Abstract
This study aimed to report penile dimensions in adult Egyptian males consulting for small-sized penis (SSP) and describe their demographics and andrological profile. A case control study was designed through retrospective data analysis of patients (n = 239) seeking advice for SSP and a control group (n = 59). This included sociodemographics, other andrological complaints, and penile dimensions (pendulous length [PL], penopubic or total length [TL], and circumference [CF]) at flaccid and erect states and the size of the prepubic fatty pad. The results reported that most patients were single, students, and smokers and had not completed a university education. Several patients reported falsely premature ejaculation (PE), penile curvature (PC), and small-sized testes. Most penile dimensions of the patients (mean, cm) were significantly lower than those of the controls, whether in flaccid (PL: 7.4 vs. 8.05, p = .008; CF: 8.7 vs. 8.98, p = .026) or erect state (PL: 11.8 vs. 13, p = .000; TL: 14.2 vs. 15, p = .000; CF: 11.3 vs. 11.8, p = .003). However, no patient presented with a pendulous penile length <4 cm in flaccid or <7 cm in erect state. In conclusion, Egyptian men consulting for SSP did not have true small organs, but their penile dimensions were slightly smaller than those of men without such complaint. The proper sexual education program is highly advisable in these situations to avoid the myths and misconceptions about sexuality.
Keywords
Introduction
Since the early medieval times, the Arabic literature emphasizes that penis size is “a sign of honor” and that “a longer penis is preferred.” This idea is still imbedded in the minds of many Arabic men. These men believe that good reproductive and sexual function accompanied by the ability to gratify themselves and their partners is associated with a larger penis size. These men also usually look at the penis as an identifier of masculinity (Al-Jahiz, 2013). In Arabic nations, and according to Islamic themes, the loss of one’s penis is comparable to losing one’s soul and life (Al-Khamees, 2003; Al-Zoaimel, 2012) in what is called di-ya, an Arabic word that means the obligatory money paid for crimes involving the loss of life or damage of one’s body organs and function. This matching between loss of one’s penis and life may indicate to which degree a penile image occupies a big area in the mind of any Arabic man. In spite of the importance of penile image in Arabic culture, there is an obvious shortage of anthropometric data of the normal penile size in Arabic countries including Egypt.
A male’s perception of his penis size can affect his self-esteem (Son, Lee, Huh, Kim, & Paick, 2003; Spyropoulos et al., 2005). This may reflect on how he communicates with his sexual partner (Spyropoulos et al., 2005). With the advent of penile enhancement procedures, men with a preoccupied perception of their penises as inadequate have found a magic solution to their problem. This has led to a rapid inflation of the number of these procedures, and the number of men consulting for small-sized penis (SSP) has increased (Vardi, Har-Shai, Gil, & Gruenwald, 2008). This obvious interest in penile size is further augmented by the global spread of the Internet and pornography (Wylie & Eardley, 2007).
Men with distress about penis size may relate this distress to penile length, circumference, or both. In addition, concerns may be present not only for the erect penis size but also for the flaccid penis size (Vardi et al., 2008). Therefore, accurate assessment of penile dimensions represents the cornerstone for evaluating men consulting for SSP, and inhibiting their unrealistic belief that they have micropenis. The latter condition is diagnosed when the penis has a normal anatomy but has a stretched length of 2.5 standard deviation below the mean for the age-group (Aaronson, 1994). This is in contrast to dysmorphophobic patients who have normal-sized penises but who perceive imaginary and unreal flaws in the organ’s image (Wylie & Eardley, 2007). Several studies have measured penile dimensions to provide nationally based reference ranges (Ajmani, Jain, & Saxena, 1985; Awwad et al., 2005; Khan, Somani, Lam, & Donat, 2012; Ponchietti et al., 2001; Promodu, Shanmughadas, Bhat, & Nair, 2007; Richters, Georofi, & Donovan, 1995; Son et al., 2003; Wessells, Lue, & McAninch, 1996). Data from these studies were retrieved from potent and/or erectile dysfunction (ED) men not concerned with penile size. Studies that provided penile measures in men consulting for SSP are now emerging (Mondaini et al., 2002; Shamloul, 2005; Wylie & Eardley, 2007). These studies recorded penile measures at flaccid and stretched states but not during an erection, and it is this penile state that is most concerning to patients (Mondaini et al., 2002; Shamloul. 2005; Vardi et al., 2008). Apart from evaluating penile dimensions in men consulting for SSP, the studies did not give much attention to the characteristics of these men that may help augmenting their concerns and urge them to seek medical advice.
