Small penis

　　What causes small penis?

　　First, the cause of the disease

　　1. The causes of small penis include:

　　(1) Hypogonadism due to insufficient gonadotropin secretion (hypogonadism);

　　(2) Hypogonadism due to excessive gonadotropin secretion;

　　(3) Primary small penis.

　　2. Hypogonadism due to insufficient gonadotropin secretion

　　(1) Abnormal brain tissue structure: Infants with anencephaly lack hypothalamic secretion function. Even if the pituitary gland develops normally, due to the lack of gonadotropin-releasing hormone, testosterone secretion is low, leading to small penis, congenital hypopituitarism, partial dysplasia of the corpus callosum leading to hypothalamic dysfunction, cerebellar malformations with movement disorders, and other midline brain development abnormalities, all of which are caused by insufficient gonadotropin secretion, and also lead to multiple malformations in other systems.

　　（2）Congenital deficiency of gonadotropin-releasing hormone without brain tissue abnormalities: Small penis caused by this reason is more common than the former. The specific etiology is unclear, and it is mostly various syndromes, such as Kallmann, Prader-Willi syndrome, Lawrence-Moon-Beidel syndrome, etc., often accompanied by multiple malformations. According to research, it is related to chromosomal and genetic abnormalities. There are also deficiencies in gonadotropin-releasing hormone, luteinizing hormone, and other syndromes caused by endocrine and biochemical metabolism abnormalities.

　　3. Hypogonadism with excessive secretion of gonadotropin. In these patients, the hypothalamus and pituitary gland secretion function are normal. However, the testes show degenerative changes in the late pregnancy, leading to reduced testosterone secretion. Through negative feedback, excessive secretion of gonadotropin occurs, and the main cause of small penis is the testes themselves, such as congenital absence of testes, incomplete descent of testes, etc. Some patients have normal testes, but their luteinizing hormone receptor is abnormal, resulting in insufficient testosterone secretion. In addition, attention should be paid to the possibility of gender abnormalities.

　　4. In addition to the above reasons, a small number of patients with primary small penis have normal hypothalamic-pituitary-testicular axis hormone secretion, but have small penis malformation. During puberty, they can grow more, and the etiology is unclear. It is speculated that it may be due to delayed stimulation of gonadotropin in the late embryonic stage, transient decrease in testosterone secretion, and some patients may have abnormal androgen receptor.

　　5. Patients with small penis may have chromosomal abnormalities, such as Klinefelter syndrome (47, XXY), poly-X syndrome (48, XXXY and 49, XXXXY), and trisomy (69, XXXY).

　　Second, Pathogenesis

　　1. The normal male penis development is completed in the first 12 weeks of the embryonic period, divided into 3 stages. The first stage is the genital bud stage, during which the genital bud gradually elongates into a small hill, with a length of 8-15mm. The second stage is the penile body stage, in which the penis continues to grow into a cylindrical shape under the action of dihydrotestosterone (DHT), with a length of about 16-38mm. The urethral groove extends to the glans penis. The third stage has a penile length of 38-45mm, with the completion of urethral development.

　　2. The embryonic development reaches the 7th to 8th week, during which the reproductive glands gradually differentiate into testes. Under the stimulation of chorionic gonadotropin (HCG) produced by the placenta, Leydig's cells in the testes produce testosterone. After 4 months of pregnancy, the fetal hypothalamus secretes gonadotropin-releasing hormone (Gonadotropin-nelasinghormone, GRH), which stimulates the anterior pituitary to produce luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Under the joint action of HCG, LH, and FSH, the testes continuously produce testosterone. Testosterone is then converted into DHT by the 5-α reductase, which stimulates the gradual growth of the penis. Small penis is often due to hormone deficiency after the 14th week of embryonic development.

　　What diseases can small penis be accompanied by?

　　1. Accompanied by incomplete or gradual regression of male secondary sexual characteristics (pubic hair, axillary hair, beard, voice change, Adam's apple, male reproductive organ shape, etc.), depression, general weakness, lack of masculinity; sparse pubic hair, decreased libido, or the occurrence of sexual dysfunction problems such as impotence and premature ejaculation.

　　2. Often accompanied by bilateral cryptorchidism, obesity, underdevelopment of the scrotum and testicles, and other malformations.

