RECENT UPDATES IN THE RIGHT DECISION AND MANAGEMENT OF “SMALL PENIS SYNDROME”

Background and objective

Many men tend to desire a larger penis than women want because it symbolizes masculinity and sexual prowess. Micropenis is a normally developed penis with at least 2.5 standard deviations below the mean size in stretched length for age. Unlike micropenis, small penis syndrome (SPS) refers to uncomfortable feelings about one’s penis size, even though penis size does not fall within the micropenis category. Some men seriously worry or feel ashamed of their penis size, and they may meet the diagnosis criteria of body dysmorphic disorder (BDD). Unlike micropenis, the differential diagnosis of BDD is very important, because it is associated with high rates of committing suicide. In particular, when combined with BDD, it is known that poor outcomes after cosmetic interventions are expected. Several validated assessment tools are available to differentiate SPS and the degree of BDD, but they are still controversial. Furthermore, many physicians are performing cosmetic interventions on patients who have not been fully assessed and counseled by a psychologist, thereby leading to unsatisfactory results. Therefore, we aimed to clarify the definition of disease for penis size and review its diagnosis and treatment. This will be helpful both for physicians to enable them to provide adequate counseling and treatment and for patients to help them avoid unsatisfactory treatment.

body dysmorphic disorder; penile augmentation; psychotherapy; small penis syndrome

1. Francken AB, van de Wiel HB, van Driel MF, et al. What importance do women attribute to the size of the penis? Eur Urol. 2002;42:426–31. https://doi. org/10.1016/S0302-2838(02)00396-2

2. Lever J, Frederick D, Peplau L. Does size matter?Men’s and women’s views on penis size across the lifespan. Psychol Men Masculin. 2006;7:129–43. https://doi.org/10.1037/1524-9220.7.3.129

3. Tran H, Goldfarb R, Ackerman A, et al. Penile lengthening, girth, and size preservation at the time of penile prosthesis insertion. Sex Med Rev. 2017;5:403–12. https://doi.org/10.1016/j.sxmr.2016. 11.005

4. Davoudzadeh EP, Davoudzadeh NP, Margolin E, et al. Penile length: Measurement technique and applications. Sex Med Rev. 2018;6:261–71. https://doi.org/10.1016/j.sxmr.2017.10.002

5. Phillips KA, Coles ME, Menard W, et al. Suicidal ideation and suicide attempts in body dysmorphic disorder. J Clin Psychiatry. 2005;66:717–25. https://doi.org/10.4088/JCP.v66n0607

6. Veale D, Miles S, Read J, et al. Sexual functioning and behavior of men with body dysmorphic disorder con-cerning penis size compared with men anxious about penis size and with controls: A cohort study. Sex Med. 2015;3:147–55. https://doi.org/10.1002/sm2.63

7. Aaronson IA. Micropenis: Medical and surgical implications. J Urol. 1994;152:4–14. https://doi. org/10.1016/S0022-5347(17)32804-5

8. Wessells H, Lue TF, McAninch JW. Penile length in the flaccid and erect states: Guidelines for penile augmentation. J Urol. 1996;156:995–7. https://doi. org/10.1097/00005392-199609000-00041

9. Association AP. Diagnostic and statistical manual of mental disorders (DSM-5®). Washington DC; American Psychiatric Pub, 2013.

10. Veale D, Boocock A, Gournay K, et al. Body dysmorphic disorder. A survey of fifty cases. Br J Psychiatry. 1996;169:196–201. https://doi. org/10.1192/bjp.169.2.196

11. Phillips KA, Menard W, Fay C, et al. Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dys-morphic disorder. Psychosomatics. 2005;46:317–25. https://doi.org/10.1176/appi.psy.46.4.317

12. Habous M, Tealab A, Williamson B, et al. Erect penile dimensions in a cohort of 778 Middle Eastern men: Establishment of a nomogram. J Sex Med. 2015;12:1402–6. https://doi.org/10.1111/jsm.12894

