Noninvasive methods of penile lengthening: fact or fiction?

NON-INVASIVE PENILE LENGTHENING METHODSODERDA and GONTERO Non-invasive methods of penile lengthening:
BJUI fact or fiction?
B J U I N T E R N A T I O N A L
Marco Oderda and Paolo Gontero
University of Turin, Molinette Hospital, Turin, Italy
Accepted for publication 7 May 2010
Penile size is a matter of great interest What's known on the subject? and What does the study add?
among men who are affected by ‘short penis syndrome’ or just believe themselves Penile lengthening methods remain a controversial issue. Surgical procedures of “lengthening phalloplasty” are characterized by poorly defined indications and an unacceptably high rate of complications, as recently outlined by a literature review, while non-surgical techniques are largely popularized by the media but often lack scientific evidence. In the literature we found only ten articles/abstracts of studies pertaining to the With our review, we aimed to explore whether non-surgical methods of penile lengthening may have some scientific background. We focused specifically on penile extenders, which among conservative methods are those whose efficacy is supported by as vacuum devices, penile traction devices some scientific evidence. It seems that penile traction devices should be proposed as the first-line treatment option for patients seeking a penile lengthening procedure.
exercises’ have been popularized through the media. Most of these techniques, however, are not supported by any scientific evidence. KEYWORDS
We briefly analyse the efficacy and scientific surgery, making these traction devices an penile lengthening, micropenis, small penis, of penile lengthening. It seems that penile ideal first-line treatment option for patients extenders represent the only evidence-based seeking a penile lengthening procedure.
INTRODUCTION
lengthening. The PubMed, Ovid, Embase and [3]) with none being a review article. Ten dealt Cochrane-Central Register of Controlled Trials with general concepts related to short penis, Penile size continues to represent a matter of of which four were used to define the terms great concern among men and an increasing combinations of the following free text: ‘short number of patients seek urological advice for penis’, ‘penile lengthening’, ‘Peyronie’, addressed the role of surgery for penile the so-called ‘short penis’, wondering if there ‘extenders’, ‘micropenis’, ‘therapy’, is the possibility of having their penis ‘dysmorphophobia’. Identified articles were comprehensive review [2] which was kept for enlarged. Notably, penile length is normal in examined by the authors (M.O. and P.G.), and comparison with the results of conservative most of these men who tend to overestimate the most relevant articles were selected normal phallic dimensions [1]. Furthermore, according to their levels of evidence, as defined by the Oxford Centre for Evidence- phalloplasty’ remain a controversial issue, based Medicine [3]. In addition, abstracts NORMAL PENILE SIZE AND CONDITIONS
presented at the 2008–2009 annual meetings OF SHORT PENIS
indications and an unacceptably high rate of What is a normal penile size is a knotty literature review [2]. In this brief overview we question which some studies have tried to aim to explore whether non-surgical methods answer. Penile length has to be measured of penile lengthening, largely popularized along the dorsal side of the penis, from the through the media, may have some scientific pubo-penile skin junction to the meatus, Among the 154 reports matching our search while the circumference is measured at the terms, only 10 articles/abstracts of studies mid-shaft. According to Wessells et al. [4], MATERIALS AND METHODS
were found to pertain to the topic of the review. These clinical data were limited to case considered to be any length within 2 SDs series (level of evidence 4 according to the of the mean, that is >4 cm for the flaccid focused on non-invasive methods of penile Oxford Centre for Evidence-based Medicine state and >7.5 cm for the stretched state. B J U I N T E R N A T I O N A L 2 010 B J U I N T E R N A T I O N A L | 107 , 1 2 7 8 – 1 2 8 2 | doi:10.1111/j.1464-410X.2010.09647.x N O N - I N V A S I V E P E N I L E L E N G T H E N I N G M E T H O D S Ponchietti et al. [5] confirmed these findings, penile skin from chronic inflammation or an outcome [6]. In conclusion, penile extenders concluding that >4 and >7 cm, respectively for the flaccid and stretched states, represent patients who complain of ‘short penis’. the normal range, bearing in mind that these measurements have to be interpreted in the NON-INVASIVE METHODS OF PENILE
recommended in all patients regardless of the light of other variables, such as body mass LENGTHENING: A NEW PERSPECTIVE
