Structured Management and Counseling for Patients with a Complaint of a Small Penis

Techniques for Penile Augmentation Surgery: A Systematic Review of Surgical Outcomes, Complications, and Quality of Life

The increase in practices related to enhancing penile size can be attributed to the belief that an improved genital appearance contributes to a man's virility, coupled with an altered self-perception of his body. It is crucial to tailor interventions to meet the genuine needs of patients by thoroughly assessing their history, psychological state, and potential surgical benefits, all while considering the associated risks of complications. This systematic review aims to summarize the available evidence on outcomes, complications, and quality of life after penile augmentation surgery, examining both minimally invasive and more radical techniques. A search of the PubMed and Scopus databases, focusing on English-language papers published in the last 15 years, was performed in December 2023. Papers discussing surgery in animal models and case reports were excluded from the present study unless further evaluated in a follow-up case series. The primary outcomes were changes in penile dimensions, specifically in terms of length and girth, as well as the incidence of surgical complications and the impact on quality of life. A total of 1670 articles were retrieved from the search and 46 were included for analysis. Procedures for penile length perceived enhancements include lipoplasty, skin reconstruction plasty, V-Y and Z plasty, flap reconstruction, scrotoplasty, ventral phalloplasty, and suspensory ligament release; techniques for increasing corporal penile length include penile disassembly, total phalloplasty, and sliding elongation. Finally, penile girth enhancement may be performed using soft tissue fillers, grafting procedures, biodegradable scaffolds, and Penuma®. In conclusion, while penile augmentation surgeries offer potential solutions for individuals concerned about genital size, the risks and complexities need to be accounted for.

The Efficacy of Injection Penile Girth Enhancement as an Option for Small Penis Syndrome Management

BACKGROUND

In recent years aesthetic injection techniques with soft tissue fillers have become popular worldwide due to their effectiveness, safety, and low cost. There is no standard approach to the management and follow-up of patients seeking penile enlargement procedures described in the literature, and the surgical penile enlargement methods are controversial.

OBJECTIVES

The goals of this study were to assess the effect of injection penile girth enlargement on sexual relationship satisfaction, confidence, and self-esteem, and to evaluate the clinical efficacy and safety of this procedure for the management of men with small penis syndrome (SPS).

METHODS

This was a single-center, clinical case series study executed from January 2019 to February 2021, which involved 148 men who were unsatisfied with the shape of their normal-size penises and requested penis girth correction.

RESULTS

A total of 132 patients completed full treatment and follow-up. Mean girth enlargement was 1.7 ± 0.32 cm for the midshaft and 1.5 ± 0.32 cm for the glans of the penis. Satisfaction with sexual life improved. Mean scores increased by 17.9 ± 3.04 points for sexual relationship satisfaction and by 12.2 ± 3.17 points for confidence. The mean score for self-esteem increased by 8 ± 2.8 and by 4.3 ± 0.97 points for overall relationship satisfaction.

CONCLUSIONS

Penile enlargement with hyaluronic acid injection positively affects sexual relationship satisfaction, confidence, and self-esteem of men with SPS. The rate of psychosocial improvement does not correlate with penile size changes. It is a simple, safe, and effective technique that can be used in daily clinical practice.

LEVEL OF EVIDENCE: 4

Pornography, Sexual Insecurity, and Orgasm Difficulty

While recent meta-analyses have provided answers to a number of historically contentious debates about correlates of pornography use, several questions remain unanswered. Whether pornography is associated with sexual functioning is one such question. Informed by theorizing on sexual scripting, social comparisons, and sexual objectification, the present study examined the possibility that pornography is related to orgasm difficulty through sexual insecurity (i.e., insecurity about one's sexual performance and sexual attractiveness). Data were from the National Survey of Porn Use, Relationships, and Sexual Socialization (NSPRSS), a U.S. population-based probability study. There was an indirect effect of pornography consumption frequency on orgasm difficulty through sexual insecurity. Participants who used pornography more frequently reported higher levels of sexual insecurity, and higher levels of sexual insecurity predicted orgasm difficulty. There was also an indirect effect of partner pressure to view pornography on orgasm difficulty. Higher levels of partner pressure to view pornography were associated with higher levels of sexual insecurity, which in turn predicted orgasm difficulty. Results were indistinguishable by gender and maintained after controlling for a number of potential confounds. These findings suggest that some men and women's personal and (pressured) partnered pornography consumption have the potential to increase orgasm difficulty through bodily and performance insecurity.

