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Comparative study of penile size before and after penile prosthesis implantation

Salem, Ahmad; Shaeer, Osama; Abdel-Aal, Alla; Younes, Mohammad

doi: 10.1097/01.XHA.0000415084.67485.67
Original articles
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Purpose Penile prosthesis is one of the main modalities for managing refractory erectile dysfunction. Changes in size of the penis with consequent dissatisfaction have been reported. This study investigates penile length and girth before and after implantation.

Patients and methods 30 patients were recruited for the study. Prior to surgery, penile length and girth were measured before and after induction of artificial erection. Upon implantation, the maximum girth possible was implanted following maximum dilatation. Measurements were repeated immediately and 6 weeks post-operative.

Results Visible length was shorter postoperative than preoperative visible length [whether stretched (5.8% difference) or erect (9.5% difference)], a statistically significant difference. True length, however, showed no statistically significant difference preoperative (whether stretched or erect) to postoperative. Postoperative girth was 4.98% less than the preoperative erect girth and 11.6% more than the preoperative stretched girth.

Conclusions These findings may permit clinicians to give patients realistic expectations prior to penile implant surgery. Patients must be informed preoperatively about the extent of change in penile length (5.8% less than the preoperative flaccid stretched length measured from skin surface to pubis) and girth (11.6% less than the preoperative erect girth). Ensuring that the patient has a realistic expectation is essential to avoid postoperative dissatisfaction.

Department of Andrology, Faculty of Medicine, Cairo University, Cairo, Egypt

Correspondence to Osama Shaeer, MD, 21 Gaber Ibn Hayan Street, Dokki, Giza, Egypt Tel: +20 233 359 047/+20 233 374 360; fax: +20 237 605 181; e-mail: dr.osama@alrijal.com

Received April 23, 2012

Accepted April 23, 2012

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Introduction

Penile prosthesis implantation (PPI) is indicated for individuals with organic factor-related erectile dysfunction (ED) in whom other treatment modalities have proven to be unsatisfactory, are contraindicated, or are rejected by the patient. It can also be considered in cases of psychogenic ED refractory to medical therapy and psychotherapy. Penile prosthesis (PP) is reliable in ED associated with Peyronie’s disease as it simultaneously corrects the deformity and the rigidity 1 or in severe structural disease, such as postpriapism or complex penile malformations 2,3. Numerous studies have shown that satisfaction levels after PPI surgery are very high including in terms of the ability and confidence to have intercourse and device rigidity and function 4–7. However, there are concerns over a decrease in penile size following implantation, not necessarily among predisposed patients with fibrotic changes, which may reflect negatively on sexual satisfaction.

The aim of the study was to test the penile size (length and girth) before and after malleable PPI to determine whether there was an actual decrease in the penile size or whether it was the patients’ false perception.

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Patients and methods

Thirty male patients with organic ED who were candidates for PPI were included in the study. Patients with Peyronie’s disease and those who had undergone radical prostatectomy and postpriapetic ED, where penile shortening occurs before surgery, were excluded. Before surgery, penile length and girth were measured before and after induction of artificial erection. Upon implantation, the maximum girth possible was implanted following maximum dilatation. Measurements were repeated immediately and 6 weeks after the operation.

Flaccid stretched penile length was recorded. Length was determined from the pubis to the tip and from the skin surface to the tip. Before surgery, penile length and girth were measured after induction of artificial erection by the application of a rubber tourniquet and an injection of saline using butterfly cannula 19 and a 50 ml syringe.

We did not induce artificial erection by an intracorporeal injection of vasoactive drugs, to avoid the risk of intraoperative bleeding and also failure to induce erection in all patients because of the organic etiology of ED. Upon implantation, the maximum girth possible was implanted following maximum dilatation. In terms of length, the prosthesis was measured as to fill the proximal third of the glans penis. Length was measured using a metallic seizer whereas girth was measured using a rubber band. Measurements were performed immediately and repeated 6 weeks after the operation. Length was measured in two forms: visible penile length (from the skin to the tip of the penis) and true penile length (from the symphysis pubis to the tip of the penis). All the measurements were performed while the patients were in the supine position.

