Penile girth enhancement (PGE) is one of the most polarizing topics in urology. I suspect much of this has to do with us having no to limited exposure to PGE interventions during or after training and the limited experience we may have, often involves seeing men with intervention-related complications.

Why It Matters

• Men with normal sized penises often ask their urologists for safe and effective ways to increase penile size.
• Negative attitudes toward genitals impact sexual dissatisfaction and overall self-esteem.^1,2
• Low genital satisfaction impacts men of all ages, races, and socioeconomic groups and is associated with a decrease in sexual activity.³
• You name it, someone has tried putting it into the penis. Importantly, not all PGE interventions are created equal and outcomes greatly differ between
  • Injectables vs implantables
  • Nonpermanent vs permanent injectables
  • Variations in physico-chemical properties of temporary fillers
  • Postprocedural protocols

Dissatisfaction Rates Greatly Vary

• In a study of 200 heterosexual men, 68.3% reported penile size as a concern.²
• In a study validating the Male Genital Self-Image Scale in the United States, 20% reported dissatisfaction with their size.⁴
• In a nationally representative survey of 3996 noninstitutionalized adults 18 to 65 years residing in the United States who completed the Index of Male Genital Image, 14.1% were classified as dissatisfied.³

What Do Scientific Societies Say?

The Sexual Medicine Society of North America and the European Association of Urology have released statements on penile cosmetic enhancement procedures advocating for psychological evaluation, safety and efficacy analysis under research protocols, and avoidance of permanent fillers.^5,6 The AUA and Urology Care Foundation state that subcutaneous fat injection for PGE has not shown safety or efficacy, though does not comment on other PGE interventions.⁷

If you were to have asked me 2 years ago for my thoughts on PGE, I would have said,

“I wouldn’t recommend it.”

“We don’t have any safe options available.”

“If there’s a problem, it’s a real problem.”

“We don’t have sufficient peer-reviewed research to support any of these procedures.”

I confess, I didn’t know much about it other than what I had heard others say in response to this question. Now, PGE with hyaluronic acid (HA) is the most common procedure I perform (Figure).

How Did This Happen?

This article will focus on the use of HA for PGE.

What Does the Research Say?

Though existing research is limited in number of studies, small sample sizes, and lack of long-term follow up, what we do know is HA has a promising safety profile, with prospective work showing no inflammatory signs or serious adverse reactions.⁸

We recently presented retrospective safety data at the 2024 annual AUA meeting in San Antonio on nearly 500 men presenting to a single clinic for HA filler.⁹ All complications were minor (Clavien-Dindo grade [Gr] 1-2 only), including 2 patients (0.42%) with injection site infections related to noncompliance post treatment with infection resolution after a course of oral antibiotic and 3 patients (0.63%) with granulomas completely resolved with a single treatment of hyaluronidase and subsequent HA injections without granuloma formation. Notably, no patients reported erectile dysfunction or loss of sensitivity. In addition to low rates of infection and nodules, subcutaneous bleeding has also been described, without severe sequelae.¹⁰ Though complications with HA are limited, there is a published case of penile abscess 4 years after HA injection despite lack of risk factors.¹¹

In my own clinical practice, I have also evaluated patients reporting dissatisfaction with prior HA filler performed elsewhere, so it is, by no means, a perfect intervention. Unsatisfactory outcomes may result from too much HA filler being injected in a single session, filler being injected in the improper space, and/or inadequate postprocedural protocol aimed at minimizing swelling, smoothing out the filler, and reducing penile retraction.

We recently presented retrospective efficacy data on 155 men undergoing HA filler at the 2023 annual Sexual Medicine Society of North America meeting.¹² On average, men experienced a 0.63-cm increase in girth per treatment with an average girth increase of 1.8 cm prior to final treatment. Research also suggests that HA in the penis may provide durable results up to 18 months.⁸ Longer-term durability data are lacking.