penile length, because of the low risk of After promising results in the treatment of complain of ‘short penis’ and who request Vacuum devices are used as a treatment for short penis, penile extenders have also been erectile dysfunction. A recent study assessed used in an attempt to correct the defect overestimate ‘normal’ penile length [1]. They associated with Peyronie’s disease. The first- suffer from so-called ‘dysmorphophobia’, a condition consisting of an imaginary flaw in the physical appearance [6], in this case a physical change after 6 months of therapy. treatment, although there is little evidence false perception of inadequacy of the penis Vacuum treatment of the penis was not found that this is effective; alternatively, the surgical even though its dimensions fall within the to be effective for penile elongation, although option must be considered once the disease normal range [7]. Dysmorphophobia can be an has been stabilized [17]. In 2008, a non- aesthetic issue, if the altered perception controlled pilot study by Aberne and Levine concerns the penis in its flaccid state, or functional, during erection [8]. In both cases, with intralesional verapamil injections plus the psychological aspect should be the main concern and a multidisciplinary approach, Recently, great attention has been given to injections alone. Another pilot study [19] penile extenders, non-surgical devices that suggested prolonged daily external penile psychological assessment, is advised [9]. A generate progressive mechanical traction to traction therapy as a new approach for the the penis. Although there are only a few well- non-surgical treatment of Peyronie’s disease, patients how they compared with other men conducted studies to assess their efficacy, it with the rationale that chronic traction can [5]. This tool was found to be very useful cause soft tissue cellular proliferation, and to reassure these patients: in a study by effective and durable lengthening of the eventually reduce penile curvature. This study Mondaini et al. [1], 70% of their sample felt penis, in both the flaccid and the stretched actually showed curvature was reduced by reassured after being educated about the states [7]. In 2002, a small study by Colpi et al. 10–45∞ after 6 months of use of the FastSize normal variation in penile size and was no [15] began to unveil the efficacy of penis- Penile extender (FastSize LLC, CA, USA). longer interested in undergoing a surgical stretching physiotherapy in the ‘small penis’ Stretched flaccid penile length increased 0.5– 2.0 cm and erect girth 0.5–1.0 cm. These Penile shortening is a phenomenon associated +3.1 cm) after 4 months of use of a penis- confirmed by a prospective study by Gontero with several medical and surgical conditions, et al. [17]. After 6 months of treatment with such as prostate cancer treated with radical (Andromedical, S.L., Madrid, Spain) for at least Andropenis, penile curvature improved only minimally, from an average of 31∞ to 27∞, showed that, after 6 months of daily use of reduction in penile length was recorded 3 the same extender device for ≥4 h/day, there satisfaction was obtained: this was probably was a significant gain in length, of 2.3 and prostatectomy [10], although the aetiology is 1.7 cm for the flaccid and stretched penis, (1.3 cm) and flaccid (0.83 cm) penile lengths. not clear. A statistically significant decrease in respectively, but no significant change in The authors, however, explained that the penile length was also found in men treated penile girth was detected. These findings were particular selection of patients (stabilized with hormonal suppression plus radiation disease, penile curvature <50∞, no severe conducted by Nikoobakht et al. [16], who penile shortening is represented by Peyronie’s found a statistically significant increase in underestimation of the potential efficacy of disease, an acquired penile deformity of the length, both for the flaccid and for the erect penis, caused by fibrous plaque. Both the stretched state, after 3 months of use of the natural history of the disease and the scarring Golden Erect extender device (Ronas Tajhiz process after surgical repair can cause a Teb, Tehran, Iran). This study also failed to decrease in penile length [12]. Short penis can show any significant change in penile girth, Other devices include penoscrotal rings that, also be congenital, as a result of embryonic or although it suggested the possibility of glans developmental defects. Lastly, sometimes the penis enhancement. Treatment with penile inhibitors, might help to augment penile size shortness of the penis is the result of the so- extenders is generally reported to be well- and maintain erections in