Nasar, Taha Abdl; Gadalla, Amr; Zeidan, Ashraf; El Batrawy, Mahmoud; Ghanem, Housen
The penis, particularly in its erect state, is a symbol of masculinity. In many cultures, it has come to symbolize attributes such as largeness, strength, endurance, ability, courage, intelligence, knowledge, dominance over men, possession of women, and a symbol of loving and being loved .
Given the historical context, it is perhaps no surprise that even today many men give more importance to the size of their penis. Hegemonic masculinity is defined by attributes such as physical strength, heterosexuality with authority over women and other men, showing no emotions (such as remorse and uncertainty, which might suggest vulnerability), economic independence, and an ability to demonstrate sexual ‘conquest’. Although most men do not embody all of these qualities, society supports hegemonic masculinity within most of its institutions .
It is perhaps relevant to state that men with a larger penis, in length and circumference, have a better body image and genital image, and have a feeling of greater sexual competence . It was documented that penile size has a racial difference, but it is not known whether it has a relationship with body physique or not. Hence in this study, we assessed penile size and its relationship with body measurements (height, weight, and waist circumference) in 1000 patients, aiming to find such a correlation if present.
Patients and methods
This is a descriptive study that consisted of a series of 1000 adult men above 21 years of age with no penile anomalies. The patients were recruited from the Andrology Clinic (Cairo University Hospitals, Egypt), excluding those with penile or urethral anomalies that affect penile size, such as micro phallus, epispadius, hypospadius, congenital or acquired chordee, Peyronie's disease, and those with hypogonadism and history of delayed puberty.
All patients were subjected to history taking. The general examination was conducted with special emphasis on body measurements, including the height, weight, and waist circumference. Local examination of the external genitalia was conducted to exclude congenital or acquired abnormalities and to measure the penile size, including penile length (both flaccid and stretched) and the penile girth.
Body measurements were taken, including the height, weight, and measurement of waist circumference, by tape measure passing along the waist midway between umbilicus and symphisis pubis at the level of superior iliac spine; measurement of flaccid penile length was taken using a ruler while the patient was standing with the penis held parallel to the floor; bone-pressed actual penile length was measured using a ruler with the penis stretched as comfortably as possible; and finally measurement of the girth was taken using a tape measure at three places along the penis, which are just below the glans, in the middle of the shaft, and at the base, and were then averaged. These methods of measurements are according to Kondo et al. .
Patients younger than 15 years, with any penile or urethral anomalies, endocrinal abnormalities, penile curvature, any acquired penile conditions that may affect penile size such as Peyronie's disease, and patients with known history of delayed puberty were excluded from the study.
Analytical tests used included the Pearson's correlation (r), where all the parameters were tested for correlation.
The 1000 patients included in the study showed a mean age of 33.2 years (range: 21–45 years, median: 33 years).
The mean height was 172.61 cm (range: 152–1921 cm, median: 173 cm), the mean weight was 80.65 kg (range: 48–142 kg, median: 78 kg), the mean body mass index was 27.05 kg/m2 (range: 16.96–49.5 kg/m2, median: 26.26 kg/m2), and the mean waist circumference was 93.93 cm (range: 65–152 cm, median: of 93 cm).
The mean flaccid penile length was 8.37 cm (range: 5–14 cm, median: 8.5 cm), the mean bone-pressed stretched (actual) penile length was 13.77 cm (range: 9.5–19 cm, median: 14 cm), and the mean penile girth was 10.48 cm (range: 8.5–13 cm, median: 10.5 cm).
The actual stretched penile length was found to be more than the flaccid penile length by 5±2 cm standard deviation (SD) (range: 4–7 cm, median: 5.5 cm).
All penile measurements are found to be interrelated to each other with statistically significant correlation between various penile measurements.
Moreover, height and weight are the other body measurements that are related to the penile measurements, that is, the more the body height, the more is the actual stretched penile length in 48% of the studied cases, and the more the body weight, the more is the penile girth in 29.1% of the studied cases (a very strange finding as there is no subcutaneous fat in the penis) (Table 1–3).
