In urosexological practice, men are often encountered who are experiencing problems with the length, size or shape of their penis. Further examination usually shows that actually there is nothing wrong. Some men present with complaints about an (in their opinion) small penis, because they experience anxiety in homosocial situations (e.g. changing-rooms) or consider themselves sexually unattractive because they have (in their opinion) a small penis which might provide insufficient arousal or satisfaction in their partner. Women, on the other hand, very seldom complain about the fact that their partner’s penis is too short or too small.
Sexological aspects of penile length
In 1899, the German physician Loeb published the results of a study on 50 men aged between 18 and 53 years [ 1]. The length of the visible, nontumescent penis varied from 8 to 11 cm (mean 9.4) and the circumference from 8 to >10 cm. The famous Kinsey report in 1948 [ 2] stated that the penis was <9 cm in erection in only 5% of the men who were interviewed and >20 cm in 1%.
A recent Dutch study, primarily aimed at problems concerning the inopportune displacement of condoms during intercourse, showed that the mean (range) circumference of the penis in full erection was 12.1 (9.0–16.1) cm [ 3]. In addition, the circumference of the erect penis was <11.0 cm in one quarter of the study subjects, <13.0 cm in three-quarters and <14.1 cm in 90%.
Because some factors, e.g. different measuring methods, may differ, the ‘normal’ values reported in the literature vary. It is also known that a small penis shows a greater mean increase in length and circumference during erection than a large one [ 4]. This is valid for both the relative and the absolute increase. When evaluating length, age should also be considered; because the number of elastic fibres in the tunica albuginea of the pars pendulans decreases with advancing age, the penis usually becomes a little shorter [ 5, 6]. This concludes the ‘objective’ measurement; the subjective experience is much more problematic.
According to the American sexologist McCarthy, two-thirds of men consider their penis too small [ 7]. He attributed the worries about the length of their penis, amongst others, to the fact that in a changing-room, other men are seen frontally; apparently, the other person’s penis looks larger because a man sees his own penis only from above. Looking down from above causes what visual artists refer to as ‘perspective shortening’. Hence, the penis looks shorter than it actually is. Another concomitant problem is that men generally do not like to talk about such intimate matters. There is little or no feedback about this delicate subject, which implies no correction of incorrect ideas or thoughts.
Research into the subjective experience of the size of the penis in a group of 112 students (all bachelors) aged 18–28 years showed that 22% of them thought that their penis was smaller than average [ 8]. Over 3% held the opinion that the size of their penis was much smaller than average; 69% thought it was average and over 5% thought their penis to be larger than average. There were no significant differences between the various groups regarding coitus (ever had, frequency in the month preceding the study or the total number of sexual partners), the use of public toilets and/or changing-rooms, whether or not they ever saw their father’s penis, whether or not they had brothers and also whether or not they ever had to endure comments about the size of their penis. However, it was also true that several men who felt that their penis was smaller than average had experienced particularly hurtful comments about the size of their penis, especially at the beginning of their puberty.
Kinsey et al. had already established that very few women become sexually aroused by looking at a penis [ 2]. Experimental psychological research into both male and female students showed that in both groups, the length of the penis had hardly any effect on sexual arousal [ 9].
Retrospective investigations of adults who had suffered from hypospadias in their youth showed that the men who had ever had to endure hurtful comments about the visual aspect of their penis experienced their genitals less ‘positively’ than those who had never had any comments [ 10]. In children and adolescents with hypospadias, this difference in experience was absent. In other words, on adults operated on for hypospadias, negative comments about the appearance of their penis may have more psychological impact than on a child or adolescent. It may be important to enquire about this aspect when recording the history of a man who complains about a short penis.
An exceptional form of anxiety exists about insufficient penile length is koro, originally a Malaysian word meaning the ‘head of a tortoise’. This psychiatric disease occurs mainly in the Far East, usually in older patients. They become convinced their penis will wither and retract inside their abdomen, with death as a consequence. Koro has also been described in the Western scientific literature as an expression of schizophrenia, depression, epilepsy and delirium [ 11]. Physiological shrinkage of the penis, e.g. through a cold bath, or detumescence after coitus or masturbation, is often the dislocating moment for koro. Not surprisingly, a physician working in the Dutch East Indies was the first to report this remarkable anxiety in the medical literature [ 12]. He wrote: ‘Sufferers are extremely frightened. As soon as they notice the first symptoms, they take hold of their penis to prevent its retraction. Sometimes they are unable to maintain this position themselves and the therapy must be continued by another person’.