Patients and partners also report high levels of satisfaction. When asked to report satisfaction from Gr 0 (very dissatisfied) to Gr 4 (very satisfied), patient satisfaction score was 3.71 ± 0.46 and 3.34 ± 0.53 at 1 and 18 months, respectively. Partner’s satisfaction score was 3.65 ± 0.48 and 3.38 ± 0.49 at 1 and 18 months, respectively.⁸ Average score using the Index of Male Genital Image statistically increased post HA injection (noting improved satisfaction) and Beliefs About Penis Size significantly decreased (representing reduced levels of insecurity and shame regarding penile size).¹³ Sexual relationship satisfaction, confidence, self-esteem, and overall relationship satisfaction have also improved.¹⁴

Currently, 24 urologists, mostly in North America, perform PGE using the standardized PhalloFILL injection and postprocedural protocols.

What Do My Colleagues Say?

PhalloFILL founder, William Moore, says, “My journey with PGE began in 2010 with platelet-rich plasma, though I realized quickly it didn’t work. Over the next few years, I saw many girth enhancement patients come in with horrible results after undergoing injections of non-Food and Drug Administration (FDA) cleared industrial designed, permanent products. My inability to help these men sparked my interest in developing an effective and, most importantly, safe solution.

In 2020, I began developing the technique now known as PhalloFILL. I came to find out that, just as important as injection technique, is the postprocedural protocol. I developed a postcare garment that I’m thrilled to say is now patented and registered with the FDA and pending FDA clearance. Our protocols have been embraced by key opinion leaders in urology. We’ve focused on training urologists, in particular, because urologists best understand penile structure and function and are most equipped to manage complications should they arise.”

Dr Alex Tatem, like me, started off as a skeptic. He says, “After an unsuccessful attempt to develop a safe silicone implant for men during fellowship, I had become convinced that the dynamic nature of the penis and underlying corpora cavernosa precluded safe, reproducible, and aesthetic augmentation.

The moment I observed my first PhalloFILL treatment, I was fascinated. The patient, back for his third treatment, looked well-endowed, yet completely natural. Shortly thereafter, I began offering PGE in my own clinic in addition to joining PhalloFILL’s medical advisory board. Inspired by my own outcomes and the absolute “normalcy” of both the procedure and men seeking these treatments, I began recruiting my colleagues to what has become one of the most satisfying parts of my job: simple, safe, effective, and noninvasive girth enhancement in the clinic setting.

What was thought to be impossible years ago is now both safe and easily accessible.”

What Do Patients Say?

Dr Kevin Zorn shares the experience of one of his patients in his late 30s with previous childhood hypospadias repair who is beyond happy with his 1.25-inch girth increase, reporting improved sexual confidence and performance and his wife noting the “best orgasms ever” after a decade of marriage.

During a recent consultation with a patient on this topic, I mentioned, “Some of the most normal men I see in my clinic are those that present for PGE. They come to me because they are interested in the safest option available to increase their girth for cosmetic, confidence, and sexual satisfaction purposes.” His response, in a grateful tone, was simply, “Thank you.”

This gentleman is like many of the other patients I see for PGE— they are the lawyers, doctors, truck drivers, small business owners, and insurance brokers—men often with penile sizes within the normal range, interested in reasonable increases in penile girth.

What’s Next

As penile specialists, we have an incredible opportunity to normalize the conversation and provide safe, effective, and innovative solutions. Creation of committees focused on cosmetic treatments within scientific societies would be a great start, just as many other societies have done.

Future research should aim to address the following questions:

○ What, if any, are the long-term complications of HA for PGE?

○ Are long-term complications associated with a greater number of injection procedures?

○ How long does HA last in the penis?

○ What factors impact durability of HA in the penis (ie, shockwave, vacuum erection devices, supplements)?

○ Which validated questionnaires are most appropriate to track patient and partner satisfaction before and at various time points post procedure?

○ What is the impact on patient and partner genital sensation during sexual activity post procedure?