13. Veale D, Miles S, Bramley S, et al. Am I normal? A systematic review and construction of nomograms for flaccid and erect penis length and circumference in up to 15,521 men. BJU Int. 2015;115:978–86. https://doi.org/10.1111/bju.13010

14. Phillips KA, Grant J, Siniscalchi J, et al. Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder. Psychosomatics. 2001;42:504–10. https://doi.org/10.1176/appi.psy.42. 6.504

15. Tignol J, Biraben-Gotzamanis L, Martin-Guehl C, et al. Body dysmorphic disorder and cosmetic surgery: Evolution of 24 subjects with a minimal defect in appearance 5 years after their request for cosmetic surgery. Eur Psychiatry. 2007;22:520–4. https://doi.org/10.1016/j.eurpsy.2007.05.003

16. Crerand CE, Menard W, Phillips KA. Surgical and minimally invasive cosmetic procedures among persons with body dysmorphic disorder. Ann Plast Surg. 2010;65:11–16. https://doi.org/10.1097/SAP.0b013e3181bba08f

17. Veale D, Naismith I, Eshkevari E, et al. Psychosexual outcome after labiaplasty: A prospective case-comparison study. Int Urogynecol J. 2014;25:831–9. https://doi.org/10.1007/s00192-013-2297-2

18. Wylie KR, Eardley I. Penile size and the ‘small penis syndrome’. BJU Int. 2007;99:1449–55. https://doi.org/10.1111/j.1464-410X.2007.06806.x

19. Schonfeld WA, Beebe GW. Normal growth and variation in the male genitalia from birth to matu-rity. J Urol. 1942;48:759–77. https://doi.org/10.1016/S0022-5347(17)70767-7

20. Tuladhar R, Davis PG, Batch J, et al. Establishment of a normal range of penile length in preterm infants. J Paediatr Child Health. 1998;34:471–3. https://doi. org/10.1046/j.1440-1754.1998.00278.x

21. Wein AJ, In Kavoussi LR, Campbell MF, Walsh PC. Campbell-Walsh urology. 11th edn. 2016.

22. Fang A, Matheny NL, Wilhelm S. Body dysmor-phic disorder. Psychiatr Clin North Am. 2014;37: 287–300. https://doi.org/10.1016/j.psc.2014.05.003

23. Phillips KA. The broken mirror: Understanding and treating body dysmorphic disorder. Oxford: Oxford University Press; 2005.

24. Wilhelm S. Feeling good about the way you look: A program for overcoming body image problems. New York: Guilford Press; 2006.

25. Veale D, Miles S, Read J, et al. Penile dysmorphic disorder: Development of a screening scale. Arch Sex Behav. 2015;44:2311–21. https://doi.org/10.1007/s10508-015-0484-6

26. Koran LM, Abujaoude E, Large MD, et al. The p revalence of body dysmorphic disor-der in the United States adult population. CNS Spectr. 2008;13:316–22. https://doi.org/10.1017/S1092852900016436

27. Buhlmann U, Glaesmer H, Mewes R, et al. Updates on the prevalence of body dysmorphic disor-der: A population-based survey. Psychiatry Res. 2010;178:171–5. https://doi.org/10.1016/j.psychres. 2009.05.002

28. Veale D, Gledhill LJ, Christodoulou P, et al. Body dysmorphic disorder in different settings: A sys-tematic review and estimated weighted preva-lence. Body Image. 2016;18:168–86. https://doi. org/10.1016/j.bodyim.2016.07.003

29. van der Meer J, van Rood YR, van der Wee NJ, et al. Prevalence, demographic and clinical characteris-tics of body dysmorphic disorder among psychiat-ric outpatients with mood, anxiety or somatoform disorders. Nord J Psychiatry. 2012;66:232–8. https://doi.org/10.3109/08039488.2011.623315

30. Grant JE, Kim SW, Crow SJ. Prevalence and clin-ical features of body dysmorphic disorder in ado-lescent and adult psychiatric inpatients. J Clin Psychiatry. 2001;62:517–22. https://doi.org/10.4088/JCP.v62n07a03

