Surgeons should encourage men who request penile lengthening surgery to try non-invasive methods first and, in some cases, consider therapy to help them feel more positive about their body.
An Italian review published in the April issue of the urology journal BJUI found that penile extenders are more successful than techniques like vacuum devices, exercises and botox injections and that psychological satisfaction is often just as important as physical changes.
"Urologists are constantly approached by men who are concerned about the size of their penis, despite the fact that the majority of them are normal sized" says Associate urology Professor Paolo Gontero, from the University of Turin, who carried out the research review with Dr Marco Oderda.
"However there are also a number of medical and surgical conditions that can cause penile shortening, such as radical prostatectomy for men with prostate cancer, Peyronie's disease and congenital abnormalities. Then there's 'hidden penis', which is caused by overlying abdominal fat and skin in obese aging men or a lack of skin because of chronic inflammation or an aggressive circumcision.
"Surgery is characterised by a risk of complications and unwanted outcomes and lack of consensus among the medical profession on the indications for surgery and the techniques used. That is why a non-invasive technique is preferable."
The review compared five evidence-based surgical studies covering 121 men and six evidence-based non-surgical studies covering 109 men, published between 2000 and 2009. Key findings included:
Further research showed that:
"No studies have been carried out to compare surgical and non-invasive methods of penile lengthening" says Professor Gontero. "However our review suggests that penile extenders represent an effective and durable method of penile lengthening, capable of elongating the penis by an average of 1.8cm with minimal side effects. This compares favourably with surgery, which is much more invasive for the patient.
"Based on current evidence, we suggest that penile extenders, not surgery, should be the first-line treatment for men seeking a penile lengthening procedure.
"Cognitive behavioural therapy can also be useful in building men's confidence if they have body image issues."
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