men suffering from called ‘hidden penis’ [13], a condition caused tolerated, although longer daily use would anxiety [20]. To our knowledge, however, the by obesity, aging with an overlying fold of probably reduce patients’ compliance [6,16], efficacy of these devices has been described in abdominal fat and skin, and a shortage of and the patients seem to be happy with the B J U I N T E R N A T I O N A L 2 010 B J U I N T E R N A T I O N A L B J U I N T E R N A T I O N A L 2 010 B J U I N T E R N A T I O N A L N O N - I N V A S I V E P E N I L E L E N G T H E N I N G M E T H O D S a high risk of patient dissatisfaction because of additional penile shortening. The current A recent study by Shaeer et al. [21] proposed evidence suggests that selected cases may injection of botulinum toxin as an alternative No comparative studies have been conducted benefit from a conservative approach with to surgery and penile extenders for alleviating so far between surgical and conservative penile retraction in patients suffering from methods of penile lengthening. Reviewing the recent literature, however, it would seem that In conclusion, level 4 evidence (according to retraction reflex. This preliminary report extenders represent an effective and durable Medicine) suggests that penile extenders are potential effect in temporarily decreasing method of penile lengthening, capable of penile retractions, as well as improving flaccid elongating the penis by an average of 1.5– penile lengthening, although further studies, 2.5 cm, with minimal side effects. We should preferably comparative, should be performed keep in mind, though, that published data on penile extenders are still limited to non- controlled case series. Further comparative CONFLICT OF INTEREST
studies should be performed to gain more evidence. Table 1 [7,8,14–17,19,23–26] shows advertisements for non-invasive procedures the results of the main studies conducted on that should increase penile size, taking the techniques of penile lengthening.
REFERENCES
small penises. This is the case for ‘penile lengthening exercises’, a technique that in CONCLUSIONS
1 Mondaini N, Ponchietti R, Gontero P
spite of the lack of any scientific evidence et al. Penile length is normal in most men
claims to represent an effective method to permanently stimulate penile lengthening penis, a certain proportion of patients still Int J Impot Res 2002; 14: 283–6
by up to 3 inches (7.5 cm). Although this request some sort of procedure to enlarge 2 Vardi Y, Harshai Y, Gil T, Gruenwald I. A
technique is not supported by any evidence, it their ‘under-estimated’ penis [1]. Surgery, is given great attention by patients, attracted however, is characterized by a high risk of complications and unwanted outcomes, apart penile size: surgical techniques, success, method of having their penis enlarged. By from the lack of consensus on indications and and complications. Eur Urol 2008; 54:
way of example, if we search Google for the surgical techniques used [2]. All those things combination ‘penile lengthening exercise’, we considered, a non-surgical approach should 3 Phillips B, Ball C, Sackett D et al. Levels
be attempted for those patients who persist in of evidence. Oxford Centre for Evidence- requesting treatment. Cognitive behavioural based Medicine Web site. Available at: therapy can be useful in building confidence for those suffering from dysmorphophobia [6]. As for non-invasive physical treatments, various procedures have been attempted – 4 Wessells H, Lue TF, McAninch JW.
vacuum devices, penile extenders, penoscrotal perfected to obtain penile girth enlargement. conservative methods of penile lengthening, augmentation. J Urol 1996; 156: 995–
claimed that penile extenders can increase penile traction devices are the technique for penile circumference by 0.6–1 cm/month [22]. 5 Ponchietti R, Mondaini N, Bonafe M, Di
It is not clear why these devices should be scientific evidence. This is mainly generated Loro F, Biscioni S, Masieri L. Penile
effective in enhancing penile girth; it has been hypothesized that chronic traction causes comparative design and further studies are 3300 young Italian men. Eur Urol 2001; soft tissue cellular proliferation with tissue needed. While the penis can effectively be 39: 183–6
growth in a multiplanar fashion [19]. These elongated by an average of 1.5–2.5 cm based 6 Wylie KR, Eardley I. Penile size and the
findings, however, were not confirmed by a on the underlying condition, there is no ‘small penis syndrome’. Br J Urol 2007; 99:
study by Gontero et al. [7], who found only evidence that the girth can be increased by negligible changes in penile girth after 6 applying traction forces. Taking into account 7 Gontero P, Di Marco M, Giubilei G et al.