Therefore, it was of interest to evaluate Egyptian men who seek advice for an altered perception of penile size on the basis of penile dimensions in flaccid and erect states and their sociodemographics and andrological profile, and to compare these features with those of men without such complaint.
Material and Method
Study Design and Subjects
This was a case control study. A retrospective analysis of consecutive patients’ records who consulted the andrology clinic at the Alexandria Faculty of Medicine for SSP, during the period between November 2003 to April 2006 was carried out. A control group consisting of consecutive men who consulted the clinic during the same time period for other reasons not including SSP was enrolled. The consecutive selections of the patients and controls were done to keep these selections randomized. The protocol of the study was approved by the departmental review board. All study participants were asked to provide informed consents. Exclusion criteria included men with a history of endocrinological disease, penile/urethral disorder, or surgery that may affect penile dimensions, such as hypospadius, epispadius, Peyronie’s disease, prostatic intervention, urethral stricture, and penile tumors. Exclusion criteria also involved testosterone replacement therapy in cases of hypogonadism and ED as studies have reported that ED may affect penile measures (Kamel, Gadalla, Ghanem, & Oraby, 2009; Khan et al., 2012). In men with sexual partners, the existence of ED depended on both patient’s self-reporting and the five questions of the international index of erectile function-abridged form (score ≤ 21; Rosen, Cappelleri, Smith, Lipsky, & Peña, 1999). In those with no sexual partners, ED was assigned when there was a poor penile hardness and satisfaction during masturbation, with the use of sexual excitation in the forms of tactile or audiovisual stimulation. These criteria were later reported to be corresponding with those introduced by other researchers (Huang et al., 2014).
Data Collection
Data collection included sociodemographics, such as age, occupation, education level, marital status, height, weight, and BMI (body mass index). Past histories were taken and recorded with special emphasis on andrological profile. Information related to any history of alcohol intake, tobacco smoking, or intake of drugs along with clinical checkup was also collected.
Penile Measurements
Penile measurements were retrieved from patients’ files. The measurements were collected by a single physician who had no knowledge of the study. The patient undressed on the bed to avoid any effect of temperature or touch on the penile dimensions. The penile measures were collected with warm examining hands and were recorded promptly and in privacy. The examination started with estimating the penile dimensions while in a flaccid state. This included penile length using a rigid ruler, and midshaft penile circumference using a tap to the nearest 0.5 cm. The length was recorded on the dorsal surface of penis extending between penopubic skin junction and penile tip. This was called the pendulous flaccid penile length. As a sizable prepubic fatty pad may be present in some men, leading to a partially buried penis with an apparent decrease in penile length, the penile length was again measured while pushing the ruler against the edge of pubic bone (J. Chen, Gefen, Greenstein, Matzkin, & Elad, 2000; Khan et al., 2012; Wessells et al., 1996). The resulting measurement was called the total (penopubic) flaccid penile length. The size of prepubic fatty pad was also estimated while pressing it against the pubic bone (Savoie, Kim, & Soloway, 2003).
Penile measures were evaluated again in the same way after induction of a completely hard and fully rigid erection (Grade 4; Boolell, Gepi-Attee, Gingell, & Allen, 1996) using PGE1 (Prostaglandin E1; 10 µg). Herein, the pendulous erect penile length, the total erect penile length, and erect penile circumference were obtained. While these measures were taken, a clinical checkup of penile image was done. This was immediately followed by photography of the penis to document any patient’s self-reported penile curvature (PC) for further management. Scrotal sonography was also done to confirm and document the clinical estimation of testicular volume in cases of the alleged small-sized testis. The validity of existence of premature ejaculation (PE) was decided by recommendations suggested by the International Society of Sexual Medicine (McMahon, Althof, & Waldinger, 2008). Other andrological problems were evaluated using criteria given by the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000).