Indications and methods for penile lengthening
In 1993, a popular science book dealing only with penis enlargement was published in the USA [ 13]. Many nonsurgical penile lengthening methods are described, varying from the ‘Polynesian stretching’ method with the aid of a heavy tube (which was drawn by the cultural anthropologist Margaret Mead) to the regular use of a vacuum pump. No research has ever been carried out into the results, positive or otherwise, of these treatments. However, the photographs shown in the book suggest that the penis can be lengthened using mechanical methods. The author, originally a biologist, also makes it clear to the layman for whom the book was written that, contrary to the effect in a child, treatment of an adult with testosterone will not influence the length of his penis.
In children with a small penis it is always important to establish the genetic lineage. In a male genotype, distinction has to be made between an anatomical anomaly and an endocrine reason for micropenis [ 14, 15]. The aetiology of congenital micropenis is inadequate androgenic stimulation of the penis (target organ) or insensitivity of the receptors in this organ. Insufficient androgenic stimulation can be a problem within the hypothalamic-pituitary axis, or can be the consequence of the inability to metabolize testosterone under the influence of 5α-reductase. The latter is usually due to a primary defect at the hypothalamus level. Testicular causes of micropenis are very rare. In the case of rudimentary testes, male pseudohermaphroditism is usually present. Treatment for a micropenis (with no other abnormalities) in childhood is primarily hormonal, and surgical only very exceptionally. Hormone therapy should be started preferably 6–8 months after birth. Chromosomal abnormalities, such as those associated with Klinefelter’s syndrome, can also be associated with a small penis.
By the early 1970s, surgical methods to lengthen the penis were described by paediatric urologists [ 15–17]. In children, penile lengthening is almost invariably carried out with another intervention such as the closure of bladder exstrophy. In adults, penile lengthening is performed for various reasons, e.g. to achieve better fixation for a condom catheter, particularly in wheelchair-dependent patients with spinal cord transection [ 18]. Surgery for cosmetic reasons did not become popular in the Western world until, in 1994, the lay press published articles about what was called ‘a new operation, developed in China being applied on a large scale in South Africa’’. However, the technique was exactly the same as that described by paediatric urologists in the 1970s, i.e. the release of the suspensory ligament in combination with an inverted V-Y skin plasty ( Fig. 1) [ 17]. A recent postmortem study on human cadavers showed that the omission of skin plasty partially counteracts the result of releasing the suspensory ligament [ 19].
In the USA, an estimated 10 000 men have undergone penile surgery for cosmetic reasons over the past 7 years [ 20]. The interventions comprised both penile lengthening and penile augmentation with autologous fat tissue. Complications included wound infection, painful scars, bending of the penis, irregular distribution of the fat tissue resulting in a bumpy aspect of the penis, and even loss of sensitivity because of nerve damage [ 21, 22]. The most common problem was dissatisfaction with the final cosmetic result. In view of these problems, a few leading American experts published guidelines detailing the indications for surgical penile lengthening for cosmetic reasons [ 20]. In their opinion, such an operation is only justified if the penile length is <4 cm when flaccid or <7 cm when erect. For adult males with a small penis, surgical lengthening, at least visually, is only one of the possible solutions. Even after (partial) penile amputation, many patients still have a satisfying sexual life [ 23].
Whether or not to operate?
Not only in ancient Greece, but also in ancient Scandinavia, and in numerous other cultures, there was an institutionalized ‘phallus’ cult. According to the Danish psychoanalyst Thorkil Vanggaard, modern man is still a phallus worshipper [ 24]. This is possibly somewhat exaggerated, but without doubt in the present western culture, the penis is more than just an organ with which to urinate or ejaculate. In erection, the penis becomes a powerful symbol, i.e. the meaning attributed to it is more than purely physical. According to Vanggaard, the erect penis symbolizes strength, the ability to enforce skill, courage, intellect and predominance over other men. Undoubtedly, this function of the phallus is also upheld by men who consider that they have a penis that is too small.
