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This study, published online in January 2006 at europeanurology.com,
assessed the management of patients requesting penile length enhancement by division of the penile
suspensory ligament. From September 1998 to January 2005, 42 patients with a variety of etiologies were included;
all underwent division of the penile suspensory ligament. The outcome was assessed objectively based on increase
in flaccid stretched penile length (SPL) and subjectively using the rates of patient satisfaction.
Introduction
The suspensory ligament of the penis is comprised of two components, the suspensory ligament proper and the
arcuate subpubic ligament that attaches the tunica albuginea to the midline of the pubic symphysis. Its function
is to support the erect penis in an upright position and to aid vaginal penetration. Surgical division of this
ligament may allow the penis to lie in a more dependent position and therefore give the appearance that the penile
length has increased. Various penile lengthening procedures have been described; the most widely used technique
is division of the penile suspensory ligament to gain some length at the expense of slight instability.
Although it is widely accepted that patients with a truly small penis would be eligible candidates for penile
enhancement surgery, no current consensus guidelines are available for the treatment of patients with a normal-sized
penis. The average penile length in white men is 12.5 cm and the most common request for penile enhancement surgery is
in patients with a normal penile size who have a subjective altered body perception, rather than an objective clinical
assessment that their penis is small. This is otherwise known as penile dysmorphic disorder.
In body dysmorphic disorder, patients present with persistent preoccupation of an imagined defect in physical
appearance that causes clinically significant distress or impairment in social or other important areas of functioning.
Patients often interpret normal appearances as abnormal and distressing, resulting in marked anxiety and depression.
The diagnosis of penile dysmorphic disorder should therefore be made by a psychiatrist.
Preoperative assessments
During the patients' initial consultation, a detailed medical and sexual history was obtained and physical
examination performed. The patients' concerns and expectations were discussed and normograms of penile length shown.
The most common scenario in patients with penile dysmorphic disorder consisted of anxiety and embarrassment
arising from changing in front of others, that is, the "locker room" syndrome. Features suggesting hypogonadism
were recorded particularly in the group with congenital micropenis.
A physical examination included an assessment of the flaccid stretched penile length (SPL), measured from the
pubic penile skin junction to the meatus under maximal extension of the penis. Ideally, erect penile length is a
more accurate assessment of penile size, repeated intracavernosal injections to measure this preoperatively and
postoperatively in this group of patients is impractical and SPL is therefore used, which has been demonstrated
to be an accurate rejection of erect penis size. The urethra was inspected to exclude the congenital anomalies of
hypospadias or epispadias and testicular size; position and secondary sexual characteristics were examined to exclude
an endocrine abnormality. Any abnormalities to the penile skin, including webbed penis, concealed penis, or penile
scrotalization were noted.
After the initial consultation, patients with a possible diagnosis of penile dysmorphic disorder were encouraged to
seek psychiatric or psychosexual counseling and discouraged from surgery. Of the 27 men with dysmorphic disorder, 11 were
referred by a psychiatrist and another 12 had a psychiatric evaluation preoperatively. Overall, this series consists of
approximately 20% of all patients who were referred to the unit but still insisted on having surgery.
Surgical technique
All patients had division of the penile suspensory ligament with some also having other augmentation techniques.
The penile suspensory ligament was approached via either a transverse or inverted V suprapubic incision and divided.
In the later part of the series, a silicone buffer (a small testicular prosthesis) was placed in the space
created by the ligament division and anchored to the base of the pubis with a 1-0 Ethibond suture, in an attempt
to prevent reattachment of the penile suspensory ligament to the pubis and to push the penis forward. In patients
with excessive obesity, an excision of the suprapubic fat pad was performed. The original incision was then closed
and usually as an inverted VY plasty. Once the wound had healed, patients were then encouraged to perform
postoperative penile stretching with either penile weights, a vacuum constriction device, or the use of a
penile stretcher device.
Results
The SPL was significantly increased by 0.4 cm - 1.3 cm when the suspensory ligament of the penis was
divided. The only specific technique that significantly lengthened the penis was the placement of a silicone buffer
to prevent ligamentous reattachment following division. All of the etiology categories had an increased penile length,
but this was only significant in the group of men with penile dysmorphic disorder. In some motivated patients who
performed postoperative stretching, a gain of 3 cm was achieved.
However, others noticed penile shortening of 1 cm.
Overall only 35% of the patients were satisfied with the outcome of surgery. Satisfaction rates were lowest
in patients with dysmorphophobia (27%) or Peyronie disease (17%). A second operative procedure was requested by
20 patients and was performed in 17. Only two patients were eventually satisfied with their penile length, raising
the overall satisfaction rate to 40%. Complications included postoperative wound infection in four patients and a
wound breakdown in one; all five men were managed conservatively.
Discussion
Division of the penile suspensory ligament with or without the additional procedures of suprapubic fat pad
excision and inverted VY plasty is a simple and a commonly used penile lengthening technique. Although this has
been related to serious morbidity, in this series, the complication rate was low as shown by others. The procedure
is simple to perform and gives similar results to more complex types of penile lengthening surgery. The operation
does lengthen the flaccid penis but usually only by 1 cm. In some patients who persevere with postoperative
stretching exercises, as much as 3 cm gain can be achieved,
but patients must also be warned that a small degree of penile shortening may also occur.
The placement of a spacer between the penis and the pubis to prevent reattachment, and possible shortening,
seems to give the best results. All other additional procedures did not help to gain length. Despite the increase
in SPLs and low complication rate, a large proportion of patients were dissatisfied with the outcome of the surgery,
being highest in the group of patients with penile dysmorphic disorder.
Clearly, surgery is not a cure for penile dysmorphic disorder because the patients often have unrealistic
expectations and any length gain would not be enough in the patient's view - "a normal penis will remain normal".
In patients with an organic cause for their shortening the satisfaction rate is higher, although it is appreciated
that these patients may also have psychological distress from their condition. The difference is that these patients
can distinguish normality from abnormality, unlike patients with dysmorphic disorder.
Patients with this condition should be discouraged from having surgery but this is not always possible. All
patients should have a psychiatric assessment to uncover predisposing factors that could be treated psychologically.
The patients must be given the correct advice about the expected gains from surgery and if they still wish to go ahead
with the operation knowing that a 1 cm - 2 cm length gain should be expected, then the satisfaction
rate will increase as their expectations are met. It is wise to encourage the patient to start the
stretching exercises before surgery so that he knows what is needed
to get the best result.
The surgeon's responsibility is to ensure that unnecessary surgery is not performed and that informed consent
has been provided by the patient. However, it is also appreciated that in this group of patients, if surgery is
refused outright by the urologist, some patients in their desperation may resort to seeking help from inappropriate
and less qualified practitioners, which would ultimately be to the detriment of the patient.
Conclusion
Division of the penile suspensory ligament or other augmentation techniques may increase penile length, but usually
not to a degree that satisfies the patient. Patients with penile dysmorphic disorder should be discouraged from surgery
and be referred for psychiatric counseling. Surgical intervention should be reserved as a last resort and only when
the patient understands the limitations of the expected outcome.
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