Micropenis is a collective concept that includes a number of conditions against which sexual dysfunction develops with the impossibility of penile-vaginal contact due to insufficient penis length. Diagnostics of possible processes that caused underdevelopment or acquired shortening of the phallus is individual, based on physical examination, assessment of hormonal background, MRI data of the pituitary gland and hypothalamus, ultrasound of the scrotum, cavernosography. If it is impossible to lead a sexual life, the issue of surgical correction is solved, its volume depends on the initial size of the organ. In the most severe cases, a falloprosthesis is performed.
N48.8 Other specific diseases of the penis
Micropenis (small penis syndrome – SPS, hypopenia), according to the Professional Association of Andrologists, micropenis (2-2.5 centimeters) is a congenital pathology based on intrauterine androgen deficiency. Statistical data are contradictory, which is due to the many components of this syndrome, which can be isolated or combined with other disorders.
An erect penis with a length of 9.5-10 cm is not a pathology if there are no previous hormonal disorders or events that led to shortening. This peculiarity of a man is caused by hereditary, constitutional factors. True congenital and acquired SPS are more often led to:
- Pathological processes in the testicles. Micropenis may be the result of unsuccessful surgical interventions on the genitals, for example, orchipexy performed for bilateral cryptorchidism at the age of 12-14, orchectomy. Hypogenitalism can provoke congenital underdevelopment of testicles of any genesis, including genetic diseases, bilateral orchitis transferred during puberty, against the background of viral mumps or measles.
- Damage to the hypothalamic-pituitary region. Injuries, some operations on the brain, cerebellar ataxia initiate a decrease in the production of gonadotropins in a man with intact testicles. Radiation therapy of head tumors can cause variable hypothalamic-pituitary disorders.
- Pathologies with fibrous changes. Peyronie’s disease, due to the formation of fibrous plaques in the protein membrane and the septum of cavernous structures, contributes to deformation, shortening of the penis. Similar changes are caused by the replacement of cavernous tissue with scar tissue against the background of chronic recurrent or acute cavernitis, prolonged priapism, trauma.
- Medical interventions. Surgical removal of a part of the organ – partial penectomy – is resorted to during the treatment of malignant neoplasms, less often – in the case of necrotizing of the head with phimosis, animal bites, self-mutilation. Excision of plaques in a patient with fibroplastic induration, intracavernous injections, circumcision with excessive excision of the foreskin can cause shortening of the penis.
A failure at any level of the hypotolamo-pituitary-gonadal axis with the development of androgen deficiency or resistance of target organs to sex hormones leads to hypopenia in a boy. A decrease in the level of testosterone and its derivatives is recorded with hypogonadotropic hypogonadism (GH) against the background of insufficient hormone production by the pituitary gland / hypothalamus; with hypergonadotropic – due to primary insufficiency of testicular functions.
Some pathological processes – Peyronie’s disease, penile fibrosis, cavernitis – cause the proliferation of fibroblasts and their derivatives – myofibroblasts that produce collagen and fibrin in excess. With concomitant inflammation, further remodeling of connective tissue into a fibrous plaque occurs, causing curvature, reduction of cavernous bodies. A false penis is formed due to defects in the fixation of the skin, deep fascia supporting ligaments or overhanging fat that hide its normal size.
There is a classification of congenital and acquired underdevelopment of the penis. The congenital form includes:
- True underdevelopment. In cases of disorders that occurred in utero, micropenis or ambiguous genitalia are diagnosed. Pathology can be combined with malformations of the urogenital system (epispadias, hypospadias, cryptorchidism).
- False micropenia. The cavernous bodies correspond to the norm, but visually the reproductive organ seems small. This includes a buried (submerged in the thickness of the scrotum), webbed (tightened by a skin fold), retractile (pulled deep due to incorrect fixation, appearing when the body position changes) phallus.
The acquired form is:
- True. The size of the penis is reduced as a result of traumatic partial amputation or a pathological process: hyperplastic tissue induration, cavernous fibrosis, some forms of hypogonadism.
- False. It includes a hidden micropenis, penile dysmorphic phobia. In the first case, the size and thickness of the cavernous bodies correspond to age, but the organ itself is covered by an excess fat fold. Penile dysmorphophobia is a mental disorder in which a man is not satisfied with the normal size of the genitals.
With true acquired forms of micropenis, the severity of manifestations depends on the period of occurrence of androgen deficiency, age at the time of treatment. In the formation of the syndrome before puberty, in addition to hypogenitalism, other eunuchoid signs are typical: high growth, underdevelopment of the chest, larynx, weakness of skeletal muscles, long limbs. When examining the genitals, attention is drawn to the absence of pigmentation, folding of the scrotum, pubic hair, prostate hypotrophy.
A decrease in the size of the testicles with any hypogonadism is combined with a violation or complete absence of spermatogenesis. There is sexual dysfunction: low libido, sluggish erection. Secondary hypogonadism is supported by an increase in body weight, symptoms of a decrease in thyroid function (weakness, apathy, hypothermia), adrenal cortex (hyperpigmentation of the skin, muscle atony, lowering blood pressure).
With false forms of SPS, deep palpation reveals a normal, age-appropriate size of cavernous bodies. Sometimes the problem is realized only with the beginning of sexual life. Obese men with a hidden penis also have signs of hypoandrogenism: fat deposition around the hips and waist (female type), scarcity of hair, complaints of decreased potency.
Depressive disorders due to the impossibility of normal sexual relations are aggravated by hormonal disorders, androgen deficiency. Many patients are diagnosed with persistent infertility. Infertility in some men with micropenis and total hypoandrogenism can be irreversible when even assisted reproductive technologies do not help.