Statistical Analyses
The retrieved data were analyzed using SPSS statistical software for Windows Release 16 (SPSS Inc., Chicago, IL) on a personal computer. Descriptive statistics (mean, standard deviation, and range) for penile measures, and distribution and percentage of demographic variables were calculated. The demographics of the patients were matched with those of the controls using a chi-square test. As sample sizes and variances of the patients and controls were unequal, the Mann–Whitney test was used to compare penile measures between both groups (Rosner, 2000). A p value <.05 was considered significant.
Results
Most penile dimensions of the patients were significantly lower than those of the controls, whether in flaccid or erect state. However, no patient presented with a pendulous penile length
Study Subjects
Two hundred thirty-nine men complaining about SSP and 59 men without this complaint (controls) were enrolled in the study. The majority of the controls (47 men; 79.7%) came for a premarital checkup. The other 12 controls alleged PC and PE, eight and four patients, respectively. All the study subjects showed well-developed secondary sexual characters and were circumcised as they all were Muslims. Both marital status and education levels in both groups were similar (Table 1). However, single men in the patient group reported to have more sexual partners, although this is an insignificant finding, than the control group. Data analysis identified that the number of sudents in the patient group was significantly higher while that of white-collars who are professional workers whose jobs do not include manual labor was significantly lower than in the control group (Table 1). Smoking was reported as significantly higher among the subjects of the patient group than those of the controls (Table 1). No subjects had a history of alcohol intake, and the age and BMI of both groups did not report significant differences (Table 2).
Demographics and Other Alleged Andrological Problems in the Study Groups. a
Note. There were no data about marital status in 6 patients and occupation in 39 patients and 10 controls. These missed data were considered during calculating the corresponding percentages.
Chi-square test.
The Age, Body Mass Index, Penile Dimensions, and Prepubic Fatty Pad in the Study Groups.
There were 5 patients with missing data for these parameters.
Mann–Whitney test.
Andrological Profile
Some men in both groups reported other andrological complaints (Table 1). Of these complaints, PE was significantly existent (71 men) in the patient group. In that 71 men group, 35 (49.3%) men were single. Of these 35 men, 14 had girlfriends (more than one girlfriend) and 21 did not claim to have partners but reported masturbation. On the other hand, the control group members with PE (8 men) included 5 who were just within the first 10 days of marriage, one who had several girlfriends, and 2 married men. Clinical evaluation and photographs taken for erect penises revealed no real PCs in any of the study subjects. Twenty participants self-reported PC. However, normal tilt of the penile glans on the shaft was discovered in 18 participants and insignificant PC was found in the other two men. Ultrasound-estimated testicular volume in men complaining of SST confirmed the normal result of testicular clinical examination and yielded normal values.
Conditions Causing Subjects to Seek Advice for SSP
Screening of 40 patients with documented data identified that the most common condition (25 patients, 62.5%) was the preoccupied idea related to the strong relation between penile size and the future ability to have a satisfactory sexual/reproductive activity with the spouse. Other causes included watching pornography and Internet advertisements (seven patients, 17.5%), comparison between the patient’s and friends’ genitalia (five patients, 12.5%), and criticizing comments from sexual partners (three patients, 7.5%).
Penile Measurements and Prepubic Fatty Pad
The controls had significantly higher value for all penile dimensions as compared to the patients, except total flaccid length, which was higher but insignificant (Table 2). In spite of the significantly higher average values of the penile dimensions in the control group, there were 59 (24.7%), 112 (47.1%), 69 (28.9%), 81 (34.6%, missed data in five patients), and 81 (34%, missed data in one patient) patients whose dimensions were equal or even exceeding the average control values of pendulous flaccid length, flaccid circumference, pendulous erect length, total erect length, and erect circumference, respectively. There were no subjects in the study who showed pendulous penile length less than 4 cm in flaccid or less than 7 cm in erect state or penile circumference less than 6 cm or less than 8 cm in flaccid and erect states, respectively. Table 2 also reveals the bigger size of the fatty pad in the patient group compared to that in the control group.