Aesthetic Penile Augmentation Procedures: A Comprehensive and Current Perspective

PURPOSE OF REVIEW

Some men experience small penis syndrome (SPS), a body dysmorphic disorder in which a patient believes their penis to be small even when it is clinically average. As cosmetic surgery becomes more widely accepted, management of SPS may present a challenge for urologists. We aim to provide an updated review of aesthetic penile augmentation procedures.

RECENT FINDINGS

Augmentation procedures range from invasive to noninvasive. Surgical solutions include grafts and flaps, suspensory ligament release, and suprapubic lipectomy. Minimally invasive solutions include injections of fillers (hyaluronic acid, polylactic acid, and polymethyl methacrylate). Noninvasive solutions include external devices such as vacuum pumps and traction devices. In the current climate, aesthetic penile augmentation is becoming a desirable option for many patients but remains clinically controversial. Our review summarizes recent and relevant studies and demonstrates the need for further research and consensus on penile augmentation procedures.

Multidisciplinary approach and management of patients who seek medical advice for penile size concerns: a narrative review

We aimed to provide an overview of the strategies available to manage patients concerned about their penile size and to provide useful surgical hints regarding the most common penile enlargement approaches, based on our surgical expertise in this field. A comprehensive research was carried out on MEDLINE/PubMed database to identify pertinent studies concerning penile enlargement issues. The search strategy included a range of keywords; e.g. penis, penile, enlargement, augmentation, lengthening, girth. Management of penile size-related concerns represents a real challenge for the urologist, especially when dealing with patients suffering from penile dysmorphophobic disorder (PDD). A multidisciplinary preoperative assessment, including a psychiatric/psychological evaluation, may help in discerning those patients who would benefit the most from counselling/conservative management from those who would benefit from surgery instead. Conservative approaches include the use of vacuum-based and penile-stretching devices, which have shown encouraging levels of efficacy and safety. Over the last decades, different surgical strategies have been developed, aimed at either increasing flaccid penile length or improving penile girth. Penile lengthening procedures are more established, and satisfactory results can be achieved by experienced, large referrals' volume, surgeons. To date, there is lack of consensus regarding the penile girth enhancing techniques, and therefore these should be regarded as experimental. A multidisciplinary approach is necessary to identify patients with PDD, who should not be offered surgical intervention and should be referred for psychiatric/psychological counselling instead. The surgical approach should be tailored to the subject's unique anatomy and underlying conditions.

Male esthetic genital surgery: recommendations and gaps to be filled

The reason behind the spread of penis enlargement practices over time is rooted in the virility that the appearance of the genitals can give a man, as well as an altered perception of his own body. The approach should be to modulate the interventions on the real needs of patients, carefully evaluating the history, the psychological picture, and possible surgical advantages. The aim of this study was to shed light on cosmetic surgery of male genitalia through minimally invasive and more radical techniques, with the purpose of laying the foundation for possible indications and recommendations for the future. A non-systematic literature review using the PubMed and Scopus databases was conducted to retrieve papers written in English on cosmetic surgery of the penis published over the past 15 years. Papers discussing cosmetic surgery in patients with concomitant pathologies associated with sexual dysfunction were excluded. The main outcomes recorded were change in penile dimensions in term of length and girth and surgical complications.

Revelations on Men Who Seek Penile Augmentation Surgery: A Review

INTRODUCTION

Men with normal penis size sometimes mistakenly believe they have below average penile dimensions and often seek out treatment. Many men suffer from significant anxiety regarding this perceived defect. In this review, we evaluate the current literature of psychological, medical, and surgical treatment options for men with a complaint of a small penis.

OBJECTIVE

To review the current practice for treatment of men presenting for penile augmentation surgery.

METHODS

A literature review was conducted, using PubMed to identify current studies regarding penile enhancement. Search terms included "penile enhancement," "small penis anxiety," "small penis syndrome," "body dysmorphic disorder," and "penile augmentation."

RESULTS

The literature consistently reveals that men who seek out penile augmentation surgery usually have normal penile dimensions. There are limited published data on the practice of penile lengthening surgery or procedures to increase penile girth. New techniques have expanded on suspensory ligament release, such as tissue grafting and flaps. Structured psychological counseling continues to be the recommended initial standard of care for these men.

