Cosmetic penile enhancement procedures: an SMSNA position statement

[madman]

Abstract

Background

Penile cosmetic enhancement procedures have been performed for many years with varying success. However, they have historically been relegated to niche areas of sexual medicine, with limited data, and have not achieved mainstream adoption. More recently, the topic has been increasingly discussed within academic congresses due to availability of novel techniques, therapies, and procedures. Given their distinctive nature, the Sexual Medicine Society of North America (SMSNA) felt that it was pertinent to develop formal position statements to help guide both patients and sexual medicine providers on the current state of the scientific literature and to give recommendations for future research.


Aim

The study sought to provide an evidence-based set of recommendations for injection and surgical procedures designed to lengthen,augment, or otherwise cosmetically enhance the penis.


Methods

A review was performed of all scientific literature listed in PubMed from inception through December 2023 relating to penile cosmetic enhancement procedures. Only invasive (injection/surgery) therapies were included due to their distinct risk-benefit profile compared with more conservative treatments (eg, vacuum erection devices, penile traction devices). Similar therapies were categorized, with pertinent data summarized and used to help create relevant position statements. All statements were expert opinion only and were based on analyses of the potential risks and benefits of the specific therapies.


Outcomes

A total of 6 position statements were issued relating to 5 distinct sexual medicine cosmetic enhancement procedures.


Results

A consensus opinion was reached by SMSNA leadership on the state of injection/surgical penile cosmetic enhancement procedures as of 2024. Key topic areas addressed included injectable soft tissue fillers, suspensory ligament division, graft-and-flap procedures, silicone sleeve implants, and sliding/slicing techniques. Distinct recommendations were tailored to each therapy and were based solely on the current state of the literature. It is anticipated that future studies will further inform position statements and will lead to ongoing modifications.


Clinical Implications

The current position statements provide both patients and clinicians evidence-based, expert recommendations on best practices relating to penile cosmetic enhancement procedures.


Strengths and Limitations

Strengths include the use of an expert panel of sexual medicine clinicians, consensus design, and summary of existing literature. Limitations include expert opinion and limited research on the topic.


Conclusion

The current SMSNA position statements provide evidence-based, consensus opinions on the appropriate role for penile augmentation and cosmetic procedures in 2024.

 

[madman]

Injection procedures

Injectable soft tissue fillers

Limited data suggest potential cosmetic benefits of temporary injectable hyaluronic acid (HA) and polyactic acid (PLA) fillers to increase penile girth with an acceptable safety profile. Clinicians performing these procedures are urged to conduct safety and efficacy analyses using Institutional Review Board(IRB)–approved research protocols.

The SMSNA strongly recommends against penile fillers using permanent materials (including paraffin and silicone).

In contrast to studies evaluating HA and PLA, the use of permanent fillers such as silicone and paraffin have demonstrated the potential for severe long-term complications, including necrosis, progressive pain, swelling, and long-term deformities.10 Multiple case reports and surgical series have reported a need for surgical removal with complex reconstructions required, including grafting, flaps, and staged procedures.Given the severity of AEs and lack of prospective data on the true rate of safety and efficacy, the SMSNA cautions against the use of these fillers in the absence of a clinical study.

 

[madman]

Surgical procedures

Suspensory ligament division

The SMSNA identifies that in the hands of experienced surgeons, suspensory ligament division may result in increases in flaccid penile length and should only be considered after a comprehensive discussion of potential complications, including erectile dysfunction, sensory changes, and penile instability, among others.

In summary, SLR has been described as a potential standalone or combination procedure to augment penile length.Given the modest volume of data available and potential for long-term complications including changes to penile sensation and instability, the SMSNA advisory panel feels that the procedure may be reasonably offered by experienced surgeons to select patients who are appropriately counseled as to expectations and potential complications.

 

[madman]

Graft-and-flap procedures

The SMSNA recommends against the use of graft-and-flap surgical procedures for penile augmentation until further outcome data are available.

With the broad diversity of techniques, absence of external validation, procedural complexity, potential for moderate complications, and limited follow-up, the SMSNA currently recommends against these procedures outside of a research protocol. Of note, the foregoing comments do not apply to more minor procedures such as scrotoplasties performed at the time of penile prosthesis insertion or surgeries for concealed/buried penis.

 

[madman]

Silicone sleeve implants

The SMSNA recommends that silicone sleeve device surgery should only be performed under the oversight of an IRB with long-term safety endpoints and without cost to the patient. The SMSNA additionally recommends against their use except in the hands of experienced surgeons and following a comprehensive discussion of potentially severe complications.

The SMSNA panel felt that, at the current time, there are limited data with unclear reliability to address the first point and inadequate data to quantify the second and third points. In the absence of these data, and in the context of a young,healthy target population with the possibility for severe long term complications, it was not felt possible to adequately counsel patients as to the true risk-to-benefit ratios at the present time. As such, the SMSNA felt that placement of Penuma/Himplant devices should be considered investigational and be performed under the supervision of IRBs pending the availability of long-term data.

 

[madman]

Sliding/slicing techniques

The SMSNA suggests that penile sliding/slicing techniques are investigational and recommends that they only be conducted with IRB oversight. The SMSNA additionally recommends against their use except in the hands of experienced surgeons and following a comprehensive discussion of potentially severe complications.

Due to the severity of complications related specifically to sliding/slicing techniques, multiple modifications have been reported over time and are ongoing. Given the limited data and potential for severe complications, the SMSNA considers these procedures to be experimental in nature. As such, patients should be thoroughly counseled as to the potential for severe complications, and procedures should be performed in research settings by experienced prosthetic surgeons. The routine use of these adjunctive procedures should not be implemented pending further data and technique evolution.