months of traction therapy. Nikoobakht et al. that surgical methods are not supported by a A pilot phase-II prospective study to test [16] did not find significant changes in better scientific background nor have they the ‘efficacy’ and tolerability of a penile- shown better results, penile traction devices extender device in the treatment of ‘short although a significant difference was found in should be proposed as a first-line treatment penis’. Br J Urol 2008; 103: 793–7
glans penile circumference. It is interesting, 8 Spyropoulos E, Christoforidis C,
however, that no girth decrease was reported Borousas D, Mavrikos S, Bourounis M,
with traction therapy, as one would have consideration may apply to Peyronie’s disease Athanasiadis S. Augmentation
where surgical correction of curvature carries B J U I N T E R N A T I O N A L 2 010 B J U I N T E R N A T I O N A L 16 Nikoobakht M, Shahnazari A,
penile retraction. J Sex Med 2009; 6:
Rezaeidanesh M, Mehrsai A, Pourmand
G. Effect of penile-extender device in
22 Gomez EA. Penile enlargement without
techniques applied. Eur Urol 2005; 48:
9 Colombo F, Casarico A. Penile
J Sex Med 2010; Jan 19 [Epub ahead of Congress 2001. Available at: http:// enlargement. Curr Opin Urol 2008; 18:
17 Gontero P, Di Marco M, Giubilei G et al.
10 Savoie M, Kim SS, Soloway MS. A
treatment of penile curvature as a result 23 Austoni E, Guarneri A, Cazzaniga A.
of Peyronie’s disease. Results of a phase II prostatectomy for prostate cancer. J Urol prospective study. J Sex Med 2009; 6:
2003; 169: 1462–4
bilateral saphenous graft – three years of 11 Haliloglu A, Baltaci S, Yaman O. Penile
18 Abern M, Levine LA. Intralesional
experience. Eur Urol 2002; 42: 245–
24 Li C-Y, Kayes O, Kell PD, Christopher N,
management of Peyronie’s disease. J Urol Minhas S, Ralph DJ. Penile suspensory
prostate cancer. J Urol 2007; 177: 128–30
2008; 179: 408
12 Pryor J, Akkus E, Alter G et al. Peyronie’s
19 Levine LA, Newell M, Taylor FL. Penile
disease. J Sex Med 2004; 1: 110–5
Eur Urol 2006; 49: 729–33
13 Shaeer O, Shaeer K. Revealing the buried
25 Panfilov DE. Augmentative phalloplasty.
penis in adults. J Sex Med 2009; 6 (3):
pilot study. J Sex Med 2009; 5: 1468–
Aesthetic Plast Surg 2006; 30: 183–
14 Aghamir MK, Hosseini R, Alizadeh F.
20 Wylie KR, Hallam-Jones R, Steward D.
26 Perovic SV, Djordjevic ML. Penile
The combination of penoscrotal rings and lengthening. Br J Urol 2000; 86: 1028–
fact or fiction? Br J Urol 2006; 97: 777–
15 Colpi GM, Martini P, Scroppo FI,
Correspondence: Paolo Gontero, Associate Mancini M, Castiglioni F. Efficacy of
Sex Relationship Ther 2006; 21: 209–
Professor of Urology, University of Turin, Urologia 1 Molinette Hospital, C.so Dogliotti elongate the ‘small penis’. Int J Impot Res 21 Shaeer O, Shaeer K, Shaeer A.
2002; 14 (Suppl. 4): 155
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