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Results

Visible length was shorter after the operation than 6 weeks after the operation [whether stretched (5.8% difference) or erect (9.5% difference)], a statistically significant difference. True length, however, showed no statistically significant difference before (whether stretched or erect) and after the operation. The postoperative girth was 4.98% less than the preoperative erect girth and 11.6% more than the preoperative stretched girth (Table 1, Fig. 1).

Table 1

Table 1

Figure 1

Figure 1

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Discussion

Patient sexual satisfaction after PPI is a complex issue that is related to many factors such as postoperative complications, cosmetic outcome, implant function, partner acceptability 8, and ease of concealment of the device 9. The satisfaction rate of penile implants was reported to be 80% by Goldstein et al. 5. Moreover partners’ rating of satisfaction with PPI was 90% as reported by 10 and increased to 96.4 and 91.2% according to the type of implant as reported by Levine et al. 10. However, in a study from the Middle East of 50 patients with a malleable implant, 70% of patients and 57% of partners were satisfied with the prosthesis 11. The relatively reduced sexual satisfaction rate of PPI in the previous Middle East’s study may have been because of the use of malleable PP, which have a lower satisfaction rate than inflatable penile prosthesis (IPP), and poor counseling of patients and partners before surgery.

The results of our study indicated a minor difference between the preoperative stretched and artificial erect visible length. The results of some previous studies are in agreement with those of our study. A study that assessed the flaccid and stretched penile length in 80 normal men and compared it with the penile length after artificial erection reported an average discrepancy of 0.5 cm 12. Following PPI, in 68% of patients, there was a decrease in the stretched penile length, ranging from 0.5 to 5.0 cm after PPI 13. A stretched penile length decreased in 71% of patients after PPI 14.

Irrespective of the pre-existing pathology, PPI per se may reduce erect penile length; the decrease in erect penile length may not be associated with a particular type of PP 15.

Moreover, another study reported prosthetic erect penile length compared with pharmacologically induced erect penile length before surgery. A total of 11 patients with artificially induced full erections at the time of penile color duplex Doppler ultrasonography were enrolled. Erect penile length after IPP implantation was measured at 6 weeks, 6 months, and at 1 year after surgery. Induced erect penile length (mean±SE) was 13.2±0.4 cm, whereas the prosthetic erect lengths were 12.4±0.3, 12.5±0.3, and 12.5±0.4 cm at the sixth week, the sixth month, and the 1-year follow-ups, respectively. There were 0.83±0.25, 0.75±0.20 and 0.74±0.15 cm decreases in erect penile length at 6 weeks, 6 months and 1 year, respectively, however, this decrease did not affect the satisfaction of IPP in treating ED 15. In our study, however, we did not induce artificial erection with a vasoactive agents as the surgeons were afraid of intraoperative bleeding.

In another study that compared the stretched flaccid penile length before and after IPP implantation reported that PP did not have a negative impact on the penile length measurements, even though 72% of patients reported a subjective impression of decreased penile length in the study. However, the patients show more concern about erect penile length 16. The possibly false subjective impression of shortening leading to dissatisfaction was evaluated in a study that included 56 patients who underwent IPP; there was no difference between flaccid stretched preoperative length and postimplantation length as measured by Deveci et al. 16. Dislike for the device was the most common reason for dissatisfaction of the patients, whereas a sense of unnaturalness was the reason for dissatisfaction among the partners 11. There were statistically significant differences only in assessments of satisfaction between men with and without subjective penile length loss, but not in erectile function scores 10.