CONCLUSION

Many social forces have increased the perception among men that their penis size is inadequate. This increases anxiety and can lead to psychological disorders such as Penile Dysmorphic Disorder and Small Penis Syndrome. Men who undergo penile enhancement are often not satisfied with the results and may develop complications. Soubra A, Natale C, Brimley S, et al. Revelations on Men Who Seek Penile Augmentation Surgery: A Review. Sex Med Rev 2021;XX:XXX-XXX.

Penile length augmentation surgical and non-surgical approaches for aesthetical purposes

The aim of this review is to describe reported techniques and to provide available scientific data on the success of penis length procedures for cosmetic purposes. Penis lengthening methods remain a controversial issue. Penis size is a matter of great interest among men who are affected by 'small penis anxiety'' or just believe themselves to have a small penis, even though the dimensions of the organ fall within the normal range. We performed a narrative review of the literature based on a comprehensive search in the MEDLINE database for original articles published until March 2021, referring to lengthening approaches exclusively for aesthetical reasons. Abstracts, opinion papers and case series ≤10 patients were not considered. We included the results of 14 papers in the review that gathered the experience obtained in a total of 1661 patients. Four of the studies referred to non-surgical procedures for penile length augmentation (PLA) and the remaining 10 analyzed the results of invasive (surgical) procedures. Both invasive and non-invasive techniques achieve similar improvements in penis length. These procedures vary in complexity and require specialized training and experience. However, the low scientific quality of the analyzed papers makes it difficult to establish recommendations to choose one technique over any other. However, it seems reasonable that, if possible, non-invasive techniques should be proposed as a first-line treatment. Before deciding the procedure, we must carry out a correct psychological evaluation of our patients, discuss with them the technique of choice, and adjust their expectations.

Nonsurgical Methods for Penile Augmentation: A Systematic Review

BACKGROUND

There is no standardized approach for nonsurgical techniques for penile augmentation despite the increase of demand for this intervention.

OBJECTIVE

To compare the efficacy and safety between different injection techniques.

MATERIALS AND METHODS

On October 8, 2019, a literature search was performed on PubMed, Embase, Ovid, and Cochrane database. All articles describing penile augmentation were included.

RESULTS

Thirteen studies were included in this article with a total of 1,311 patients. Five studies were prospective cohort. The most commonly described technique was hyaluronic acid fillers with a total of 4 articles and 205 patients. The mean injected volume ranged from 20 to 40 mL. In all included studies, a minority of patients had side effects, but some had disabling complications.

CONCLUSION

There are no defined clinical guidelines for penile augmentation techniques implemented yet. Hyaluronic acid seems to be safe, efficient, and with a high satisfaction score. Further randomized control trials are warranted.

EBM LEVEL OF EVIDENCEBASED MEDICINE

2a.

Comparison of Clinical Outcomes between Hyaluronic and Polylactic Acid Filler Injections for Penile Augmentation in Men Reporting a Small Penis: A Multicenter, Patient-Blinded/Evaluator-Blinded, Non-Inferiority, Randomized Comparative Trial with 18 Months of Follow-up

Although several types of penile augmentation (PA) fillers have been recently introduced, no long-term follow-up studies have compared them. This study aimed to compare the long-term clinical outcomes of hyaluronic acid (HA) and polylactic acid (PLA) filler injections for PA. Our multicenter, patient-blinded/evaluator-blinded, randomized comparative trial was performed for 18 months after the single injection of fillers. Sixty-seven healthy men reporting a small penis were administered an injection between November 2016 and May 2017. Subjects were divided into the HA group (n = 33) and PLA group (n = 34). At 18 months, the mean penile girths had significantly increased in both groups (each p < 0.001). Changes in the mean penile girth of both groups were not significantly different during the study period. Satisfaction levels at 18 months were significantly higher than those at baseline in both groups (each p < 0.01). Changes in satisfaction levels did not differ significantly during the study period. Injection-associated adverse events (AEs) occurred in three (9.1%) patients in the HA group and in two (5.9%) patients in the PLA group; no serious AEs occurred. In conclusion, HA and PLA filler injections for PA led to significant augmentation and increased satisfaction. Clinical efficacy and safety were comparable between groups.

