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Digest of recent discussions on ISSM mail (January 2006)Hussein Ghanem MD Penile Augmentation Discussion DigestThe most active discussion we had -so far- on ISSM List was initiated by Dr. Oscar Sapena Pastor about patients wanting a larger penis. More than 30 responses were obtained. The majority of ISSM members advised patient education and counselling. We hope all points of view are represented adequately and fairly. We are presenting it as a separate digest due the amount of responses, confirming the importance of this issue. Digests for other discussions will still be grouped together as usual. Question PostedDr. Pastor inquired if there is a successful treatment for penile augmentation and how successful is it. Opinions of ISSM membersSurgery versus Education, Psychotherapy and counsellingDr. Carlos Da Ros advised against surgical intervention due to frequent complications and lack of significant results with surgery. He advised patient education and counselling. Dr. Charles Moser advised studying the motivation of these men who are wiling to pay large sums of money for treatments that are dangerous and ineffective. Dr. Yoram Vardi agreed and pointed out that in the next issues of the European Urology Dr Ralph presents data confirming patients are not satisfied with the results of penile augmentation procedures. Dr. Gila Bronner agreed with the above comments and suggested that these patients should consult a sex therapist for a possible associated sexual dysfunction that could be treated efficiently. Dr. Michael Lowy stated that this complaint comes under the body image conditions, called body dysmorphic disorder and cautioned that a penile lengthening and widening procedure makes little difference to the psycho-social problems, and potentially deteriorates the patient's psychological status. Dr. Kevan R Wylie commented that this was also their experience in his practice in the UK. Dr. Wylie also referred to a recent study suggesting that the majority of men who undergo penile enlargement end up dissatisfied with the results http://news.bbc.co.uk/go/em/fr/-/1/hi/health/4710308.stm Dr. David Rabinowitz advised that without psychiatric treatment, the condition may continue for years and advised a combination of psycho-education, psychotherapy, and possibly medications, including SSRI's and pimozide. Stretching devicesDr. Carlos Moreira suggested a stretching device. However, Dr. Sudhakar Krishnamurti pointed out the lack of data supporting the use of these devises, and Dr. Geng-Long Hsu questioned its the mechanism of action. The rights to cosmetic surgery versus complicationsDr Hesham Nabil Khaled summarised his experience in Jeddah where many patients are satisfied with education and explanation, and that complications and lack of effectiveness led many surgeons to abandon the procedure. Dr. Santiago Richter also commented that while acknowledging that we are living in a cosmetic world for both genders, he quit performing these procedures, not because he is against the idea but because he considers that there is still no appropriate and satisfactory surgical technique developed. Dr. Krishnamurti also acknowledged the right of a patient to augmentation surgery, but pointed out that the problem is that we do not have an operation that delivers good results. Dr. Kevan Wylie also agreed to the patients� rights to buy cosmetic procedures but found that most of his patients, seen, in collaboration with surgeons in the UK, choose not to proceed to surgery especially when they appreciate the consequences with size changes and potential scarring. Penile Augmentation compared to other cosmetic proceduresDr. Teloken commented that cosmetic procedures elsewhere in the body can not be compared to those on the penis as they usually do not influence any body functions, and that an unsuccessful procedure on the " man symbol & most complex male anatomical structure" may be catastrophic for those unstable, highly sensitive or anxious individuals. Dr. Teloken while acknowledging the right of the patient to undergo cosmetic procedures also stresses the right of the patient right to be informed about possible complications, long term results, decent literature published under real scientific methodology. H Ghanem quoted Prof Saad Girgis and Prof Anwar El Etriby, founders of the department of Andrology in Cairo University who warned that any surgical or even medical (placebo) intervention on a patient with a delusion of a small penis (the term that was used to describe body dysmorphic disorder-Penis) at that time would result in a patient more convinced that he has a problem, since the physician acknowledged it by intervention rather than education and counselling. Dr. Cila Ankier agreed with these comments. Possible Benefits from surgeryDr. Laurence A Levine agreed that the problem is that the available techniques to try to surgically fix the problem have been less than satisfying for all concerned. However there are men who would accept the 1-2 cm length enhancement with suspensory ligament release. Dr. Levine pointed out that it seems that those who are offering lengthening procedures are not giving proper preoperative expectations to the patients. Dr. Osama Shaeer pointed out his latest publication in the journal of sexual medicine about his technique for Penile Girth Augmentation using Flaps to augment the penile girth. Money MattersDr. Giuseppe La Pera suggested that such surgeries should be considered experimental since they have uncertain results. If so they should only be conducted in university settings, under the regulations of the hospitals� ethics committee, with no financial burden on the patient. Dr. Yoram Vardi supported this proposal but raised the question �would that so called cosmetic surgery have been so popular without the money issue?