Noninvasive extenders are better than surgery for men who want a longer penis

Surgeons should encourage men who request penile lengthening surgery to try non-invasive methods first and, in some cases, consider therapy to help them feel more positive about their body.

An Italian review published in the April issue of the urology journal BJUI found that penile extenders are more successful than techniques like vacuum devices, exercises and botox injections and that psychological satisfaction is often just as important as physical changes.

"Urologists are constantly approached by men who are concerned about the size of their penis, despite the fact that the majority of them are normal sized" says Associate urology Professor Paolo Gontero, from the University of Turin, who carried out the research review with Dr Marco Oderda.

"However there are also a number of medical and surgical conditions that can cause penile shortening, such as radical prostatectomy for men with prostate cancer, Peyronie's disease and congenital abnormalities. Then there's 'hidden penis', which is caused by overlying abdominal fat and skin in obese aging men or a lack of skin because of chronic inflammation or an aggressive circumcision.

"Surgery is characterised by a risk of complications and unwanted outcomes and lack of consensus among the medical profession on the indications for surgery and the techniques used. That is why a non-invasive technique is preferable."

The review compared five evidence-based surgical studies covering 121 men and six evidence-based non-surgical studies covering 109 men, published between 2000 and 2009. Key findings included:

• The average age of the men included in the studies ranged from 24 to 56 and the average follow-up ranged from three to 16 months.
  
• Surgical techniques resulted in average flaccid size increases of between 1.3cm and 2.5cm. One report mentioned a highly invasive surgical procedure that achieved up to 4cm, but the authors could find no reports to suggest this has been reproduced by others. Meanwhile, studies of three types of penile extenders resulted in average flaccid increases of 0.5cm to 2.3cm.
  
• The most common surgical technique - used on 83 per cent of patients - was dissection of the suspensory ligament, carried out on men with underdeveloped penises, Peyronie's disease, very small penises (micropenis), penile carcinoma or trauma. A number of patients had surgery because of dysmorphophobia, a psychological dislike of their body.
  
• Nineteen men with an erect penis length of 6-10cm received the invasive surgery that involved penile disassembly with autologous cartilage and five of those experienced moderate dorsal penile curvature after surgery. The authors foresee a high complication and dissatisfaction rate with this surgical technique.
  
• A total of 72 men used the penile extenders. Six reported minor problems, with three experiencing bruising and one each reporting temporary discolouration, pain and itching.
  
• A study on the long-term effects of repeated vacuum treatment showed no significant physical change after six months of therapy, but it did provide a degree of psychological satisfaction for some men. Two of the 37 men experienced side effects, with one haematoma (blood under the tissue) and one case of numbness recorded.

• One study showed that botox may have a temporary effect in decreasing penile retraction and improving flaccid length.
  
• Another suggested that penoscrotal rings could help augment penile size and maintain erections in men suffering from anxiety if combined with a PDE5 inhibitor (erectile dysfunction drug). However, the authors could only find two case reports that described the efficacy of these devices.
  
• There is no scientific evidence to show that penile lengthening exercises work. Despite this, it is very attractive to patients who like the idea of a non-invasive, low-cost method of penis enlargement and is widely discussed on the internet.
  
• Many men feel that their penis is too small when, in fact, very few seeking help have a micropenis. This suggests that therapy could play an important role in helping men to address their concerns.

"Based on current evidence, we suggest that penile extenders, not surgery, should be the first-line treatment for men seeking a penile lengthening procedure.

"Cognitive behavioural therapy can also be useful in building men's confidence if they have body image issues."