Penile difference - lack of penile development, small size, hypospadias and Peyronie's disease

There's huge pressure on men who have a penis that looks different to the "norm", or who feel they don't match up in the size stakes. And while sometimes this is just the result of insecurity, more often it isn't, and men who do indeed have a penis that's different from the norm can experience great emotional distress and shame.

Hypospadias is a congenital condition in which the urethral opening of the penis is in the wrong place, while the rest of the penis may also be an unusual shape. By contrast, Peyronie's disease, which is marked by a significant bend in the shaft of the penis, is a condition acquired during adult life, usually as a result of injury during sex. Having said that, a few boys are born with a penis that develops a significant curve on erection.

Challenged by feeling less well-endowed (where your penis is concerned)?

Suppose you were four and a half inches long when erect: would you feel better knowing most men are around 5.9 inches? What if your penis was only four inches long and very thick, but your partner loved it because it stretched her vagina where she was most sensitive?

Would you feel more of a man if she told you your size was ideal for her? The probable answer to these questions is "no", because so much of the size "problem" is in the mind of the man attached to the end of the penis.

What's more, the smaller the flaccid penis, the more it tends to expand on erection. In fact, the average expansion is actually around 3 inches, though penises of 6 inches in length or more often don't grow in length at all when they become erect.

Now, when I tell you that how big you are most probably doesn't matter to a woman, do you believe me? The truth is that it's not the way most women assess your suitability as a partner, and if it does matter it only matters as yet another factor in the complex mix of things that go into sex. You can give a woman all the pleasure she needs with your hands, your tongue, your lips, and of course your mind (we're talking emotional bonding here!).

And yet, having said all that, I still understand that we judge our masculinity by the size of our sexual organs. How would you feel if one of these was your penis?

small penissmall penissmall penis
small penissmall penissmall penis

It's not meant to be a question with any easy answer, for there obviously is none. As long as we men see the size of our penises as the measure of masculinity, then men with penises like those above are set up for a sense of inferiority, regardless of what their partners might say to try and disabuse them of the idea.

The problems of the well-endowed man

And while I suppose we all secretly admire the large swinging dicks we see in the locker room, how much fun can having a penis like this actually be? I mean, where do you put it?

large penislarge penislarge penislarge penislarge penis

There are several problems with having such a large organ (above, I suppose, 7 inches in length or 6 inches in girth). First, you may not be able to enjoy full penetration.

Second, you're much more vulnerable to injury during sex - Peyronie's disease seems to affect the larger penis more often than the smaller penis.

 Third, there's the simple physical inconvenience and embarrassment of it all - which, for a well-endowed teenager, with spontaneous erections occurring all the time, I'd imagine to be considerable. There's a large penis support group, presumably designed for the owners of these organs to exchange stories of good and bad luck.

The only other comment I want to make is the observation that size does not correlate with sexual satisfaction for a woman. Women want to be loved and get most enjoyment from having sex and orgasms within a loving relationship.

These orgasms are most often produced by oral sex or masturbation: few women (less than one in four, for sure) can come through vaginal thrusting, though I suspect that number would be rather higher if men didn't ejaculate so quickly and could go on for longer during lovemaking.

What is clear, however, is that if a woman gets satisfaction from a large penis, it's because it stretches the opening of her vagina rather than because it's so long it can poke her cervix, which several women have told me can be very painful.

(Unfortunately for my argument, several others have told me that it can be very intensely orgasmic, provided they are extremely aroused at the time.) I suppose any shame that accrues from having a large penis is just as likely to cause sexual problems as a small penis. Particularly the thorny issue of stopping premature ejaculation.

Hypospadias

This is a congenital condition of the penis - meaning that a boy is born with it - which affects a heck of a lot of baby boys. The latest estimates vary between 1 in 300 and 1 in 125 live births - it is, in fact, the most common male birth defect. Does it matter? Well, that depends chiefly on how serious it is. The milder forms of hypospadias involve the opening of the urethra being misplaced down the glans or penile shaft:

coronal hypospadias hypospadias

While the more serious ones involve some considerable distortion of the penile shaft and the foreskin:

hypospadias hypospadias

hypospadias hypospadias

In the past, corrective surgery was generally carried out around the age of five years, often in a series of operations, and frequently with pretty poor results.

Nowadays techniques have improved a lot and the surgery can be carried out at a much younger age, often producing a penis which is indistinguishable from a circumcised penis.

Having counseled many men with hypospadias, I would say the major problem is the impact it can have on a guy's self-image. To have an abnormal penis - one that is different from the "norm" - is a painful thing.

