Psychotherapy is important for many men with concerns about having a small penis. Whether the penis is actually small or just perceived to be small, cognitive behavioural therapy (CBT) can be useful in building confidence and counteracting negative thoughts. CBT involves exploring the typical thinking patterns experienced by the patient and ascertaining if some of these can be ascribed as automatic, protective but also unhelpful and self-defeating. Substitution of alternative generated thoughts (alone or with the input of the therapist) and/or changes in ways of responding (behaving) to such thoughts can bring about dramatic changes. Where the penis is on the lower side of normal dimensions, the man can be provided with suggestions on how to cope and accept these facts. CBT is also effective in BDD . Wherever possible, explorative work with a partner should be encouraged. Themes around self-confidence, self-esteem, anger, fear of rejection and narcissism might emerge. Therapy in a facilitated group might help men to challenge each other and their stated anxieties more effectively than in individual therapy, although equally there might be ongoing competitiveness to have the ‘smallest penis’ or greatest social impairment.
These include use of vacuum devices, penile extenders and traction devices, and penoscrotal and penile rings. Evidence on their efficacy is very limited and it is important that the patient is aware of this. Vacuum devices are ordinarily used as a treatment for ED but can also be used to ‘exercise’ the penis. This can have both a psychological uplifting effect for the patient but evidence suggests that there is minimal physical change. A recent study reported on 37 men with a stretched penis length of <10 cm who used the device for 20 min, three times a week. The mean penile stretched length increased from 7.6 cm to 7.9 cm after 6 months of treatment, although this change was not statistically significant. Interestingly, three men had an increase in their penile length of >1 cm, and nine were satisfied with the treatment .
Penile extenders have also been used as a means of stretching the penis, and devices are available for use throughout the day. There are several commercial devices available (including the Jes extender and Andropenis) although there are few data showing efficacy for any of them. A recent study of 31 men, with a mean baseline stretched penile length of 12 cm, showed that with daily use of the Phallosan® extender system for ≥3 h, by 3 months there was a mean stretched length of 13 cm with a further increase to 13.8 cm by 6 months (P < 0.001) . Changes were also seen in penile diameter. There was a good correlation between the duration of use of the device and increase in length, and 80% of patients were happy with the outcome.
An older study reported the use of a stretching device (Penistretcher®) in nine men with a baseline stretched length of 12 cm. They reported that after using this device for ≥6 h per day over a 4-month period, the mean increase in stretched length was 1.8 cm . Both these reports included few men and were only reported as abstracts. There are currently no peer-reviewed publications related to the use of these devices in men with SPS.
Other devices that have been used in this group of patients include ‘Cock rings’ and penoscrotal rings. In one small report, there was a suggestion that they might help to augment penile size and maintain erections in men with anxiety .
Inevitably, many men, rather than seek formal medical help, prefer to use other sources of information, but might then seek medical advice. The Internet is a rich resource of sources offering to help men ‘increase their manhood’. Inevitably, there are no efficacy data relating to most of these treatments (especially the many pills and lotions available). Common sense advice can be found by some retailers, including ‘bulge underpants’ and swim shorts, body and genital hair trimming or shaving, the use of ‘hot towels and wraps’ and ‘jelqing’. The last is an ancient Arab technique whereby the hand pulls on the penis causing stretching (and effectively self-focus work encouraging psychological acceptance of the penis, which will change in size and shape during the process) and is recommended on many websites. Some websites advocate that ‘small is beautiful’ and that the smaller penis can be celebrated by both the man and his partner.
This would appear to be an attractive option for many men with SPS, and indeed, for those who research the Internet there is no shortage of sites encouraging such an approach. However, the results of surgery are poorly documented and significant complications can ensue. Accordingly, it is recommended that any surgical procedure should only be used after a careful preoperative assessment, which should include a thorough psychological assessment as outlined above. Furthermore, careful advice on the potential results of surgery and the potential complications that might ensue is essential. Indeed, the 2nd International Consultation on Sexual Dysfunctions concluded that ‘most men will not wish to proceed to surgery when properly informed of the likely outcome and risks of complications’. The ethical issues of offering such surgery to men with a normal sized penis (which is usually the case ) are reviewed by Vardi , especially as this appears to be increasing in the private sector rather than research or university settings .
If, after such an approach, the man wishes to consider surgery, then several surgical options are available. Some surgical approaches will potentially increase the flaccid length of the penis (e.g. division of the suspensory ligament of the penis), while others have been reported to increase both flaccid and erect length. Similarly, some approaches offer an increase in erect girth only, while others offer an increase in both erect and flaccid girth.
Either liposuction or suprapubic lipectomy are potentially valuable in men with a significant suprapubic fat pad, thereby making a partly buried penis appear more prominent. Other than bruising, there are few complications with such an approach, and the cosmetic results are reasonable. However, there are few reported results for this approach .