� H Ghanem pointed out that preliminary data from a combined research project (MD thesis for Dr. Amr Kaddah) between the departments of Andrology and plastic & reconstructive surgery, Cairo University, shows that that if patients were given sufficient information about normal ranges of penile size and reasonable expectations about the outcome of surgery, they would choose not to undergo the augmentation procedure, even if offered for free. Possible role for ISSMDr. Prithy Ramlachan suggested media statements from the ISSM advising and informing males worldwide about the issues regarding penis size problems and the fallacies and misconceptions regarding the issue . ISSM �in his opinion- would thus go a long way in alleviating a lot of suffering worldwide ,both financially and psychologically. Dr. Yoram Vardi strongly supported this suggestion. SummaryMost ISSM List members advised against surgical intervention for penile augmentation, and suggested mainly education, psychotherapy and possible SSRIs or other psychotropic medications. However, other members pointed out those patients do have the right to this cosmetic procedure. There was no disagreement about the statement that this is still an experimental procedure with limited benefit and significant potential complications. Limiting further study in this field to University settings, with supervision from appropriate ethics committees, and no financial burden for the patient -suggested by Dr. La Pera and supported by D. Vardi- might be the safest and most fair way to go ahead for both the patient and the physician, and was not contested by any of the ISSM List members. The details of the previous discussions on ISSMList may be read on http://www.issm.info/ by clicking ISSM List / interesting cases and discussions / and scrolling down to the topic of interest. Ihab Othman, M.D. Hussein Ghanem, M.D. Question PostedDear ISSM /SLAMS Members, I have a question about penis enlargment treatments. A lot of young males want to have a bigger penis. Is there a succesfull treatment? Where? And how succesfull is it. Thanks, Oscar. Cordialmente, Detailed responsesI personally do not agree in this kind of procedure. And I do not know any professional, in my country, that performs this procedure with really good results. We generally see bad results and a lot of complications. Than, I think that the patients who complain about the penile dimensions have to be treated with psychotherapy, conversation and/or explanations about the normal anatomy and dimensions, and not with surgical procedure. Carlos Da Ros Dear folks, I have a somewhat different question about this issue. Does anyone know of data concerning the motivation of these men? Is it a sexual turn-on for them, for their partners? Dear all Hi, I do agree that an investigation into the underlying reasons and expectations after the enlargment are most important. Maybe, we should recomend that every man who wishes to have penis enlargement will meet a sex therapist for such an evaluation. According to my experience, we sometimes diagnose a sexual dysfunction that can be treated efficiently. As a sexual health physician I counsell many men who wish to undergo this procedure. They all have in common on examination a completely normal average sized penis (stretched flaccid length 5 to 6 inches). These men have a perception that their penis is small and the cause of relationship and social problems. I am inevitably told their partner complained their erection was not long or wide enough for satisfying sex. This condition comes under the body image condition called body dysmorphic disorder. It can be difficult to treat with counselling and psychotherapy. A penile lengthening and widening procedure makes little difference to the psycho-social problems potentially deteriorating the patient's psychological status. Penile lengthening surgery should only be indicated for micro-penis. I support this, and this is our local practice in the UK. Dear Colleagues, Dear all, Dear Oscar: for 3 years we have being using de Andropenis device. Actualy more than 70 patients used it. Results: average enlargement cm.4,2 through 8 to 10 month of use for about 10 hours/dayly. I think is much better than the chirurgical solutions that some phalloplastic surgeons still perform.. Dear Dr. Moreira: Dear Dr. Moreira: Thank you in advance. sincerely yours Dear all I have seen a lot of young males in my practice much concerned about their penis size and in many cases they have strong and deep beliefs that they really have small penis.actually,on examination they are completely normal so I like to stress on the following points: 1) we must admit that the old-new dream of all men since adam,s age is to have a bigger penis. 2) most if not all who ask about these procedures are young(sexually- fanatic ) adults. 3) many of them respond and get satisfied by my explanation and assurance. 4) in many cases most of what is called augmentation phalloplasty end to nothing but failures if not mutilation or severe disfigurement forcing many surgeons to quit such procedures. 5) I strongly agree that those patients should undergo detailed sexual and psychological evaluation Dr hesham Nabil Khaled In the world of sexual medicine I think we need to move from reversible to irreversible methods to help patients with this unusual syndrome. This is particularly the case when there is considerable dissatisfaction in the patient group after surgery � hardly surprising when most of the men have a normal penis size and shape in the first place. There are many options to me including self help work, internet support, psychotherapies, devices and pumps, but most of all, the chance to have an interaction in a challenged environment before proceeding to surgery. I believe all physicians and therapist should work together with surgeons to ensure a thorough assessment takes place before any type of surgery is offered. However, we also need to respect patient rights to buy cosmetic procedures but to give them accurate information in advance. Most of the patients I see, in collaboration with surgeons in the UK, choose NOT to proceed to surgery especially when they appreciate the consequences with size changes and potential scarring. Kevan. Kevan R Wylie MD DSM FRCPsych Dear friend Santiago We should extend some credit to Freud... do not compare penile cosmetic with something else cosmetic surgery. There is nothing to do.... smelling, hearing.... with phallic scar, pain, etc. Dear friends, If the surgery of penile augmentation have uncertain results and short follow up this should be considered an experimental surgery. An excellent proposal but not a realistic one! Dear All: There are two issues here: i) Whether there is at all a NEED for such operations, and whether a man has a RIGHT to augment his penis if he wants to: just like a lady can augment her breasts, etc.. I believe that a man cannot