31. Conroy M, Menard W, Fleming-Ives K, et al. Prevalence and clinical characteristics of body dysmorphic disorder in an adult inpatient setting. Gen Hosp Psychiatry. 2008;30:67–72. https://doi. org/10.1016/j.genhosppsych.2007.09.004

32. Buhlmann U, Glaesmer H, Mewes R, et al. Updates on the prevalence of body dysmorphic disorder: A popu-lation-based survey. Psychiatry Res. 2010;178:171–5. https://doi.org/10.1016/j.psychres.2009.05.002

33. Monzani B, Rijsdijk F, Anson M, et al. A twin study of body dysmorphic concerns. Psychol Med. 2012;42:1949–55. https://doi.org/10.1017/S0033291711002741

34. Lopez-Sola C, Fontenelle LF, Alonso P, et al. Prevalence and heritability of obsessive-compulsive spectrum and anxiety disorder symptoms: A survey of the Australian Twin Registry. Am J Med Genet B Neuropsychiatr Genet. 2014;165b:314–25. https://doi.org/10.1002/ajmg.b.32233

35. Didie ER, Tortolani CC, Pope CG, et al. Childhood abuse and neglect in body dysmorphic disorder. Child Abuse Neglect. 2006;30:1105–15. https://doi. org/10.1016/j.chiabu.2006.03.007

36. Buhlmann U, Marques LM, Wilhelm S. Traumatic experiences in individuals with body dysmorphic disorder. J Nerv Ment Dis. 2012;200:95–8. https://doi.org/10.1097/NMD.0b013e31823f6775

37. Neziroglu F, Khemlani-Patel S, Yaryura-Tobias JA. Rates of abuse in body dysmorphic disorder and obsessive-compulsive disorder. Body Image. 2006;3:189–93. https://doi.org/10.1016/j.bodyim. 2006.03.001

38. Weingarden H, Curley EE, Renshaw KD, et al. Patient-identified events implicated in the devel-opment of body dysmorphic disorder. Body Image. 2017;21:19–25. https://doi.org/10.1016/j. bodyim.2017.02.003

39. Spyropoulos E, Christoforidis C, Borousas D, et al. Augmentation phalloplasty surgery for penile dys-morphophobia in young adults: Considerations regarding patient selection, outcome evaluation and techniques applied. Eur Urol. 2005;48:121–8. https://doi.org/10.1016/j.eururo.2005.02.021

40. Shamloul R. Treatment of men complaining of short penis. Urology. 2005;65:1183–5. https://doi. org/10.1016/j.urology.2004.12.066

41. Mondaini N, Ponchietti R, Gontero P, et al. Penile length is normal in most men seeking penile length-ening procedures. Int J Impot Res. 2002;14:283–6. https://doi.org/10.1038/sj.ijir.3900887

42. Veale D, Eshkevari E, Read J, et al. Beliefs about penis size: Validation of a scale for men ashamed about their penis size. J Sex Med. 2014;11:84–92. https://doi.org/10.1111/jsm.12294

43. Veale D, Eshkevari E, Ellison N, et al. Validation of genital appearance satisfaction scale and the Cosmetic Procedure Screening Scale for women seeking labiaplasty. J Psychosom Obstet Gynaecol. 2013;34:46–52. https://doi.org/10.3109/0 167482X.2012.756865

44. Wilhelm S, Phillips KA, Steketee G. Cognitive-behavioral therapy for body dysmorphic disorder: A treatment manual. New York: Guilford Press; 2012.