Systematic Review of Surgical and Nonsurgical Interventions in Normal Men Complaining of Small Penis Size

INTRODUCTION

Evidence on penile enhancement interventions is lacking. Nonetheless, many non-evidence-based solutions are readily available.

AIM

To investigate enhancement and nonenhancement interventions in men without penile abnormalities seeking to increase penis size.

METHODS

We performed a systematic review with no time restrictions adhering to the PRISMA guidelines. Studies with fewer than 10 cases or including men with organic penile pathologies or previous penile surgeries were excluded.

MAIN OUTCOME MEASURES

When available, treatment efficacy was evaluated based on patient satisfaction, penile size increase, and complications.

RESULTS

We included 17 studies, assessing a total of 21 interventions in 1,192 men screened, with 773 followed up after nonsurgical (n = 248) or surgical (n = 525) treatment. The quality of the studies was poor in terms of methodology for patient selection and outcomes assessment. The vast majority of series reported normal penile size. Among nonsurgical treatments, extenders increased flaccid length (but by <2 cm), injectables increased girth but were associated with a high complication rate, and vacuum devices did not increase size. Surgical interventions included suspensory ligament incision (the most used method; n = 12), tissue grafting (autologous, n = 2; dermal fat, n = 3, ex vivo, n = 2), flaps (n = 2), and penile disassembly (n = 1). Some men reported a significant size increase; however, complications were not infrequent, and none of the techniques was externally validated. When provided, counseling was effective, with the majority of men coming to understand that their penis was normal and unwilling to undergo any further treatment.

CONCLUSION

Treatment of small penis in normal men is supported by scant, low-quality evidence. Structured counseling should be always performed, with extenders eventually used by those still seeking enhancement. Injectables and surgery should remain a last option, considered unethical outside of clinical trials. Marra G, Drury A, Tran L, et al. Systematic Review of Surgical and Nonsurgical Interventions in Normal Men Complaining of Small Penis Size. Sex Med Rev 2020;8:158-180.

Infrapubic Liposuction for Penile Length Augmentation in Patients with Infrapubic Adiposities

INTRODUCTION

Hidden penis, inconspicuous and concealed penis are synonyms for the same entity "buried penis" where the penile shaft is hidden below the surface of the prepubic fat to an extent that gives an impression of a short penis, despite corporeal length being normal.

AIM

The aim of our work is the reduction in the amount of the suprapubic fat by liposuction to reveal the buried penis and assess the results, patient satisfaction and possible complications.

METHODS

The procedure of suprapubic liposuction was carried out on ten men who were attending the outpatient clinic of Andrology complaining of small-sized penis.

MAIN OUTCOME MEASURES

Pre-, immediate (on table) postoperative and 3 months postoperative skin to tip flaccid and stretched penile lengths were measured. Patient satisfaction was assessed using the five-point Likert scale.

RESULTS

There was a statistically significant increase between the pre- and postoperative flaccid and stretched penile lengths in our patients with a p value <0.001 in both.

CONCLUSION

An acquired adult buried penis is a correctable problem. Simple buried penis due to excess fat at the mons pubis should be differentiated from other complex cases that may require combined techniques to achieve good results with minor complications. Suprapubic liposuction is a very safe and successful procedure with minor or no complications if performed meticulously. It could improve self-esteem along with the associated physical and esthetic concerns.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Relationship between self-discrepancy and worries about penis size in men with body dysmorphic disorder

We explored self-discrepancy in men with body dysmorphic disorder (BDD) concerned about penis size, men without BDD but anxious about penis size, and controls. Men with BDD (n=26) were compared to those with small penis anxiety (SPA; n=31) and controls (n=33), objectively (by measuring) and investigating self-discrepancy: actual size, ideal size, and size they felt they should be according to self and other. Most men under-estimated their penis size, with the BDD group showing the greatest discrepancy between perceived and ideal size. The SPA group showed a larger discrepancy than controls. This was replicated for the perceptions of others, suggesting the BDD group internalised the belief that they should have a larger penis size. There was a significant correlation between symptoms of BDD and this discrepancy. This self-actual and self-ideal/self-should discrepancy and the role of comparing could be targeted in therapy.

