods of rat penis and clitoris development. ACTA ACUST UNITED AC 2009; 33:e144-52. [PMID: 19656234 PMCID: PMC2816361 DOI: 10.1111/j.1365-2605.2009.00978.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Androgen control of penis development/growth is unclear. In rats, androgen action in a foetal ‘masculinisation programming window’ (MPW; e15.5–e18.5)’ predetermines penile length and hypospadias occurrence. This has implications for humans (e.g. micropenis). Our studies aimed to establish in rats when androgen action/administration affects development/growth of the penis and if deficits in MPW androgen action were rescuable postnatally. Thus, pregnant rats were treated with flutamide during the MPW ± postnatal testosterone propionate (TP) treatment. To assess penile growth responsiveness, rats were treated with TP in various time windows (late foetal, neonatal through early puberty, puberty onset, or combinations thereof). Phallus length, weight, and morphology, hypospadias and anogenital distance (AGD) were measured in mid-puberty (d25) or adulthood (d90) in males and females, plus serum testosterone in adult males. MPW flutamide exposure reduced adult penile length and induced hypospadias dose-dependently; this was not rescued by postnatal TP treatment. In normal rats, foetal (e14.5–e21.5) TP exposure did not affect male penis size but increased female clitoral size. In males, TP exposure from postnatal d1–24 or at puberty (d15–24), increased penile length at d25, but not ultimately in adulthood. Foetal + postnatal TP (e14–postnatal d24) increased penile size at d25 but reduced it at d90 (due to reduced endogenous testosterone). In females, this treatment caused the biggest increase in adult clitoral size but, unlike in males, phallus size was unaffected by TP during puberty (d15–24). Postnatal TP treatment advanced penile histology at d25 to more resemble adult histology. AGD strongly correlated with final penis length. It is concluded that adult penile size depends critically on androgen action during the MPW but subsequent growth depends on later androgen exposure. Foetal and/or postnatal TP exposure does not increase adult penile size above its ‘predetermined’ length though its growth towards this maximum is advanced by peripubertal TP treatment.
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Affiliation(s)
- Michelle Welsh
- MRC Human Reproductive Sciences Unit, Centre for Reproductive Biology, The Queen's Medical Research Institute, Edinburgh, UK
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Potential determinant factors of sexual identity in ambiguous genitalia. J Pediatr Urol 2005; 1:383-8. [PMID: 18947576 DOI: 10.1016/j.jpurol.2005.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2005] [Accepted: 06/06/2005] [Indexed: 01/13/2023]
Abstract
This is a review of literature scanning the potential factors which may affect Sexual Identity (S.I.) and Gender Identity (G.I.) in patients with ambiguous genitalia. Definitions of these concepts are outlined. Genetic, gonadal, hormonal, social and cultural pressures are reviewed as well as lessons to learn from clinical experiences and outcomes. Current criteriae used to assign gender in a child with ambiguous genitalia are discussed including medical and surgical criteriae as well as cultural disruptors. At the dawn of the third millennium, it is remarkable how little we know about the establishment of our individual and social identities.
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Mazur T. Gender dysphoria and gender change in androgen insensitivity or micropenis. ARCHIVES OF SEXUAL BEHAVIOR 2005; 34:411-21. [PMID: 16010464 DOI: 10.1007/s10508-005-4341-x] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
This review article answers three questions relevant to the medical management and care of individuals born with complete androgen insensitivity syndrome (CAIS), partial androgen insensitivity syndrome (PAIS), or a micropenis: (1) Do any of these individuals reassign themselves from their initial gender assignment? (2) Do more reassign than the ones who do not? (3) Is there evidence of gender dysphoria in those who do not self-initiate reassignment? Reviewed were all articles on CAIS, PAIS, and micropenis cited in K. J. Zucker (1999) plus articles published through 2004. There were no documented cases of gender change in individuals with CAIS (N= 156 females) or micropenis (N= 89: 79 males, 10 females). Nine (9.1%) out of 99 individuals with PAIS changed gender. Thus, self-initiated gender reassignment was rare. Gender dysphoria also appears to be a rare occurrence. The best predictor of adult gender identity in CAIS, PAIS, and micropenis is initial gender assignment.
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Affiliation(s)
- Tom Mazur
- Department of Pediatrics, School of Medicine and Biomedical Sciences, University of Buffalo and The Women and Children's Hospital of Buffalo, Buffalo, NY 14222, USA.
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Abstract
AIM To compare declared sexual identity to sex-of-rearing in individuals with disorders of sexual differentiation. METHODS All 84 patients > or =5 years old in a pediatric psychosexual development clinic were assessed for sex-of-rearing and sexual identity. Diagnoses included 1) male-typical prenatal androgen effects but an absent or severely inadequate penis - 45 patients with cloacal exstrophy or aphallia; 2) inadequate prenatal androgens and a Y-chromosome - 28 patients with partial androgen insensitivity (pAIS), mixed gonadal dysgenesis (MGD), hermaphroditism, or craniofacial anomalies with genital ambiguity; 3) inappropriate prenatal androgen effects and a 46,XX karyotype - 11 patients with congenital adrenal hyperplasia (CAH). RESULTS Of 73 patients with disordered sexual differentiation and a Y-chromosome, 60 were reared female; 26 of the 60 (43%) declared female identity while 32 (53%) declared male identity including 18 (55%) with cloacal exstrophy, six (55%) with MGD, four (40%) with pAIS, one (50%) with aphallia, one (100%) with hermaphroditism, and two (67%) with craniofacial anomalies; two (3%) declined to discuss identity. Nine of 11 patients with CAH and a 46,XX karyotype were reared female and two reared male; six (55%) declared female identity and five (45%) declared male identity. Of 84 total patients, 69 were reared female, but only 32 lived as female, while 29 lived as male; four patients refused to discuss sex-of-living; parents of four patients rejected their declarations of male identity. All 15 patients reared male lived as male including two genetic females. CONCLUSION Active prenatal androgen effects appeared to dramatically increase the likelihood of recognition of male sexual identity independent of sex-of-rearing. Genetic males with male-typical prenatal androgen effects should be reared male.
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Affiliation(s)
- William G Reiner
- Department of Urology-Pediatric Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA.
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