45. Wilhelm S, Phillips KA, Fama JM, et al. Modular cognitive-behavioral therapy for body dysmorphic disorder. Behav Ther. 2011;42:624–33. https://doi. org/10.1016/j.beth.2011.02.002

46. Ghanem H, Shamloul R, Khodeir F, et al. Structured management and counseling for patients with a com-plaint of a small penis. J Sex Med. 2007;4:1322–7. https://doi.org/10.1111/j.1743-6109.2007.00463.x

47. Nikoobakht M, Shahnazari A, Rezaeidanesh M, et al. Effect of penil-extender device in increas-ing penile size in men with shortened penis: Preliminary results. J Sex Med. 2011;8:3188–92. https://doi.org/10.1111/j.1743-6109.2009.01662.x

48. Nowroozi MR, Amini E, Ayati M, et al. Applying extender devices in patients with penile dys-morphophobia: Assessment of tolerability, effi-cacy, and impact on erectile function. J Sex Med. 2015;12:1242–47. https://doi.org/10.1111/jsm.12870

49. Lee WK, Yang DY. Penile augmentation. Springer; 2016. Classification of soft tissue filler; 71–82. https://doi.org/10.1007/978-3-662-46753-4_10

50. Goldberg DJ. Breakthroughs in US dermal fill-ers for facial soft-tissue augmentation. J Cosmet Laser Ther. 2009;11:240–7. https://doi.org/10.3109/ 14764170903341731

51. Ezzat WH, Keller GS. The use of poly-L-lactic acid filler in facial aesthetics. Facial Plast Surg. 2011;27:503–9. https://doi.org/10.1055/s-0031-1298782

52. Kwak TI, Oh M, Kim JJ, et al. The effects of penile girth enhancement using injectable hyaluronic acid gel, a filler. J Sex Med. 2011;8:3407–13. https://doi. org/10.1111/j.1743-6109.2010.01748.x

53. Yang DY, Lee WK, Kim SC. Tolerability and efficacy of newly developed penile injection of cross-linked dextran and polymethylmethacrylate mixture on penile enhancement: 6 months fol-low-up. Int J Impot Res. 2013;25:99–103. https://doi. org/10.1038/ijir.2012.41

54. Yang DY, Ko K, Lee SH, et al. Efficacy and safety of a newly developed polylactic acid microsphere as an injectable bulking agent for penile augmentation: 18- months follow-up. Int J Impot Res. 2017;29:136–41. https://doi.org/10.1038/ijir.2017.10

55. Kim MT, Ko K, Lee WK, et al. Long-term safety and longevity of a mixture of polymethyl methacrylate and cross-linked dextran (Lipen-10(R)) after penile augmentation: Extension study from six to 18 months of follow-up. World J Mens Health. 2015;33:202–8. https://doi.org/10.5534/wjmh.2015.33.3.202

56. Yang DY, Ko K, Lee SH, et al. A comparison of the efficacy and safety between hyaluronic acid and polylactic acid filler injection in penile augmen-tation: A multicenter, patient/evaluator-blinded, randomized trial. J Sex Med. 2019;16:577–85. https://doi.org/10.1016/j.jsxm.2019.01.310

57. Perovic SV, Byun JS, Scheplev P, et al. New per-spectives of penile enhancement surgery: Tissue engineering with biodegradable scaffolds. Eur Urol. 2006;49:139–47. https://doi.org/10.1016/j.eururo. 2005.08.016

58. Austoni E, Guarneri A, Cazzaniga A. A new technique for augmentation phalloplasty: Albugineal surgery with bilateral saphenous grafts – Three years of expe-rience. Eur Urol. 2002;42:245–53; discussion 242–3. https://doi.org/10.1016/S0302-2838(02)00264-6

59. Panfilov DE. Augmentative phalloplasty. Aesthet Surg J. 2006;30:183–97. https://doi.org/10.1007/s00266-004-0153-y

60. Shaeer O, Shaeer K. Penile girth augmentation using flaps “Shaeer’s augmentation phalloplasty”: A case report. J Sex Med. 2006;3:164–9. https://doi. org/10.1111/j.1743-6109.2005.00104.x

61. Shaeer O. Girth augmentation of the penis using flaps “Shaeer’s augmentation phalloplasty”: The superficial circumflex iliac flap. J Sex Med. 2014;11:1856–62. https://doi.org/10.1111/jsm.12537