Six weeks after the operation penile girth was less than the preoperative artificial erect girth and more than the preoperative stretched girth. To our knowledge, no published papers have compared the preoperative stretched girth and erect girth with the postoperative girth moreover preoperative flaccid stretched penile length and artificial dynamic erect penile visible and true lengths with 6 weeks postoperative lengths

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Conclusion

The findings reported here may allow clinicians to provide patients with realistic expectations before penile implant surgery. Patients must be informed preoperatively about the extent of change in penile length (5.8% less than the preoperative flaccid stretched length measured from the skin surface to the pubis) and girth (11.6% less than the preoperative erect girth). Ensuring that the patient has a realistic expectation is essential to avoid postoperative dissatisfaction.

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Acknowledgements

Conflicts of interest

There are no conflicts of interest.

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References

1. Montague DK, Angermeier KW, Lakin MM, Ingleright BJ. AMS 3-piece inflatable penile prosthesis implantation in men with Peyronie’s disease: comparison of CX and Ultrex cylinders. J Urol. 1996;156:1633–1635
2. British Society for Sexual Health. Guidelines on the management of erectile dysfunction. 2007
3. Merino GA Penile prosthesis implantation in the treatment of erectile dysfunction. Santiago de Compostela Galician Agency for Health Technology Assessment (AVALIA-T). 2005. p.111
4. Hatzimouratidis K, Amar E, Eardley I, Giuliano F, Hatzichristou D, Montorsi F, et al. Guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation. Eur Urol. 2010;57:804–814
5. Goldstein I, Newman L, Baum N, Brooks M, Chaikin L, Goldberg K, et al. Safety and efficacy outcome of mentor alpha-1 inflatable penile prosthesis implantation for impotence treatment. J Urol. 1997;157:833–839
6. Montorsi F, Rigatti P, Carmignani G, Corbu C, Campo B, Ordesi G, et al. AMS three-piece inflatable implants for erectile dysfunction: a long-term multi-institutional study in 200 consecutive patients. Eur Urol. 2000;37:50–55
7. Carson CC, Mulcahy JJ, Govier FE. Efficacy, safety and patient satisfaction outcomes of the AMS 700CX inflatable penile prosthesis: results of a long-term multicenter study. J Urol. 2000;164:376–380
8. Mulhall JP, Ahmed A, Branch J, Parker M. Serial assessment of efficacy and satisfaction profiles following penile prosthesis surgery. J Urol. 2003;169:1429–1433
9. Ferguson KH, Cespedes RD. Prospective long-term results and quality-of-life assessment after Dura-II penile prosthesis placement. Urology. 2003;61:437–441
10. Levine LA, Estrada CR, Morgentaler A. Mechanical reliability and safety of, and patient satisfaction with the ambicor inflatable penile prosthesis: results of a 2 center study. J Urol. 2001;166:932–937
11. Salama N. Satisfaction with the malleable penile prosthesis among couples from the Middle East: Is it different from that reported elsewhere? Int J Impot Res. 2004;16:175–180
12. Wessells H, Lue TF, Mcaninch JW. Penile length in the flaccid and erect states: guidelines for penile augmentation. J Urol. 1996;156:995–997
13. Savoie M, Kim SS, Soloway MS. A prospective study measuring penile length in men treated with radical prostatectomy for prostate cancer. J Urol. 2003;169:1462–1464
14. Munding MD, Wessells HB, Dalkin BL. Pilot study of changes in stretched penile length 3 months after radical retropubic prostatectomy. Urology. 2001;58:567–569
15. Wang R, Howard GE, Hoang A, Yuan JH, Lin HC, Dai YT. Prospective and long-term evaluation of erect penile length obtained with inflatable penile prosthesis to that induced by intracavernosal injection. Asian J Androl. 2009;11:411–415
16. Deveci S, Martin D, Parker M, Mulhall JP. Penile length alterations following penile prosthesis surgery. Eur Urol. 2007;51:1128–1131
Keywords:

girth; length; penile implant; penile prosthesis; penis; satisfaction; size

© 2012 Human Andrology