The cause of congenital short penis is still unclear, although low levels of gonadotrophic hormone, hypogonadism, and insensitive receptors of androgenic hormones have been related to this problem. Huang Pingzhi 1 described microphallus as a stretched penis shorter than 4 cm for a 4-year-old or 5.5 cm for an adult. Burns of the perineum, with the resulting adhesions and scar traction, can also cause hypogenesis of the cavernous body of the penis.
Congenital or traumatic hypogenesis of the penis will result in the distinct deformity of short penis, which interferes with the patient’s sexual activities, sometimes to the point of ending a marriage. Our previous work 2 in 1991 reported satisfactory results in both appearance and lengthening of short penis by covering the corpus cavernosum with a scrotal flap. However, in recent years, we modified our previous surgical method further to get better results, and the details are presented herein.
Patients and Methods
Our study included 52 patients, 23 to 52 years old; 39 cases were of congenital microphallus (erect length of penis was less than 8 cm) and 13 were the result of traumatic injuries. All operations were performed between 1991 and 1998. Thirty-eight patients were or had been married before the operation (one patient had been married six times; all the marriages ended because of unsatisfactory sexual activities); 14 patients were unmarried, 10 of whom had had sexual activities before the operation.
Lumbar anesthesia was recommended. First, 5 mg of tolazoline hydrochloride was injected in the corpus cavernosum for induction of an artificial erection, and a rubber band was placed around the root of the penis for about 10 minutes, which made the operation convenient. Then, a “+” shaped incision was made at the root of the penis on the dorsal side (Fig. 1, above, left). This incision provides good exposure of the suspensory ligament system. Skin and superficial fascia were incised, after which the corpus cavernosum was dissociated from the root of the penis to the deep layer of the pubic symphysis.
The superficial suspensory ligament and all surrounding fascial bands were completely released on the upper part of the pubic symphysis (Fig. 1, above, right). If further lengthening was needed, the deep suspensory ligament could be dissected and released partly through the surface of pubic symphysis (its periost might be dissected also, if necessary). Close attention should be paid to the dissection of suspensory ligament because of its deep location and small field of exposure. Any neurovascular injury to the penis will be disastrous.
A proper scrotal flap was designed and transferred to cover the elongated corpus cavernosum from the root of the penis, after complete hemostasis by ligation. The scrotal incision was sutured directly.
For patients with a traumatic injury, the scar at the root of the penis is loosened by incision, and the corpus cavernosum is elongated in the same way as described above. Skin grafts can be used to cover the wound if the scrotal flap is not an option. In patients with abundant hair, we suggest shearing of the hair follicles to achieve a better appearance.
In cases with more than 4 cm of elongated length, we suggest a V-Y suture on the ventral side of the penis root (Fig. 1, below, left and right). This method avoids traction from the ventral side in the erect state and also achieves a better appearance (Figs. 2 and 3).
The average stretched length of a penis is about 13.3 ± 1.6 cm; microphallus is diagnosed when the penis is 2.5 cm shorter than the average length. Du Peilin 3 suggested that a man whose erect length of penis is less than 10 cm and who is unable to meet the erogenous demands of his sexual partner could be a candidate for surgery. We think that the length of the penis can be affected by environment, climate, and many other factors. There are intraindividual differences between the flaccid and the erect state. For some men, the penis is shorter than 4 cm in the flaccid state, whereas it can be 10 to 12 cm in the erect state. For other men, there is only a 2- to 3-cm difference between lengths in the flaccid state and in the erect state. “Stretched length” is the length measured along the dorsal surface of penis when the glans is stretched completely by the thumb and index finger of the examiner and the ruler is pushed into the pubic branch until it meets resistance. The length of the prepuce is excluded. We do not think that this method results in an accurate length while in the erect state. All of our patients showed short penis in appearance, and almost all desired operations because of unsatisfactory sexual activities. The erect lengths were less than 9 cm after injection of tolazoline hydrochloride in the corpus cavernosum in 41 cases. The lengths in the remaining 11 cases were 9 to 11 cm; surgical lengthening was necessary for them. However, the penis is the symbol of virility; therefore, some men desire a larger penis, a concern similar to that of women who desire breast augmentation.
Covering the Elongated Corpus Cavernosum
In 11 patients who had sustained traumatic injury and had serious adhesions from scarring at the root of the penis, the defects were covered with skin grafts after loosening the scar. In the other 41 cases, scrotal flaps from bilateral sides were used to cover the wound. The advantages of scrotal skin are elasticity, rich blood supply, expansion when heated and contraction when cooled, and especially good sensation. Above all, the donor site can be sutured directly without an obvious scar. To achieve a good appearance in patients with abundant hair, we sheared the hair follicles on the scrotal flaps. This procedure produces ultrathin flaps.
Blood Supply of the Penis
Grossman et al. 4 found, through microdissection, that a pair of dorsal arteries are present in the dartos layer on the dorsal side of the penis. These arteries ran from the root of the penis to the prepuce and ended around the coronal sulcus. Their many perforating branches to the skin provide the penis skin with a rich blood supply. The penises operated on had heavy edema 3 days after the operation in our experience; in some cases, the edema lasted for approximately 7 days. However, in most cases, the edema began to diminish after the fifth postoperative day. There were no cases of necrosis. All patients reported satisfactory results.
Elevating the buttocks could abate edema and improve blood reflux. Analgesia is necessary because of the typically severe pain after the operation. During the first 3 days after the operation, 5 mg of stilbestrol and 5 mg of diazepam should be taken orally half an hour before the patient goes to sleep to reduce painful nocturnal erections, which are harmful to the wound healing process.
According to measurements taken just after the operations, penis length increased 3.5 to 6.5 cm. However, only 20 patients were followed up. The length diminished an average of 0.5 to 1.5 cm within 6 months; there was no diminishing after a year.
In conclusion, our modified surgical method achieved better appearance and satisfactory lengthening of the penis. The patients’ sexual activities were significantly improved after the operations.
1. Huang, P. Diagnosis and treatment for microphallus. Chin. J. Androl. 2:243, 1988.
2. Shirong, L., Dongli, F., Zhaohua, L., et al. Surgical treatment for the congenital and after-burn short penis. J. Pract. Aesthetic Plast. Surg. 2:24, 1991.
3. Peilin, D. Comparison of the vagina lengths between the Uygur and the Han nationality. Chin. J. Clin. Anat. 1: 45, 1988.
4. Grossman, J. A., Caldamone, A., Khouri, R., and Kenna, D. M. Cutaneous blood supply of the penis. Plast. Reconstr. Surg. 83:213, 1989.