In practice, a patient’s urgent wish apparently plays an important, if not decisive, role. It is not difficult to imagine a ‘medical’ indication after surgical treatment for penile cancer or severe trauma; very few people will object to this. However, the situation will be very different when there is no medical indication, but only a personal subjective wish. In these cases, people speak in terms of ‘wish surgery’ or ‘luxury surgery’ and ‘cosmetic surgery’. These concepts are difficult to define and it is even more difficult to demonstrate the improper application of medical facilities. After all, the aim of medical science is to heal diseases and promote health. ‘Wish’ surgery would therefore entail treatment that does not aim at recovery or healing, but promotes subjective well-being only. Consistently, dental prostheses, sleeping pills and surgical intervention for trans-sexuality all fall under this ‘wish’ medicine. However, the problem is that a major part of medical science is already intended to improve subjective well-being, e.g. the surgical correction of abnormal but well-functioning protruding ears. Saying to a child that ‘Mother Nature’ has ordained the situation is considered as being unsympathetic. The same also applies to a man who complains that his penis is too small. Undoubtedly, there will be psychological and/or social suffering. A famous ‘case’ is the psychiatrist Adler, who suffered frustration all his life about the smallness of his penis.
Complaints about a penis that is too small should not be ignored or trivialized. First, doctors should make it clear that sexual functioning does not really depend on the length or circumference of the penis. This is also valid in relation to the sexual partner achieving orgasm. Nevertheless, some men are not content and want to undergo an operation at any cost. In our experience, these are mainly the men who experience problems in a homosocial situation (e.g. changing-rooms or shower).
A ‘real’ small penis, or micropenis, is defined as a penis with an anatomically normal form but with a length that is 2–2.5 standard deviations shorter that the normal age-related value [ 20]. For an adult male, this implies a penis of <7 cm when erect. The potential penile length in erection can be established by extending it to the maximum length and measuring it from the top of the glans to the dorsal penile base, excluding the foreskin.
The difficulty with suggesting a visit to the psychologist is usually that the patient is not aware of any psychological problem. Such a visit is only regarded as an ‘examination’; the patient denies any problem, personal or in his relationship, but simply has the problem of having a small penis. To operate on such cases nevertheless implies an attempt to solve an emotional problem with a scalpel; a precarious undertaking, that can produce good results nevertheless. Obviously, honesty and openness, especially about the possible disadvantageous consequences, are essential ingredients in the information process. Physicians, in all modesty, can only hope that the penile lengthening surgery, with an apparent increase in length of no more than 2–3 cm, will resolve some of the patient’s complaints.
The situation in which the urologist or psychologist, together with the patient, consider whether subjective wishes should be satisfied surgically has begun to meet more objections. The patient is the ‘one who knows best’ what he wants and that ‘the doctor or psychologist should just do their job’ is an opinion sometimes expressed by current patients. However, this opinion cannot always be upheld without financial consequences. It is not known how many penile lengthening operations are performed each year in our country for cosmetic reasons. Compared with the number of breast enlargement procedures (over 1400 per year), it is probably modest. This may be because breast enlargement (usually financed by the patient) is accepted by society, certainly more so than is penile lengthening. A second explanation is that at a Dutch private clinic, the cost for penile lengthening can be more than US$5800, an exorbitantly high price in relation to the level of difficulty and the duration of the procedure.
A commonly expressed opinion is that ‘cosmetic surgery and wish-medicine are certainly allowed, but the patient has to pay’. In itself, there seem to be no objection to this in the Western European situation, but awkward questions remain to be answered. Why in many countries are dental prostheses covered by a basic health insurance policy, but penile lengthening not? Or is it necessary that an ethically unacceptable minimum length (e.g. 7 cm) has to be met before a penile lengthening operation may be considered and performed? Undoubtedly, in certain patients surgical lengthening of the penis may have a positive effect on psychological well-being; but who should have surgery and who should not? That question remains, but a standard approach with a ruler is probably not in the best interest of these patients.