Penile Dysmorphic Disorder: Development of a Screening Scale

Penile dysmorphic disorder (PDD) is shorthand for men diagnosed with body dysmorphic disorder, in whom the size or shape of the penis is their main, if not their exclusive, preoccupation causing significant shame or handicap. There are no specific measures for identifying men with PDD compared to men who are anxious about the size of their penis but do not have PDD. Such a measure might be helpful for treatment planning, reducing unrealistic expectations, and measuring outcome after any psychological or physical intervention. Our aim was, therefore, to validate a specific measure, termed the Cosmetic Procedure Screening Scale for PDD (COPS-P). Eighty-one male participants were divided into three groups: a PDD group (n = 21), a small penis anxiety group (n = 37), and a control group (n = 23). All participants completed the COPS-P as well as standardized measures of depression, anxiety, social phobia, body image, quality of life, and erectile function. Penis size was also measured. The final COPS-P was based on nine items. The scale had good internal reliability and significant convergent validity with measures of related constructs. It discriminated between the PDD group, the small penis anxiety group, and the control group. This is the first study to develop a scale able to discriminate between those with PDD and men anxious about their size who did not have PDD. Clinicians and researchers may use the scale as part of an assessment for men presenting with anxiety about penis size and as an audit or outcome measure after any intervention for this population.

Applying extender devices in patients with penile dysmorphophobia: assessment of tolerability, efficacy, and impact on erectile function

INTRODUCTION

Most men seeking penile enhancement techniques have a normal penile size. They are either misinformed or suffer from penile dysmorphophobia and should be discouraged from undergoing invasive procedures. Less invasive techniques including penile extenders are not associated with major complications and may be beneficial from a psychological perspective.

AIM

We conducted this study to assess the efficacy and safety of AndroPenis (Andromedical, Madrid, Spain) penile extender.

METHODS

Between December 2010 and December 2013, 163 men presented to our institution complaining of small penile length and/or girth. All patients received structured psychosexual counseling. Fifty-four patients were willing to use the AndroPenis penile extender after counseling. Patients with major psychiatric disorders were excluded from enrollment. The patients were instructed to wear the device between 4 and 6 hours per day for 6 months. Penile dimensions including flaccid stretched and erected lengths were measured at baseline and after 1, 3, 6, and 9 months. Erectile function was assessed at baseline and 9 months after treatment using the simplified International Index of Erectile Function (IIEF-5). An institutional nonstandardized questionnaire was used to evaluate patient satisfaction at the end of study.

MAIN OUTCOME MEASURES

Penile length and girth enhancement as well as satisfaction rate and improvement in erectile function were assessed during follow-up.

RESULTS

At 6-month follow-up, a mean gain of 1.7 ± 0.8, 1.3 ± 0.4, and 1.2 ± 0.4 cm was noted for the flaccid, stretched, and erected penile lengths, respectively (all P values < 0.001). During the off treatment period, there were no significant changes in penile lengths. No effect on penile girth was observed. Patient satisfaction survey revealed modest satisfaction. From 13 patients with mild baseline erectile dysfunction, nine patients reported normal erectile function after 9 months.

CONCLUSION

Penile extender as a minimally invasive technique is safe and provides modest benefits and patient satisfaction.

Am I normal? A systematic review and construction of nomograms for flaccid and erect penis length and circumference in up to 15,521 men

OBJECTIVE

To systematically review and create nomograms of flaccid and erect penile size measurements.

METHODS

Study key eligibility criteria: measurement of penis size by a health professional using a standard procedure; a minimum of 50 participants per sample.

EXCLUSION CRITERIA

samples with a congenital or acquired penile abnormality, previous surgery, complaint of small penis size or erectile dysfunction. Synthesis methods: calculation of a weighted mean and pooled standard deviation (SD) and simulation of 20,000 observations from the normal distribution to generate nomograms of penis size.

RESULTS

Nomograms for flaccid pendulous [n = 10,704, mean (SD) 9.16 (1.57) cm] and stretched length [n = 14,160, mean (SD) 13.24 (1.89) cm], erect length [n = 692, mean (SD) 13.12 (1.66) cm], flaccid circumference [n = 9407, mean (SD) 9.31 (0.90) cm], and erect circumference [n = 381, mean (SD) 11.66 (1.10) cm] were constructed. Consistent and strongest significant correlation was between flaccid stretched or erect length and height, which ranged from r = 0.2 to 0.6.

LIMITATIONS

relatively few erect measurements were conducted in a clinical setting and the greatest variability between studies was seen with flaccid stretched length.