Division of the suspensory ligament is the procedure that has been most commonly described for flaccid penile lengthening [39–44]; it allows the corpora cavernosa to be partly separated from the pubis, thereby increasing the apparent flaccid length of the penis. Some form of adjustment of the suprapubic skin is needed (usually a V-Y advancement flap or a Z-plasty), and it is sometimes helpful to place a ‘spacer’ between the pubis and the corporal bodies to prevent re-scarring at the site of the divided suspensory ligament. At best, the proponents of this technique suggest a 2-cm increase in flaccid length (Table 2) [39,41–44]. Potential problems include the inevitability that the erect penis will tend to point downwards when the man is upright, rather than standing ‘erect’ and perpendicular to the body. Specific complications include re-scarring of the infrapubic region, with the consequence that there might be no increase in length and in some cases there might even be penile shortening. A surgical approach to prevent this complication was reported recently . Finally, the advancement skin flaps, when healed, might be unsightly and might result in the disfiguring advancement of suprapubic hairy skin onto the shaft of the penis . It is relevant that in one series, of men with BDD who had this surgery, despite a mean increase in length of 1 cm, only 27% were satisfied and 54% requested further surgery.
Table 2. The reported results of penile lengthening procedures
|Study||N, type of patients||Technique||Follow-up, years||Initial length, cm (range or sd)||Length after surgery, cm (range)||Mean gain, cm (range or sd)||Comments|
|||19, MP + BDD||Penile disassembly + cartilage insertion||3.3 (mean)|| 3.6 (F) (2.6–4.7) 8.3 (E) (6.2–10)|| 6.6 (F) (5.5–8.2) 11.4 (E) (9–14)||–||–|
|||18, MP + BDD||DSL||0.75 (≤3)|| 8.9 (E)||10.5 (E)||1.5–2.5||–|
|||42, MP + BDD||DSL||–||–||–||1.3 (1.2)||35% satisfied|
|||27, BDD||DSL||–|| 11.5 (1.7)|| ||1 (1.1)||27% satisfied|
|||11, BDD||DSL||2|| 9.12 (7–11.3)||10.75 (9.2–12.9)||1.65 (1–2.3)||–|
|||31, BDD||DSL||–|| 8.72 (6.5–10)||–||2.42 (1.5–4.8)||–|
|||15, BDD||DSL||2.25||–||–||3.45 (2.1–4.5)|| |
The so-called ‘Perovic procedure’ involves penile disassembly, with dissection of the glans penis off the corpora cavernosa in continuity with the dorsal neurovascular bundle and the urethra . A piece of costal cartilage is then sutured onto the distal corpora before the glans is replaced over the cartilage. This procedure should result in an increase in both flaccid and erect penile length. It is clearly quite extensive surgery, and runs the risk of glans numbness due to damage to the neurovascular bundle. Short-term results were reported , with increases in length of 2–3 cm for both the flaccid and erect states. However, long-term results have not been reported, and given what is known about the tendency of devascularized rib cartilage to resorb with time , scepticism about the long-term outcome is inevitable.
Several techniques have concentrated on bulking of the subcutaneous fat with fat injections, free dermal fat flaps, or biodegradable materials. There are few reported results of such surgery in peer-reviewed reports, which is in itself a worry. One recent report of the early results of subcutaneous fat injections was promising, with increases in circumference of 1.4–4 cm reported , but studies with a longer term follow-up suggest disappointing results, with complications including disfigurement, scarring, lumpiness and infection [48,49]. One recent study reported the use of a biodegradable scaffold seeded with fibroblasts, that was formatted into a tube and wrapped around the degloved penis . Although the authors operated on 204 men a follow-up was available for 84, with a mean follow-up of 24 months. The authors reported a mean increase in flaccid girth of 3.15 cm and a mean increase in erect girth of 2.47 cm; 81% of patients judged their satisfaction with the outcome of surgery as either excellent or very good. Recently a technique involving use of a groin fasciocutaneous flap was reported . Another approach to penile girth enhancement was reported by Austoni  and involves the use of bilateral longitudinal saphenous vein grafts that are inlaid into the tunica albuginea along the penis. These grafts would be expected to allow expansion on penile erection, thereby increasing erect but not flaccid girth. Austoni reported that there was a minimal change in flaccid diameter, but that the erect diameter increased from 2.85 cm to 4.21 cm (P < 0.01). There is a theoretical risk of ED, as a proportion of men undergoing the ‘Lue’ procedure for Peyronie’s disease develop de novo ED, although this was not reported. As yet there are no long-term surgical outcomes reported in peer-reviewed reports.
Several techniques to augment the glans penis were reported, including injection with hyaluronic acid gel  and placing fasciocutaneous flaps . Robust data on the outcomes of such approaches are at present limited.
One final situation where surgery might be helpful is the case of a man with a genuinely small penis and ED, e.g. secondary to Peyronie’s disease, previous failed penile implant surgery, or priapism. A technique was reported whereby there is simultaneous implantation of an inflatable penile implant while the tunica albuginea is inlaid with a series of circumferential saphenous vein grafts . The results in a small series were promising, although verification is needed from other authors, and a longer follow-up would confirm the place of such operations. The reconstruction of deformities that might arise in men who have had augmentation surgery are reviewed elsewhere .