Digest of recent discussions on ISSM mail (May 2009 - Aug 2009)

VII

T R MURALI

Complaint of a Small Penis by Parents of Overweight Boys        

 27 July 2009: 9 messages

1

I see a large number of boys in the age group 10 to 12 years, whose parents complain of a small phallus and small testes. Such boys are fat, with fullness of their breasts, and have excessive pubic fat which buries the penis and makes it even shorter. Such kids sometimes themselves complain of the small size of their organs being made fun of by their peers.
Evaluation of the fasting hormone profile shows a low s testosterone, low s. LH, often low FSH and normal s. prolactin. When these cases are seen by the endocrinologist, invariably the parents are asked to wait till the pubertal growth spurt; which is not predictable. Definitely these patients must be having a tardy pituitary response since the physical characteristics and hormone profiles are correlative and unlike other boys.
Since most parents are anxious and do not want to wait for the onset of puberty,
I, in my practice, give a six week stimulation with HCG injections 1500 units twice a week for six weeks. I insist that I see them at the end of three weeks and again at the end of the course at 6 to 12 weeks. I have noticed invariably that there is a significant improvement in the size of the penis as well as the size of the testes. In a few cases, pubic hair just makes its appearance. Both the patient and the parents are greatly satisfied by this growth. They are psychologically reassured about normal further growth at puberty for which I ask them now to wait.
I follow with annual hormone estimations, and though the s. test and s. LH drop again, the changes in the penis and testicles sustain.
In two patients who had nocturnal enuresis after this course the NE disappeared completely.
This satisfied the patients even more. I postulated it was due to increased resistance due to the growth of the prostate.

I would like to know from my colleagues whether they see such cases, and what they do. Is short course hormonal stimulation advocated, if not and one has to wait for the puberty, how long should the wait be? Does onset of puberty always correct this problem? What is wrong with this short course of stimulation? If it is going to be effective without causing any damage, and most of all if it is going to satisfy this group of anxious patients with its final outcome, why not advocate it? Thank you.

 T R Murali (golde2003@gmail.com)

2

We frequently see this complaint in the Middle East.  Our main concern is to avoid the development of
 a body dysmorphic disorder in these boys due to the neurosis / lack of information of the parents.
 I have heard comments by parents, in the presence of the child, like ‘his younger brother has a much 
larger penis’.  I've also seen attempts to pass off the body dysmorphic disorder as from father to son:
 ‘his penis is small like mine, its hereditary’.  A physical examination followed by educating the parents
about the normal size of the prepubertal penis is almost always sufficient to 

alleviate the concerns.  An empathetic attitude is very important. Inducing precocious puberty in these
 boys in response to the parents complaints might end up with a boy who is convinced that he does 
have a small penis requiring treatment. I conclude by suggesting to the parents, after 

building rapport to avoid offending them, that their son doesn't have a problem but they do.

Hussein Ghanem (hmghanem@HOTMAIL.COM)

3

4

What worries us is that entity called body dysmorphic disorder, that can be treated by reassurance and, in some cases (like in OCD), by the use of an SSRI. Dr Ghanem, myself, Dr Glina & Dr. Buvat have written a paper for the Standards committee of the ISSM about the small penis. Hussein, I think it is time to publish it.

Pierre Assalian (pierreassalian@3WEB.NET)

5

I have been following the hot discussions regarding young boys with small penis. I have the following points:
1) We, as andrologists, see a lot of boys with such a complaint. The basic approach is never to interfere before the age of 14. The best `treatment’ is proper reassurance of the worried parents and the boy plus good sex education, stressing that most of these boys will catch up, in time, and resume normal development later.
2) Many of these boys have constitutional delayed puberty, so what is the value of measuring the T, LH and FSH at this stage ?
 
Hesham Nabil (heshamnk@HOTMAIL.COM)

6

I want to add two points for emphasis:

1) the source of the sexuality (mis)education - friend, professional prostitute, etc...

2) the effect of pornography on the devaluation of normal people with normal penis sizes. 

Shedeed Asahour Shedeed (shedeedash@YAHOO.COM)

7

I treat such boys with conservative watchful follow-up every 6 months: height, weight, phallus and testicular measurements, after the initial hormonal assays. Reassurance, weight loss, exercise, TV-watching no more than 2 hours a day, and no eating while watching TV. I start intervention at 14 if adrenarche does not start by then, with very small doses of androgen (to guard against premature closure of the epiphyseal plates). Nobody can be sure that all of them will attain normal puberty levels but if intervention is needed, at least the timing will be optimal. The cornerstone is the pubertal generator check and the point at which this will start, so regular observation with reassurance and education of the parents is of utmost importance.

Shedeed Asahour Shedeed (shedeedash@YAHOO.COM)

8

The penis is a symbolic part of the body. Unfortunately there is a worldwide false link between penis size 
and manhood. Teenage is also the age of much questioning on the body. If penis size is normal, it is very i
mportant to explain to the boy his normality.  For that, we can use the aid of human penis size averages 
and statistics. Anxiety, lack of self-assuredness, and sometimes even major depressive disorders can result
 if size and/or body image are perceived as subnormal. The patient must be reassured that size is not
 important for a woman to obtain an orgasm, and that size is not important to be a man. Usually, the problem
 is not the size of the penis per se but something else. It is a symptom and maybe the patient needs the help
 of a sexologist, a psychiatrist or a psychologist concerning his anxiety or a major depressive disorder.

Marc Bonnard (marc.bonnard@WANADOO.FR)

9

I agree with Dr. Bonnard. Before we do more harm by using unproven treatments such as HGH which may have
 a testosterone-like effect on tissues including bone, we should try to reassure our young patients; that 
patience is necessary to allow the body to grow; that we all have different growth rates; and that waiting will 
not interfere with later treatment. This kind of delay would be indicated in the great majority of young men 
unless of course they have evidence of a micropenis (defined inconsistently but <5cm stretched length in 
post-pubescent male is a reasonable measure to use). It is certainly reasonable to use the consultation to 
stress weight loss and its beneficial effects on visible penile length.

  

                                                                                 Laurence A Levine (drlevine@HOTMAIL.com)