Discussion
This study is a retrospective case control study describing penile dimensions in potent Egyptian men seeking/not medical advice for SSP whether in flaccid or erect state. Several studies from different parts of the world, including the Middle East, described previously penile dimensions but only in men referred for ED (Awwad et al., 2005; Kamel et al., 2009; Khan et al., 2012; Promodu et al., 2007). Penile length was reported in some studies to be shorter in men with ED than in men without ED (Kamel et al., 2009; Khan et al., 2012). Penile dimensions in the present study report represent real penile measurements in adult Egyptian males with a decreased incidence of the confounding impact of ED-associated disease. These criteria made the present data the largest Middle East study investigating men who present for SSP. It also start to establish a reference range for penile dimensions in adult Egyptian healthy males in flaccid and erect states based on the dimensions of the study controls. These results could be useful for physicians consulted for SSP.
Several previous studies assessed penile dimensions, but their data included adult males without the SSP complaint. The mean pendulous flaccid penile length reported in the present study for the patient group was 7.4 cm. This was larger than reported by Son et al. (2003, 6.90 cm, Korea) and X. B. Chen, Li, Yang, and Dai (2014, 6.50 cm, China), but shorter than reported in other studies from different countries (Ajmani et al., 1985, 8.16 cm, Nigeria; Khan et al., 2012, 8.70 cm, England; Ponchietti et al., 2001, 9.00 cm, Italy; Promodu et al., 2007, 8.21 cm, India; Wessells et al., 1996, 8.85 cm, the United States). The current work included some measures not available or considered in many previous studies. These measures included an estimation of the prepubic fatty pad. Savoie et al. (2003) and Son et al. (2003) estimated it to be 2.5 cm ± 0.9 and 1.1 cm ± 0.4 in their American and Korean patients, respectively. The depths of the prepubic fatty pad in the control and patient groups as demonstrated in the present study (1.97 cm ± 0.8 and 2.4 cm ± 1.2, respectively) were smaller than the pad values in the first study but bigger than these values in the second study. The difference between our data and the two other study data may be related to the difference in the body constitution between our studied Egyptian men and American and Korean men in the Savoie et al. (2003) and Son et al. (2003) studies. Estimation of the fatty pad is useful as some penile enhancement procedures entail removal of this fatty pad (Vardi et al., 2008). The flaccid total (penopubic) penile length, which was assessed by exceptionally few studies (J. Chen et al., 2000; Khan et al., 2012; Son et al., 2003), was also evaluated in this study. Assessment of this length is of special interest as it helps standardize measurements in patients with variations of their prepubic fatty pad (Vardi et al., 2008). The mean total flaccid lengths for the controls and patients reported in the present study were 10.02 and 9.7 cm, respectively. These were shorter than that reported by Khan et al. (2012, 10.2 cm, England), but larger than that reported by Son et al. (2003, 8 cm, Korea) and J. Chen et al. (2000, 8.3 cm, Israel). Assessment of penile midshaft circumference was missing in many previous studies (Awwad et al., 2005; Khan et al., 2012; Richters et al., 1995). In the present work, this dimension was also estimated. It was 8.98 cm ± 0.9 for the controls and 8.7 cm ± 0.95 for the patients. This was larger than that reported by Son et al (2003, 8 cm, Korea), X. B. Chen et al. (2014, 8.00 cm, China), and Mehraban, Salehi, and Zayeri (2007, 8.66 cm, Iran). Girth assessment is important as many men are now requesting its enhancement (Alter & Jordan, 2007; Vardi et al., 2008) .