CONCLUSIONS

Penis size nomograms may be useful in clinical and therapeutic settings to counsel men and for academic research.

Phenomenology of men with body dysmorphic disorder concerning penis size compared to men anxious about their penis size and to men without concerns: a cohort study

Men with body dysmorphic disorder (BDD) may be preoccupied with the size or shape of the penis, which may be causing significant shame or impairment. Little is known about the characteristics and phenomenology of such men and whether they can be differentiated from men with small penis anxiety (SPA) (who do not have BDD), and men with no penile concerns. Twenty-six men with BDD, 31 men with SPA, and 33 men without penile concerns were compared on psychopathology, experiences of recurrent imagery, avoidance and safety-seeking behaviours. Men with BDD had significantly higher scores than both the SPA group and no penile concern group for measures of imagery, avoidance, safety seeking and general psychopathology. The groups differed on the phenomenology of BDD specific to penile size preoccupation clearly from the worries of SPA, which in turn were different to those of the men without concerns. The common avoidance and safety seeking behaviours were identified in such men that may be used clinically.

Internet Pornography Use and Sexual Body Image in a Dutch Sample

OBJECTIVES

A commonly attributed cause of sexual body image dissatisfaction is pornography use. This relationship has received little verification.

METHODS

The relationship between sexual body image dissatisfaction and Internet pornography use was tested using a large-N sample of Dutch respondents.

RESULTS/CONCLUSION

Penis size dissatisfaction is associated with pornography use. The relationship between pornography use and breast size dissatisfaction is null. These results support prior speculation and self-reports about the relationship between pornography use and sexual body image among men. These results also support a prior null finding of the relationship between breast size satisfaction for women and pornography use.

Evaluation of surgical outcome of penile augmentation and lengthening procedures

Our study included 280 patients complaining of small-sized penis. They were seen in the outpatient clinic of the Andrology Department, Kasr El Aini, Cairo University. Patients were collected from 2002 till 2008 and classified into 4 categories from an etiological point of view. Eleven patients (3.9%) were operated upon according to fine selection criteria; six patients were selected for lengthening procedures, while two patients were selected for increasing girth procedures and three patients for combined operation of lengthening and increasing girth techniques. Seven patients showed subjective satisfaction after lengthening procedures and four patients showed subjective satisfaction after increasing girth techniques. In conclusion, detailed analysis of short penis complaint with a proper diagnosis and patient education are required for accurate management of patients complaining of a short penis.

Penile reconstruction

A variety of surgical options exists for penile reconstruction. The key to success of therapy is holistic management of the patient, with attention to the psychological aspects of treatment. In this article, we review reconstructive modalities for various types of penile defects inclusive of partial and total defects as well as the buried penis, and also describe recent basic science advances, which may promise new options for penile reconstruction.

Relationship between penile size and somatometric parameters in 2276 healthy young men

The aim of this study was to determine the average penile length of a group of healthy, young Turkish men, and to investigate the relationship between penile length and somatometric parameters in the same group. The flaccid and stretched length and circumference of the penis was measured in a group of 2276 physically normal, young men. The correlation between penile length and weight, height and body mass index (BMI) of the participants was determined by Pearson's analysis. The mean age of the participants was 21.1 ± 3.1 (18-39) years. The mean flaccid, fully stretched and circumferential length of the participants' penises were 8.95 ± 1.04, 13.98 ± 1.58 and 8.89 ± 0.86 cm, respectively. There was a significant relationship between all of these variables (P<0.01). Although weak positive correlations were found between the mean circumference length and BMI, there were no correlations between both the flaccid and stretched lengths and BMI. The penile length must be known to be able to determine the abnormal penile sizes and to make convenient decisions in the counseling and/or treatment of people with short penis concerns. Our study provides mean penile lengths in a large sample of healthy, young Turkish men, and the penile dimensions were found to be weakly correlated with somatometric parameters.

The Global Online Sexuality Survey (GOSS): ejaculatory function, penile anatomy, and contraceptive usage among Arabic-speaking Internet users in the Middle East

INTRODUCTION

Sexuality is a sensitive issue that may be difficult to explore through surveys involving direct contact. Epidemiological studies in this domain are scarce. Online surveys may provide more anonymity and less direct contact encouraging participation. The Global Online Sexuality Survey (GOSS) reports on different aspects of male and female sexuality. The Global Online Sexuality Survey-Arabic-Males (GOSS-AR-M) is the Arabic version reporting on male sexuality.