There are the taunts of fellow children as one grows up; there is the lack of support (for even now it is a condition rarely discussed openly in the family environment, and this secretiveness around his penis often feels very shameful to the child); there is the sense of being different from other boys and men; there are doubts about one's masculinity; and there is often an obsession with normal penises which can lead a man with hypospadias to believe he is gay - which is no more or less likely than for any other man. If in addition, the hypospadic penis is smaller than average (as many tend to be) then there is the double challenge of size and appearance to cope with.

Why would a man with hypospadias be obsessed with the appearance of the penis? I think it's something to do with the search for understanding: the understanding of how he is different, and perhaps it also has something to do with an attempt to see how different he actually is.

What's most interesting to me about the men I have seen with hypospadias is that even if their partners tell them again and again that the hypospadias doesn't matter, their self-image often doesn't change. Women are not penis-centered in the way men are, and they simply cannot understand how much the penis really is the center of our sense of masculinity. 

If you have hypospadias, I recommend that you join the support group you can find here: Hypospadias support group.

Peyronie's disease

Ah, a twist in the tale here, and no mistake. Have a look at these photographs:

Peyronie's disease Peyronie's Peyronie's disease

Peyronie's disease Peyronie's disease

If your penis looked like this, you wouldn't have much choice but to undergo surgery if you wanted to enjoy penetrative sex. And the problem? Well, surgery does work, but it often shortens the penis. See below for more details.

Peyronie's affects between 1 and 2% of men. It can come on very suddenly - indeed, it can appear almost overnight. What happens is that after an injury in the tunica albuginea, the internal chambers of the penis form scar tissue as they heals.

This reduces the elasticity of the erectile chambers so that a bend develops at that point. There are, however, several variations of this condition.

The penis may be hard at the base and soft and skinny up top due to restricted blood flow. Or it may look like an hour glass shape, with a constricted band around the middle. But most often it develops a sharp bend to the left or right, or up or down. 

Of course, many penises do naturally bend a bit one way or the other. But it's the suddenness with which Peyronie's comes on, or the extreme degree of bending, or the painfulness inside the penile shaft which tends to accompany it, that are the giveaway features of this distressing condition. 

Many men will injure the layer of tissue that is responsible for Peyronie's formation during sex, but only occasionally does it heal so badly as to produce the massive bend that is so characteristic of Peyronie's. In some cases the problem begins merely as a painful inflammation of the tunica albuginea.

 In all cases this becomes a hardened lump of scar tissue, which may become calcified. In fact you can usually feel the lump of scar tissue with your fingers; and a doctor can certainly detect it with an ultrasound scan.

The theory that bleeding in the erectile chambers causes Peyronie's is probably true in cases where an identifiable injury to the penis has occurred, but in other cases there seems to be no precipitating event, and Peyronie's develops slowly from mild inflammation.

(There is another disease of the connective tissue: 10 - 20 % of men with Peyronie's also develop Dupuytren's contracture. This is a benign condition which manifests as bent fingers: the cause is the contraction of a sheet of connective tissue just under the surface of the palm of the hand.

This layer, or fascia, is a kind of reinforcing structure to the palm of the hand. In some cases, the threads of collagen which give the fascia its strength begin to contract in length, and the fingers gradually become unable to straighten. These cords are not themselves tendons: they are situated between the tendons and the skin.)

It was François de la Peyronie who gave his name to the condition in 1743. He thought it was a form of impotence, though he was wrong: impotence may be associated with the disease, but it is not always.

If the condition heals in less than a year, the scar tissue does not usually calcify; but if Peyronie's progresses for more than a year, the plaque develops the characteristic tough fibrous tissue and calcification typical of the more advanced form.

Symptoms of Peyronie's disease

The plaque is non-cancerous and not related to arterial cholesterol as some men fear. It is most often found on top of the shaft, which makes the penis bend upwards.

If the plaque is on the bottom side, the penis will bend in the opposite direction - downwards. (Likewise for side to side bends.) If the plaque forms on both sides of the shaft, indentation and shortening of the penis are likely to develop. The erection can be painful, and the bending or indentation of the penis can be psychologically and emotionally distressing.

Ways to diagnose Peyronie's

The appearance of the bent penis is usually enough for diagnosis, but in addition the doctor may wish to conduct an ultrasound scan of the penis, or a Doppler examination, which measures blood flow inside the blood vessels of the penis.

Peyronie's disease: can it be treated?

Factors which affect the action taken by a doctor after diagnosis include the man's age, health, medical history, medications, any previous procedures, and a view of the effectiveness of the therapies available.

At the very least, a doctor will aim to keep a patient sexually active - which means able to enjoy penetrative intercourse. Sometimes the disease heals spontaneously within a year or so. Therapies available include:

Injection of chemicals into the plaques: the various agents tried over the years have included Vitamin E, Potaba, Colchicine, Verapamil, and collagenase.