be denied this right, and that those who men are genuinely `needy' and those who are refractory to counseling and therapy must have an option to choose if they want to undergo such an operation. Many men are sexually crippled because of this falsely held belief that they are not `big enough'. They deserve help. This brings us to the second aspect, viz. ii) Do we have today, the ideal operation/s that can deliver the goods ? Since the answer to this seems to be an emphatic NO, the question is whether research to develop such operation/s should continue or not. I believe that the answer to this is YES. If we can deliver a longer and thicker penis with good cosmetic and functional results, without significant complications, short term or long term, and enduring results, that would be ideal. Just because we don't have such an operation today, we cannot say that such surgery must never ever be performed. That might be a bit drastic and unfair. Sudhakar Krishnamurti. Dear All, I have another issue related to this topic. I was recently consulted by a
young man with a micropenis. Reading about your concerns re penis
enlargement surgery in men without a genuinely small penis, I wonder whether
penis enlargement surgery could be recommended in this case. If so, I would
be grateful if you could let me know who would be most experienced
preferably in Germany and neighbouring countries. Dear Claudio - Does the individual really want the surgery, even after we showed him that his penis is of an average normal size? - Is he psychologically stable or is there a "fixation" that may develop into a different mania later on? - Do we have a good, safe and durable surgical technique to offer? One should not deny Cosmetic surgery to someone only because we think that it is useless, or we are satysfied with the size of our penis. I agree with the ongoing discussion that penile enhancement surgery is a complex phyical and psychological problem for the effected individual. The problem is that the available techniques to try to surgically fix the problem have been less than satisfying for all concerned (ie the patient as well as the critcal physician). There are clearly men who can benefit from suspensory ligament releas, all be it just 1-2cm on averag, and if the patient accepts this as success then it's a win-win. Unfortunately in the US it seems that those who are offering lengthening procedures are not giving proper preop expectations to the patient.Girth enhancement remains a problem as well but the new grafting techniques are interesting.There is also a large group of these men who clearly are psychologically distressed by what they think is a small penis. First line approach with these men should be psychotherapy and maybe a consideration for surgical remedy down the road. Lastly it may be that some of these streching devices emerging on the market will provide some benefit. We need to see some properly done studies reported b/4 jumping on this band-wagon. Larry One of the main issues to treat these cases is to explain to both members of the couple that pleasure is not measured by and does not depend on the size of thr penis. Through pleasuring and learning how to feel without thinking alot on what could block the sexual response, and explaining that the most sensitive anatomical area of the vagina are the 2 outer inches of it. The couple must understand the diferences between all the penises she/he coul see or feel and becoming a better lover is better than complaining or choosing a partner for the size of the penis. I think that Dr Sudhakar got to the point!
Penile Girth Augmentation Using Flaps "Shaeer's Augmentation Phalloplasty": Thank you and best regards.
Dear Colleagues Dear friends, it is very interesting this discussion, where all are right. In much of these cases the attention multidisciplinary (sexologist, psychiatrist, psychologists, Urologist, etc), they have not been able to convince them that the woman has the whole sencibility in the entrance of the vagina and that They are not necessary to have a long penis that the important thing is that this rigid one and to know it appropriately use. We have operated some cases of lengthening with less than 8 - 9 cm (episipadias and hipospadias, amputations for cancer and Peyronie�s disease), where the surgery was suitable, because they were not able to penetrate in vagina or their penis came out easily. The great majority of the patients that they consult for "small penis", without having it really. We are convince their that they are more the risks that the benefits that they would obtain with a lengthening surgery and we achieve them to desist, but in very special cases, we don't achieve, not even that they listen to us. Their depression and necessity to be helped, for sexologists recommendations, psychologists and psychiatrist, they recommend us that it is convenient (Like the Doctor Rossello says) that they are operated. In our small experience, we have had to operate two cases with 11 and 13 centmeters of long, with this indication and in both cases they are happy with their two centimeters that represent as two Kilometers for them. One of these patients was operated March 14 the 2003, with the Professor Rosello Barbara in a Course of Surgery Andrology post 16 World Congress of Sexology in the Havana and the recently did it with him and with Larry and them We could check its satisfaction with its Surgery of Lengthening and engrosamiento peneano, we even have its picture. I would like the Professor Rossello to make some comments of its experience with these cases. I write them in Spanish to be able to express my idea better with
relationship to this topic. A Hug. Dr. Hussein Thank you for your information, as psychologist, I confirm your findings. There is much more hidden under body dysmorphic disorder then only the size of the penis, nose, breast, and so on, that lead people to want and look for surgeries to correct them. Wise advise by Profs. Saad Girgis and Anwar El Etriby. Cila Ankier Dear Hussein / Colleagues: Why can't a normal man, with a normal sized penis, who already knows that his penis is normal sized, simply want more ? This is not an unreasonable request. Yet, we are not addressing it. Best. Sudhakar Krishnamurti. The latest from the BBC... ** Most men 'unhappy with penis ops' ** Dr Kevan Wylie
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