Penis Enlargement

Roger was changing the nappy of his week-old son when Wow! What was going on? the baby had a tiny erection and the little hole wasn’t winking at him— where was it? Roger knew the child was able to wee, or he wouldn’t need a change…but this apparatus didn’t look at all like his other son’s.
He quickly took the baby down to the family doctor, where he was told: ‘Yes, young Mitchell has hypospadias. This is relatively common and is an accident of development. It occurs in about one in every 350 births. You will notice as Mitchell gets a little bigger, that when he has an erection, his little worm will probably have a slight downward curve. This is called chordee and almost always goes with hypospadias. It is caused by a fibrous band of tissue that pulls the penis into a curved shape. I’m going to refer him to the paediatric urologist, and when he’s a little older—say about a year—he’ll be scheduled for a surgical repair. You can see the opening to his urethra just on the underside of his glans, so it is possible that the urologist will be able to repair it in one operation…but we’ll leave that to him; he’s the expert!’

Hypospadias is relatively common and is usually detected on routine well-baby examinations. The skin closing over the passage that forms the urethra is deficient in part and is just replaced by a groove along the under¬side of the penis. It is usual to try to repair it early in life, before the child enters school, so he doesn’t suffer from the remarks of other children.

Hypospadias is usually mild, and men who have unde¬tected hypospadias are able to have intercourse normally and father children. (One well-known historical figure who had hypospadias was the French King Henri II, husband of Catherine de Medici. Henri fathered at least thirteen children on both sides of the blanket.) Obviously, if chordee is severe, intercourse would be impossible; fortunately, this situation is almost always repaired in childhood. Corrective surgery usually results in a penis that looks normal and functions normally. Many women never know that their partner had this condition as a child or had surgery for it.

Why does this happen? There are lots of theories, but no one really knows. Links have been made between things as diverse as vegetarianism in the mother, oestro¬gens in the environment and parental age. But if your child has hypospadias, it is not your fault! We don’t know what causes it, therefore, we don’t know how to prevent it.

One thing worth noting is that the repair for hypospa¬dias requires as much loose skin as possible, to reconstruct the urethra all the way to the usual place of opening on the tip of the penis. So obviously a little boy with hypospadias should not be circumcised—he needs every bit of skin he can get.
Sometimes, a baby is born with the urethral opening at the junction of the penis and the scrotum. He must be carefully checked for the presence of his testes and, if both are not down in the sac, evaluated for possible ambiguous sexual determination. You may have heard stories in the media of people assigned a sex when young and later being unhappy with their gender. For this reason, gender assessment and assignment are now handled with great care, assessing the chromosomal sex of the child as well as the ‘eyeball assessment’.

What happens if the baby’s testes are not down in the sac? First we need to explain that the testes initially begin development up in the abdominal cavity and track down through the inguinal canal in the groin into the scrotal sac. This is completed in most babies by the time of birth, although it may occasionally be delayed up to three months after birth, especially in premature babies. You’ll notice that many baby boys have little balls on elastic strings—that is, you can actually see their balls spring up into their groin with the shock of cold air or a startle. This is quite normal because their balls do mostly stay down in the scrotum.

But when the testes are not in the scrotum at all, it may mean that they have never formed—in which case the sex of the baby may need to be determined by testing the chromosomes—or that one or both got lost in the developmental migration from the abdominal cavity down through the groin and into the scrotal sac. This condition is called cryptorchidism (hidden orchids!) and it is necessary for the concealed testis or testes to be surgically removed or brought down into the scrotum because there is a much-increased risk of testicular cancer later in life if they are left lurking elsewhere. There are other forms of congenital (at birth) deform¬ities of the penis, but they are very unusual. They include the rare incidence of a double penis.

Kimberly recently got the scare of her life: she was potty training Jamie and he was straining hard. As he turned a bit red in the face, she saw his little scrotum blow up like a balloon. It seemed to be only on one side. Immediately, she snatched him up and rang the doctor. Dr Hatch came to the phone and very calmly reassured Kimberly that it was probably ‘just a hydro¬cele’ and to bring Jamie in. Sure enough, Dr Hatch held a penlight against the skin of Jamie’s scrotum and it looked like a glowing ball. Dr Hatch said this pretty much confirmed it was a hydrocele. However, the next step was an ultrasound of the scrotum.

A hydrocele is a fluid collection within the scrotum. It should still be possible to feel the testis within the sac, it commonly occurs on one side only, and it in fact has no pathological significance. It is present in about 6 per cent of male babies and can occur in adults as well. In the babies, it is usually the result of a persistent opening of the tube through which the spermatic cord leaves the abdomen and goes into the scrotum (see Figure 2.2). This tube, present in the developing foetus, is called the processus vaginalis. It usually closes off in early infancy. This type of hydrocele is called a communicating hydrocele. Later in life, hydroceles may arise from increased fluid production
in the scrotum or impaired absorption of this fluid. This is usually a response to some trigger of inflammation in the scrotum, such as a viral illness or an injury.