AIM

To evaluate male ejaculatory function, penile size and contraceptive trends among Arabic speakers in the Middle East.

METHODS

The survey was randomly offered online to web surfers in the Middle East.

MAIN OUTCOME MEASURES

Prevalence of premature ejaculation, ejaculatory latency, penile size and their correlation with erectile function.

RESULTS

A total of 82.6% reported various degrees of premature ejaculation, associated with a statically significant decline in erectile function, despite a median intravaginal ejaculatory latency time (IELT) of 5 minutes, 95% confidence interval (CI) of 8.4-9.8. Adjusted to the World Standard Population by the World Health Organization, the collective prevalence was 83.7%. Local anesthetics gave better results and tolerance in delaying ejaculation. Self-measured erect penile length from symphysis pubis to glans was 15.6 cm ± 4.1, 95% CI = 15.4-15.9, yet, 30% were dissatisfied with size, mainly in the flaccid state, with dissatisfaction being inversely proportional with erectile function. Intrauterine device was the method mostly used by couples, and condoms had a high dissatisfaction rate.

CONCLUSION

The prevalence of premature ejaculation appears to surpass that of erectile dysfunction, despite the possibility that it may be overreported considering the acceptable IELT of the population surveyed. Premature ejaculation and concerns over genital size may be considered as risk factors for ED. More male contraceptive measures should be introduced and popularized. Alleviating dissatisfaction with condom utility via health education should be a priority.

Male homosexuality: nature or culture?

INTRODUCTION

Debate continues on whether or not male homosexuality (MH) is a result of biological or cultural factors. The debate persists despite the fact that these two sides have different abilities to create a scientific environment to support their cause. Biological theorists produced evidence, however, that these are not always robust. On the other hand, social theorists, without direct evidence confirming their positions, criticize, with good argument, methods and results of the other side. The aim of this Controversy is to understand the reasons of both perspectives.

METHODS

Two scientists (R.B. and A.C.C.) with expertise in the area of biology of MH were asked to contribute their opinions. The nurture position is discussed by a third expert in sexology (J.B.).

MAIN OUTCOME MEASURE

Expert opinion supported by the critical review of the currently available literature.

RESULT

The role of the Controversy's editor (E.A.J.) is to highlight the strengths and weaknesses of both sides. The two experts of the biological issue answer with their data to the questions: “Is male homosexuality partly explainable by immunology?” and “How is male homosexuality a Darwinian paradox?”, respectively. Genetic and immunological factors, birth order, and fertility of relatives are largely discussed. Finally, the expert sustaining the idea that culture and experiences are important determining factors in sexual orientation used a psychosocial and holistic perspective to explain his position.

CONCLUSIONS

The JSM's readers should recognize that there are several biological factors in MH. However, these findings do not seem to be able to explain all cases of homosexuality. Some others may be due to particular environmental factors. The issue is complicated and multifactorial, suggesting that further research should be undertaken to produce the final answer to the question raised in this Controversy section.

Treatment of clitoromegaly of culturally diverse patients

OBJECTIVE

Clitoroplasty is a procedure usually performed in young children, but its long-term psychosexual importance is controversial. We present two adult women from different cultural backgrounds who desired surgery for clitoromegaly.

METHODS

A similar clitoroplasty procedure with preservation of the neurovascular bundle was performed on both patients. Preoperative and postoperative interviews were conducted by an independent observer to learn about the effects of the condition and the surgery.

RESULTS

The Icelandic patient had bilateral ovarian dysgerminomas and a gonadoblastoma. The Bolivian patient had a 17beta-hydroxysteroid oxidoreductase deficiency. Both patients reported normal libido but sexual inactivity because they felt 'embarrassed'. Postoperatively, our patients reported normal clitoral sensation and that they were sexually active. They differed in their opinion regarding the optimal timing of clitoroplasty - one suggesting surgery soon after birth and the other recommending deferral until informed consent by the patient is possible.

CONCLUSIONS

Regardless of cultural background patients are affected by clitoromegaly. This is demonstrated in these cases by the reported feelings of discomfort, distress, and sexual inactivity due to embarrassment. The long-term significance of clitoromegaly and the value of clitoroplasty for young patients with disorders of sexual differentiation remain controversial.