In the present study, penile dimensions at erection were assessed after pharmacological induction. These dimensions are considered important by many men as essentials for their future fertility and potency capability (Al-Jahiz, 2013; Wylie & Eardley, 2007). They were not substituted with penile measurements during full stretching like many other past studies (Awwad et al., 2005; Kamel et al., 2009; Khan et al., 2012; Mondaini et al., 2002; Ponchietti et al., 2001; Savoie et al., 2003; Shamloul, 2005; Son et al., 2003; Spyropoulos et al., 2005). There were a number of reasons for this decision. First, many subjects in the current study consulted the andrology clinic for a premarital checkup. The tests in the checkup usually include induction of pharmacological erection. Second, several patients complained, in addition to the SSP, of PC. To exclude or approve its real existence, induction of erection was necessary. Third, several patients complained of SSP at erection (data not reported). It was very difficult to convince them that measures of the fully stretched penis are closely comparable to those of the erect penis (Spyropoulos et al., 2005; Wessells et al., 1996). Fourth, the assessment of the penis in a stretched state does not yield a value for girth comparable to that in the erect state. This measure is of special interest as studies have reported that a considerable number of women suggested the erect penile girth to be more important than length for sexual activity (Francken, van de Wiel, van Driel, & Weijmar Schultz, 2002). Fifth, penile length assessment during stretching may be associated with remarkable variations depending on the technique and user variation of stretching (Bondil, Costa, Daures, Louis, & Navratil, 1992). Sixth, missed data of penile measures in erect state were considered as limitation in some studies (Spyropoulos et al., 2005). The present study, therefore, is the first study from the Middle East that provides a reference range for erect penile dimensions in normal men and those concerned with their penile images.
In the current work, the mean pendulous penile length in erect state was 11.80 cm in the patient group. This was similar to the Jordanian study (Awwad et al., 2005) but shorter than the Indian (Promodu et al., 2007, 12.93 cm), Chinese (X. B. Chen et al., 2014, 12.90 cm), and the U.S. studies (Wessells et al., 1996, 12.89 cm). Reports on the mean erect circumference have only been investigated in India (Promodu et al., 2007, 11.49 cm) and the United States (Wessells et al., 1996, 12.3 cm). In the present study, this dimension in the patient group (11.3 cm ± 1) was smaller than that of the two compared studies but larger than the Chinese study reported by X. B. Chen et al. (2014, 10.50 cm). Data on the total or penopubic erect penile length were only investigated by J. Chen et al. (2000, Isreal) study who reported a mean length of 13.6 cm. This measurement was shorter than that of the patients in this study (14.2 cm) and the controls (15 cm). In general, data of different penile dimensions from different areas in the world identify obvious discrepancies. This could be due to variations in ethnic background and the technique used to estimate the penile dimensions, especially the length and the studied sample size. It is of note that these previous studies included adult males without concern about penile image. On the other hand, a comparison between the penile dimensions of the patients in the current study and those patients who presented with concerns about short penis followed by aesthetic surgery (Perovic & Djordjevic, 2000, erected length 8.3 cm, Serbia; Spyropoulos et al., 2005, stretched length 9.12 cm and girth 6.4 cm, Greece; Yacobi, Tsivian, Grinberg, & Kessler, 2007, stretched length 9.5 cm, Israel) identified larger penile dimensions. However, the estimated dimensions in these studies were not less than 7 cm. Thus, no patient could be assigned to have a real short penis (Mondaini et al., 2002; Shamloul, 2005; Wessells et al., 1996).
The current data related to penile dimensions during flaccid and erection states identified a significant difference between the two study groups in regard to all estimated dimensions, except the total flaccid length (Table 2). This may be related to multiple factors, including the presence of prominent prepubic fatty pads in the patient group that could mask some centimeters of the penile length. Also, the psychological nature of the patients consulting for SSP could be inhibited due to unfavorable surrounding circumstances and being in the hospital during erection measurement. This may stop the full ability of the corpora to expand maximally (Promodu et al., 2007). Furthermore, the relatively small sample size (59 controls) available for statistical comparison may not be large enough to obtain the most statistically accurate means. This can be avoided by increasing the number of controls in a future study, which is currently in progress. However, no patient in the current work presented with penile length <4 cm or <7 cm at flaccid or erect state, respectively. These values were taken into account as normal (Mondaini et al., 2002; Shamloul, 2005; Wessells et al., 1996). Accordingly, none of the patients who consulted initially for SSP had a true small penis as compared to the control group. In addition, several patients had penile dimensions that were equal to or even exceeding the average control values of these dimensions.