Measurements of penis have great importance because the collection and reporting of scientific data have been used to address the concerns of men with regard to their normality , particularly in response to increased reported dissatisfaction with phallus dimensions and increased request for surgical enhancement .
With regard to the penile length, our results showed that the mean apparent penile length was 8.37 cm±1.31 SD (range: 5–14 cm), which are comparable with most of the clinical human studies carried out at the University of California, San Francisco, by Wessells et al.  who stated that the mean apparent flaccid penile length is 3.5 inches (8.9 cm) with an average of 9–10 cm. The length of the flaccid penis does not necessarily correspond to the length of the erect penis.
Measuring the fully stretched penile length has great importance as it has been taken as an indicator of erect length [8,9].
The results of this study agree with a research carried out by Wylie and Eardley , who compared results of 12 studies conducted on different populations in several countries. After a review of all studies, they concluded that the average size at the beginning of puberty was 6 cm (2.4 inches) with adult size reached approximately 5 years later. They also concluded that flaccid penile length is a poor estimate of erect length, and a better estimate of stretched length, which is 12–13 cm. This agrees with the study carried out by Kamel et al.  who reported that the mean fully stretched penile length was 12.9±1.9 cm (SD 5.2±0.8 inches), and the minimum and the maximum fully stretched lengths were 5 and 19 cm (2.0 and 7.6 inches), respectively. In 949 normal Egyptian individuals, their age ranged from 17 to 60 years (mean: 36 ±10.9 years).
In contrast, our results disagree with that of Kondo et al.  who reported that the mean value of stretched flaccid penile length is 14.5 cm±2 SD, as measured by the researchers in 150 normal Caucasian adults, which may reflect racial difference.
With regard to the penile girth, our results showed that the mean penile girth was 10.48 cm±0.69 SD, which was close to the value reported by Kamel et al.  [who reported that the mean fully stretched girth was 8.9±0.9 cm (3.6±0.4 inches)]. The minimum and the maximum fully stretched girths were 6.5 and 12.5 cm (2.6 and 5.0 inches), respectively.
However, our results were different from the results of Bogaert and Hershberger  who reported that the penile girth mean was 12.2±1.8 cm SD, by a self-measurement study in 3417 heterosexual men. This study values are slightly more than the results of our study, this difference may be attributed to the method of assessment, which depends on patient self-measurement and may not be accurate, may be overestimated, or may be related to racial difference.
With regard to the relation of penile size and body measurements, Sutherland et al.  stated that the height and weight may be the primary indicators of penile size.
Our results showed that there was a positive correlation between actual penile length and the height in 48% of cases, which agrees with most human studies similar to that conducted at the University of California, San Francisco, by Wessells et al. , who stated that there is a correlation between weight, height, and penile length. Furthermore, the study of Lever et al.  stated that self-reported penile size correlated positively with height.
We have found that weight affects the apparent length more than the actual length because of the presence of suprapubic fat, which falsely affects the apparent length. However when we measured the actual length with the penis fully stretched and the ruler bone pressed, we eliminated this problem, which agrees with most human studies. Ponchietti et al.  reported that in men who are overweight, there are dual factors of a perspective issue: the penis cannot be seen with the abdominal overhang and the presence of significant suprapubic fat pad causes the penis to be partly buried. Alter  reported that a large suprapubic fat pad shortens functional and visual length. In addition, Wylie and Eardley  reported that the buildup of fat on the pubic bone above the penis may give a shorter appearance, even though the length of the penis from the base is normal.
Finally, we conclude, from the findings in our study, that all penile measurements are interrelated to each other; the height and weight are the other body measurements that are related to the penile measurements but in less than 50% of cases.
It seems that the penile measurements are polygenic traits and are under multifactorial influences, including racial factors, hormonal factors, etc.
It is important to conduct a large-scale study on penile size to obtain an average of the population, especially in patients complaining of small-sized penis, although they have normal average penile size.
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