Vitamin E is an antioxidant: it's been used in the treatment of scars and has been used as an agent in treating Peyronie's for many years.

POTABA (potassium para-amino-benzoate) has been described by the Food and Drugs Administration as a possibly effective treatment.

Colchicine has been used as an anti-gout medication, which reduces inflammation and inhibits the production of scar tissue.

Verapamil is injected directly into the scar. It inhibits the manufacture of scar tissue in the body.

Collagenase is an enzyme which dissolves scar tissue.

All of these treatments are of variable effectiveness, but urologists with experience may recommend one or other of them depending on the antecedent factors.

Radiation therapy is not recommended due to the high preponderance of side-effects, but it has been used to reduce inflammation and relieve pain.

Treatment of Peyronie's

There's no simple cure for Peyronie's, though it does sometimes go away with time. The best thing to do is to find a really good urologist who has extensive experience in dealing with it - often you'll find a high level of expertise at a teaching hospital.

One of the more promising treatments involves the injection of a drug into the scar tissue of the penis that seems to soften it. But in the end, surgery may be the best option. There are several options to remove the scar tissue or plaque in the tunica albuginea which line the corpora cavernosa.

As you may have realized by now, one of the major issues with this disease is that treatment varies in effectiveness between men. There is therefore little consensus on when intervention with medication or surgery gives optimal results.

The early stages of the disease may offer greater opportunity to reverse its progress, while the later stages, which involves scarring and plaque formation, tend not to be reversible. This means that early treatment can be more successful - certainly within the first six months.

The success rate of treatment in reducing bending is around 60%: the factors which make it likely that the bending will be irreversible are the presence of Dupuytren's contractures, advanced plaque calcium deposits, and severe curvature (over forty-five degrees, say).

If you're thinking of surgery...

You should have a stable bend, which is not getting worse or better; you should have a severe bend; you should have tried other therapies; and the usual health risks for surgery should be acceptable.

What are the risks of penile surgery?

Surgery can be effective, but there are risks: of incomplete correction, of shortening of the penis, of sensory loss (usually temporary), and in the worst cases, of impotence.

Surgical Options:

Nesbit procedure

Used for moderate bends or those that have been present since birth, the Nesbit procedure relies on plicating (or gathering) the tunica albuginea on the opposite side of the corpora cavernosa to the bend.

There is much less likelihood of erectile dysfunction, as the process does not involve grafting; it's effectively a counterpoint to the bend on the outer, longer side of the curve, and it is the procedure least likely to reduce diameter or produce erection problems. It will shorten the penis to some extent, though.

1 Plication or removal of several pieces of the tunica albuginea on the non-affected side of the penis. The side-effect of this surgery is to shorten the penis, so a simultaneous operation to lengthen the penis by cutting the suspensory ligaments and allowing it to drop down may be performed. However this in itself has the effect of rendering the erect penis less rigid.

2 When there is a slight curve, incision or excision of the plaque with a graft of artificial material to repair the tunica may be possible.

Tissue Grafts

When the diameter of the penis is reduced or the bend is severe, tissue grafting, which involves excising the plaque and grafting healthy tissue from some other site in the body into the site of the excised plaque can be an effective treatment.

There is some risk of erectile dysfunction, but it is a remedy that substantially maintains the length of the erection. As you may expect doctors have considered many options for the material used in such grafts, including pericardial tissue from cadavers, Gore-Tex, small intestinal submucosa, dermis and vein grafts. The important issue is that the graft does not produce inflammation, loss of muscle fibre or loss of  elasticity through fibrosis in the penis.

Penile implants

These are inflatable cylinders, biologically compatible with the tissues of the penis, which can be implanted in the corpus cavernosa. They are now only used in a few cases since grafting surgery is so effective.

At least one expert has a theory that some men may have a genetic predisposition to injury to the internal tissues of the penis. Others disagree: they think it's just the cumulative result of too much energetic sex over a period of time.

In any event, if you want to avoid Peyronie's you should avoid the more extreme sex positions - the ones which put a considerable strain on the penis.

You should also be careful in some of the more common ones - the worst of these being the woman on top position, in which you're liable to pop out of her vagina; if she then comes down seeking reentry, and misses your penis.....well, snap and ouch! Lastly, enjoy a constant stream of new sex positions.

Finally, just to confuse the issue, here's a photo of a penis which does not have symptoms of Peyronie's.

bent penis

This seems to be a rather uncommon condition in which a penis just naturally bends more than usual. If you have this problem (e.g., if you're a teenager who hasn't had sex or injured himself, and it still looks like this), see a doctor to get some advice on whether corrective surgery for your penis is possible.

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