A hydrocele is not, in and of itself, a cause for alarm. Those occurring later in life will be investigated to be sure that there is no associated pathology, such as a testicular tumour, but usually they resolve themselves with a wait-and-see approach. Many paediatric surgeons repair persistent communicating hydroceles in children; this is a delicate procedure, but is very safe. It is also safe to leave it alone as long as one is sure that it truly is a hydrocele, as a hydrocele has no adverse effect on health or sexual function.

All doctors are aware that a hydrocele can conceal the surgical emergency of a testicular torsion. In this, the testis is twisted upon itself, like a melon on a stalk. This threatens the blood supply to the testis and requires urgent surgical intervention. In this case, the man or boy has excruciating pain in the scrotum and it should be the first thing the doctor thinks of. Fortunately, torsion does not happen often.

Adults can be pretty kinky, too. There is a condition called Peyronie’s Disease, which occurs in between 0.3 and 4 per cent of white men, most commonly between the ages of 40 and 60, although it can be seen as young as 30 and as old as 80. It is uncommon in African men and virtu¬ally unheard of in Asian men.

Gerald was in bed with Deirdre, getting all hot and bothered, when he noticed that his best man hurt as it got hard. This was a new one. Good job he could ignore it. When he got up later to pee, he checked himself out and found a very small firm lump in the shaft of his pride and joy. He figured it was probably just an ingrown hair and would go away. But over the next couple of months, the nodule in his penis seemed to thicken more and he continued to have some minor pain whenever he had an erection. He might still have ignored it but one night Deirdre said: ‘Good god, Gerald, your dick looks like a ram’s horn!’ (Deirdre was never a very tactful person.) And, indeed, his penis was curved downward . . . until her remark deflated him and it curled into a shy little snail.

Gerald’s doctor explained to him that, while we don’t really know what causes Peyronie’s, there seems to be an association with trauma and that it has been historically associated with ‘excessive sexual inter¬course’—whatever that is. In most cases, there is a slow progression of plaque or nodule formation in the shaft of the penis, leading to varying degrees of curvature. Less often, the curvature happens sud¬denly and then remains static. There is a spectrum of severity which goes all the way from having painless but palpable plaques in the shaft of the penis to having a curvature so severe that it is impossible for the man to have intercourse.

Gerald was a 40-year-old white man and this was quite typical for Peyronie’s. He didn’t have any of the other associated risks: he was not diabetic, did not have high blood pressure and had no problems with soft erections. Peyronie’s is a risk for elderly men with soft erections who engage in frequent vigorous intercourse. In black men, it is associated strongly with diabetes. It also may be seen in men who have Dupuytren’s contracture—a similar fibrous thickening in the palm of the hand, that draws one or more fingers into the palm. None of this was terribly inter¬esting to Gerald; he just wanted to know what could be done.

Medical treatments for Peyronie’s have been discourag¬ing, although our favourite peckerchecker Dr Cohen advises that there is a place for the use of anti-inflammatory drugs, both to relieve pain and to reduce inflammation. He also reports that Verapamil, a heart and blood pressure drug, has been reported to be helpful in Peyronie’s, applied as a cream or gel directly to old Jack. We’re not sure why this works or how it was first discovered, but if it works, hey, who cares? An anti-fibrosis drug, amino-benzoate (Potaba) has also been used recently with some success. Some other medical approaches can actually cause harm. Viagra or other erectile aids can trigger more scarring. So can steroid injections into the area, which is why these are absolutely contraindicated. Acupuncture has been tried and, although it doesn’t do harm, neither does it seem to help. If the pain or curvature is severe enough to warrant treatment, surgical intervention may be helpful. This is done by a urologist.
It is most important for the man with Peyronie’s that he and his partner understand that this is not a cancerous or otherwise medically serious condition and that, in most cases, it is not so severe as to interfere with satisfactory sex. Of course, the partner will also need to be sensitive to her man’s feelings about this and not, like Deirdre, make jokes or adverse comments.

Certain infections such as gonorrhoea, some injuries and some kinds of surgery can lead to narrowing of parts of the urethra in young and older men, making peeing difficult. Napoleon Bonaparte apparently had such a stricture; his troops were used to seeing him leaning against a tree on the battlefield, waiting patiently for the stream of urine to start. Such difficulty is also a common symptom of enlargement of the prostate gland, a benign but annoying condition that frequently strikes men after the age of 50 or so. In the case of prostate enlargement, it is usual to offer surgery through the urethra (a trans-urethral resection or TUR of part of the offending gland, done by a urologist). Other causes of urethral narrowing may be treated by dilating the tube with instruments of increasing size (these instruments are called bougies, from the French word for candle). In Victorian times, gentlemen who suffered the effects of urethral strictures carried metal catheters for personal dilatation in their top hats! These days the procedure is restricted to the operating theatre. If dilata¬tion is insufficient, more extensive surgery by a urologist is required.

These are the most common kinky problems, although we understand that there are some Australian penis puppeteers who can do very kinky things indeed with their appendages…but that’s entertainment, not medicine.