Androgen deficiency leads to dysfunction in the work of organs and systems: cardiovascular, digestive, endocrine. With complicated Peyronie’s disease, cavernous fibrosis, the deformation of the organ can be so pronounced that it interferes with normal urination. The constant stagnation of urine contributes to the attachment of the inflammatory process in the bladder, prostate, kidneys.
Diagnosis of micropenis is based on the analysis of patient complaints, anamnesis assessment, physical examination with anthropometry, identification of symptoms of hypogonadism, determination of the degree of maturation. In children and adults, the examination algorithm is different. Diagnostics include:
- X-ray. On the basis of an X-ray of the hands of adolescents, the bone age is estimated by the terms of ossification of the wrist joint, the hand. The lack of visualization on the images of anatomical synostoses in a 13-14-year-old boy indicates a lag in puberty from the passport age and pre-recurrent hypogonadism. Densitometry shows the degree of decrease in bone density, it is prescribed for late treatment of the patient (16-18 years old).
- Cavernosography. It is used in men with Peyronie’s disease, local fibrosis to detect pathological foci, atrophy of cavernous bodies, vascular changes. Additionally, an intracavernous test is performed with the introduction of vasoactive substances.
- MRI of the brain. It shows an inflammatory, tumor process in the anterior pituitary or hypothalamus region, the relationship of the neoplasm with neighboring tissues. CT is less informative in detecting brain tumors.
- Ultrasound scanning. Ultrasound of the genitals can reveal testicular hypotrophy, cryptorchidism, determine the true size of the cavernous bodies with a false small phallus. Ultrasound of the prostate with hypogonadism, developed in pre-puberty, demonstrates its underdevelopment.
- Hormonal background research. Before puberty, the analysis for sex hormones is uninformative without stimulating samples. In favor of primary GH, an increase in LH gonadotropins, FSH in the blood, and a decrease in their level of secondary GH. Serum testosterone is much lower than normal in both cases. A high level of prolactin is suspected of prolactin, estradiol is suspected of an estrogen–producing tumor of the testicle or adrenal glands.
- Spermogram. The study of the ejaculate is carried out after the completion of puberty. The results show azoospermia or oligospermia, with total testicular atrophy, sperm cannot be obtained.
Differentiation of micropenis in a man is carried out with micropenis, agenesis, buried and membranous organ, constitutional growth and maturation delay, and other diseases. To exclude genetic syndromes, it may be necessary to consult a geneticist, an assessment of the karyotype to exclude chromosomal defects.
Therapeutic measures are aimed at the possible elimination of the cause of hypopenia. If other endocrine pathologies are detected, the underlying disease is treated. In adults, it is possible to correct some manifestations of hypogonadism with hormonal disorders. Urologists-andrologists, endocrinologists are engaged in the treatment of the micropenis.
If the normal level of hormones in the blood is confirmed, drug treatment is not carried out. Penile dysmorphic phobia requires the consultation of a psychiatrist. If hypogonadism is an independent pathology or part of a symptom complex, hormone replacement therapy is indicated. Depending on the nature of the pathology , prescribe:
- Androgens. They are shown with SPS with primary and secondary GG. Treatment begins from 13.5 -15 years with preserved testicles and from 11-12 years with rudimentary testicles. Minimum dosages at the first stage simulate natural maturation and prevent early closure of growth zones. The level of testosterone in the blood should be in the range of 13-33 nmol / l, otherwise the dose is adjusted.
- Gonadotropins (hCG) and androgens. They are used for penis enlargement and correction of hypogonadotropic GH. The use of androgens can lead to infertility. The beginning of therapy with FSH mimics the beginning of maturation of Sertoli cells during puberty, helps to establish their relationship with Leydig cells, which is important for maintaining spermatogenesis in the future. There are several treatment regimens with gonadotropins, using various combinations of FSH and hCG.
The application of dihydrotestosterone to the skin of the scrotum with micropenis demonstrated the effect of the growth of the latter by 1-1.5 cm in children with 5-alpha-reductase deficiency. Early systemic hormone therapy is not carried out for boys, as stunting, acceleration of sexualization, infertility are expected. Traction of the micropenis with the help of an extender with regular manipulations in adults allows you to increase the length by 1-2 cm in a calm state. The size remains the same when excited.
Indications for augmenting operations are divided into medical (Peyronie’s disease, micropenis, the consequences of injuries) and functional (removal of obstacles to coitus). Aesthetic criteria are considered separately with preserved functional ability and dissatisfaction of the patient with the appearance of a micropenis (penile dysmorphic phobia). The main surgical methods of enlarging the phallus include:
- Elongation, thickening or a combination of them – ligamentotomy, autotransplantation of tissues, fat, synthetic materials, rotated flaps on the feeding leg.
- Correction of erectile dysfunction with enlargement – falloprosthetics with corporotomy (dissection of the protein membrane) or mobilization of cavernous bodies.
- Operations for the formation of neophallos – total phallourethroplasty from a skin flap.
Prognosis and prevention
The prognosis depends on the initial genitometry data, the genesis of pathology. Performing a falloprosthesis helps restore the possibility of leading an acceptable sexual life, but does not always solve the problem of infertility. Operations to extract an organ from the thickness of the scrotum with congenital true underdevelopment completely normalize all functional abilities.
Prevention implies the inadmissibility of self-administration of hormonal drugs by the mother during pregnancy. Every newborn boy must be examined by a surgeon or urologist for cryptorchidism, determining the normal size of the external genitals. If the testicles are not missed, it is important not to miss the deadline for performing the operation before the age of 2 in order to avoid the development of atrophy.