Penile Girth Enlargement Strategies: What’s the Evidence?
Marah C. Hehemann MD; Maxwell Towe BS; Linda My Huynh MSc; Farouk M. El-Khatib MD; Faysal A. Yafi MD, FRCSC
FIRST PUBLISHED: January 4, 2019 – Sexual Medicine Reviews
Many men feel anxious and distressed about their penis size and seek medical procedures to increase it. Most men in this situation already have a normal-sized penis (The average length of an erect penis is 13.1 centimeters; the average girth is 11.65 centimeters.)
Motivations and strategies for penile lengthening have been researched, but less is known about penile girth enhancement. This study reviewed the reasons men seek girth enlargement and the medical, traction, injection, prosthetic, and reconstructive approaches used to achieve it.
Penile dysmorphophobic disorder (PDD) is a subtype of body dysmorphic disorder (BDD), characterized by “a preoccupation with a minor or non-existent flaw in body image that causes marked impairment in various areas of functioning.” For men with PDD, the flaw is the appearance of their penis. They may feel ashamed, embarrassed, depressed, or anxious. Some avoid sexual situations and develop sexual problems like erectile dysfunction (ED). For this diagnosis, however, true micropenis (flaccid length <4 centimeters and erect length <7.5 centimeters) must be excluded.
Goals of Girth Enhancement
Girth enhancement procedures aim to increase both flaccid and erect penile circumference while maintaining a natural-looking shaft and normal sensory and erectogenic function. However, since PDD is a psychological problem, appropriate evaluations should be conducted before any procedure begins.
Oral therapies are intended to increase penile girth and treat PDD-related psychological distress.
- Penile enhancement products. Sold over the counter, these “natural male enhancement” products are generally not regulated and not approved by the U.S. Food and Drug Administration (FDA). There is no scientific evidence to support their efficacy, and some products contain potentially dangerous undeclared ingredients. Physicians should warn patients about their use.
- Phosphodiesterase type 5 (PDE5) inhibitors. These drugs are used to treat erectile dysfunction and “have also been found to have significant implications in regeneration of penile smooth muscle and in tissue remodeling.” However, little is known about their use in penile enlargement, and more study is needed.
- PDE5 inhibitors combined with psychotherapy. More research is encouraged based on results in men with psychogenic ED.
- Fluoxetine. This selective serotonin reuptake inhibitor (SSRI) has been useful in treating body dysmorphic disorder and may be helpful for PDD. More research is warranted.
Vacuum and Traction Therapy
- Vacuum erectile devices (VEDs). Studies of VEDs for penile lengthening have had poor results. It is surmised that girth would not be significantly affected by VED use, and the approach was called “untenable.”
- Penile traction devices. These devices might increase length, but they do not enhance girth and “should not be recommended in the man exclusively concerned with increasing penile girth.”
Some of the more common substances used in penile subcutaneous injection therapy include the following:
- Fat. Autologous fat injections into the penis might increase girth, but complications (e.g., irregular fat nodules, skin deformity, and scarring) might require corrective surgery. One death from fat embolism has been reported. Such procedures are considered “experimental.”
- Silicone. Injections of liquid injectable silicone into the penis have led to severe edema, penile distortion, and sexual dysfunction. Some problems have occurred 30 years after injection. Silicone embolism, silicone pneumonitis, and multi-organ failure have been reported as well. A suggested microdroplet approach needs more study.
Soft Tissue Fillers
- Hyaluronic acid. Injections of hyaluronic acid may increase girth, but problems with erections and penile sensation have occurred. One study showed that satisfaction rates declined over an 18-month follow-up period. Other studies have shown major complications, including vascular occlusion and severe hypersensitivity after injection.
- Polymethyl-methacrylate microspheres (PMMA). This non-absorbable soft tissue filler was tested in a study of over 700 men who had a mean increase in penile girth of 2.4 cm. This increase was maintained in flaccid, stretched, and erect states. Just over half the patients reported “nodularity, ridges, irregularity, indentations, or voids in tissue filler.”
Few studies on dermal fillers for girth enhancement have long-term follow-up data, and results have not been reproduced. As a result, there is a lack of evidence-based clinical guidelines, and dermal filler use should be considered experimental.
Graft and Flap Procedures
- Dermal fat grafts. These grafts are described as “free onlay grafts consisting of de-epithelialized dermis and subcutaneous fat, the former of which is important in increasing bulk and blood vessels to aid in graft vascularization.” Complications such as preputial edema and painful erection were reported.
- Fasciocutaneous arterial island flap. There has been only one case report on this technique, but its complexity, among other issues, makes it “unjustifiable to offer to young men with physiologically normal penises.”
- Porcine dermal acellular matrix graft. This approach showed high rates of sexual self-esteem and satisfaction. While girth increased, about 13% of men had penile shortening due to graft fibrosis. A pilot study of a related acellular collagen matrix graft had a lower satisfaction rate, and 22% of the patients required graft removal.
Subcutaneous Penile Implants
A subcutaneous silicone implant is inserted subdermally and wrapped around the dorsal three-quarters of the penile shaft. No complications were reported by the device inventor, who did not evaluate sexual function, penile sensation, and partner satisfaction. A subsequent retrospective review did not discuss long term adverse events and implant removal.
A later study of silicone implant complications described patients presenting with “severe edema, subcutaneous masses, penile curvature or other sexually disabling deformity, infection, non-healing wounds, and scarring.”
Corporoplastic phalloplasty “uses bilateral corporal venous grafts to expand corporal girth.” Research has shown that this “radical and invasive” technique may increase penile girth in the erect state, but not when flaccid. It should be considered experimental. Patient selection and realistic expectations are critical as this procedure can impact erectile function.
Most patients (96%) who undergo cosmetic procedures for BDD report worsening or no change in symptoms, the authors said. Therefore, it is important to include psychological distress, sexual function, and quality of life concerns in any treatment approach. If appropriate, patients should try oral medications before any invasive procedure. They should also have counseling beforehand and understand that there are no clinical guidelines for girth enhancement, that complications may be underreported, and that procedures are considered experimental.
Future research of penile girth enlargement should consider both physiological and psychological outcomes measured with validated instruments.