The reasons men may have concerns about their penile images vary from population to population. In an Italian study (Mondaini et al., 2002), the reasons involved a comparison between the patients’ organs and their friends’ ones from early childhood (62.7%) and after watching pornography (37.3%). In other studies, sexual inadequacy was the leading reason to seek advice (Austoni, Guarneri, & Cazzaniga, 2002; Perovic & Djordjevic, 2000; Spyropoulos et al., 2005, from Italy, Serbia, & Greece, respectively). These were in contrast to the patients in the current study who expressed questions about any possible relationship between their penile dimensions and future potency/fertility potentials. In all these studies, no men were found to have a penis that qualified as a short penis (Mondaini et al., 2002; Shamloul, 2005; Wessells et al., 1996, from Italy, Egypt, & the United States, respectively).
In the present study, there were 71 men in the patient group versus 8 in controls (p < .01) who reported PE. However, this condition was not found to be present when the history they provided was compared with the definition introduced by International Society of Sexual Medicine (McMahon et al., 2008). Men with this complaint did not have consistent sexual relations with their sexual partners. These partners were girlfriends who were frequently changed and not wives. Ejaculation almost always started beyond 2 minutes following penetration. Data of the present study also identified that 8 and 12 patients complained of SST and PC, respectively. The existence of both conditions was rejected after assessment of testicular volume using orchidometer and ultrasound evaluation, and during clinical examination after pharmacological erection in case of PC. These frequent andrological complaints of the current study patients reflect many concerns in these patients about their genital image and function. These findings agree with Ropponen, Aalberg, Rautonen, and Siimes (1994), who speculated that the perception of the small size of a sexual organ (penis) may trigger the psychological experience of wrong development of other genital organs. These frequent andrological complaints may also be related to lack of knowledge about many anatomical and physiological basics of human sexuality, leaving the door open for myths and misconceptions. These beliefs might be initiated by lack of proper sexual education as the majority of patients in the current study (77.4%) had no university education. The proper sexual education about different andrological problems is supposed to help reduce the hospital visits.
The present study reported that concern about penile size had some relation with the person’s occupation. This appeared evident in both the significantly higher number of students with no actual jobs and the lower number of white-collars in the patient group. The abundance of free time, rapid inflation in Internet use, and being single may have influenced these students, who had not yet finished their university education, to check many unsuitable websites. These conditions might represent the initial step of generating concern about penile size. Future research as to the degree to which the social and pornography influences determines perception of penile length is, therefore, warranted. In contrast, white-collars, who have university degrees, are mostly married, are busy with their jobs, and have different life interests. Thus, their concerns about penile image would be low.
Some limitations are present in the current study. One limitation is that the sample size of the control group was relatively small, and this might affect the results of comparing differences in the penile dimensions between the patient and control groups. It would be advisable to study a larger sample in a prospective manner to get a well-balanced comparison between the patients’ and controls’ data and be able to establish a comprehensive nomogram for penile dimensions in Egyptian men that is absent so far. Another limitation is that the study participants represented standard clinical samples from a single clinic and were not picked up from the general population. This might be associated with selection bias, which is frequently incriminated in most past studies (Promodu et al., 2007; Shamloul, 2005).
Conclusion
The present findings support observations, documented in several previous studies from different parts of the world and with diversity in sociocultural background, of normal penile dimensions in most men seeking advice for SSP and their altered perception of penis size. The penile dimensions of the control group can provide a preliminary reference value for adult Egyptian males. This can help comparison between Egyptians and men of other races and aid in counseling men concerned about SSP before stepping toward a penile enhancement procedure. The current study throws the light on the remarkable deficiency of sexual education programs in the Egyptian community that leave young men with the wrong information provided by their mates and unsuitable websites.
Therefore, an extension of the study to include more men who can provide big data about penile dimension is highly recommended. This will ultimately establish a solid and well-described nationally based nomogram of penile measures in Egyptian males. The extended study should verify if altered perception of penis size among Egyptians is due to just wrong information or related to penile dysmorphophobia under which patients need psychiatric consultation to get the proper management. In addition, proper sex education programs are highly advisable to avoid the myths and misconceptions about sexuality.
Footnotes
Author’s Note
A master table of the current study containing the retrieved data is documented, certified, and saved at the Department of Urology, Alexandria Faculty of Medicine, Alexandria, Egypt.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.