　　1. The penis is particularly small, not matching the age, but the appearance is normal. The length-to-diameter ratio is normal, and the length is less than the average length of the normal penis by more than 2.5 standard deviations. Some penile corpora cavernosa may not develop well.

　　2. Examination shows no scrotum, small, soft testicles, incomplete descent, or absence, and other malformations.

　　3. Rectal examination shows that the prostate is smaller than normal.

　　1. Exercise more and maintain a balanced diet.

　　2. Choosing the correct underwear is very important.

　　Traditional underwear can lead to the following situations:

　　(1) Loosely fitting underwear pulled too high to the left or right can easily lead to curvature of the penis to the left or right;

　　(2) Long-term pressure on the penis scrotum by close-fitting underwear (especially during sleep) can easily lead to shortening and curvature of the penis. To avoid the above situations, it is recommended to pay special attention to avoid long-term compression of the penis scrotum, especially at night when sleeping.

　　(3) Reduce the intake of high-calorie foods, as frequent consumption of high-calorie foods can easily lead to obesity.

　　1. Routine examination of karyotype, blood glucose, potassium, sodium determination, or hormone tests related to growth hormone, and thyroid function tests. For those with low LH, FSH, and testosterone, primary hypogonadism should be suspected. Human chorionic gonadotropin (HCG) stimulation test can be performed (injection of HCG 1000 to 1500U intramuscularly every other day for a total of 7 times, and serum testosterone should be tested within 24 to 48 hours after the last injection), if testosterone, LH, and FSH are all

　　2. Imaging examination: Those who have the condition should take magnetic resonance imaging (MRI) as a routine examination. The main examination is to check for hypothalamus, pituitary malformation in the brain, and pay attention to the optic nerve crossing, fourth ventricle, and corpus callosum in those with craniofacial abnormalities.

　　Dietary therapy for small penis:

　　1. Animal penis and testicles, such as bull penis, dog penis, deer penis, sheep kidney, and chicken testicles, can be dried at low temperature and ground into fine powder. Take 6g to 10g each time, once or twice a day, before meals; or simmer the fresh ones; or cook them separately with goji berries, Polygonum multiflorum, and Cistanche deserticola, and consume them long-term for better effects.

　　2. Regular consumption of beef, mutton, dog meat, and soy products may promote the development of the penis and secondary sexual characteristics; dry and grind the testicles and placenta of pigs, sheep, or dogs into powder, take 2 grams each time, twice a day, and long-term use has a similar therapeutic effect.

　　3. Eat more high-protein foods, and you can use Epimedii Herba, Cistanche, and Burnt Bone to make soup.

　　When taking androgen therapy, it can be taken

　　I. Traditional Chinese medicine treatment methods for small penis

　　1. Kidney deficiency and Tian Gui deficiency syndrome

　　Treatment method: For those with kidney yang deficiency, it is advisable to warm the kidneys and strengthen yang; for those with kidney yin deficiency, it is advisable to nourish yin and benefit the kidneys.

　　Prescription: For those with penile shortening due to kidney yang deficiency, use modified Yougui Decoction, in which Shudihuang, Shanyao, Shanyao, and Gouqizi are used to reinforce kidney yin; Roudi and Fuzi are used to warm and nourish kidney yang; Gancao is used to reinforce the middle and Qi; Duzhong is used to strengthen and invigorate essence, working together to warm the kidneys and strengthen yang and benefit Tian Gui. For those with kidney yin deficiency, use modified Zuogui Decoction, in which Shudihuang, Gouqizi, and Shanyao are used to nourish the yin of the liver and kidney; Shanyao, Yunling, and Gancao are used to nourish the yin of the spleen and stomach, and the herbs work together to reinforce kidney yin and benefit Tian Gui.

　　2. Liver channel blood stasis syndrome

　　Treatment method: Activate blood and remove blood stasis, and regulate Tian Gui.

　　Prescription: Modified Xuefu Zhuyu Decoction. The peach and red four-herb decoction in the formula is used to activate blood and remove blood stasis, nourish yin and blood with Shudihuang; Chaihu and Zhishen are used to regulate Qi to assist in blood activation, Niuxi is used to activate blood and remove blood stasis to guide the medicine downward, and Gancao is used to harmonize all the herbs. The whole formula, when combined, can activate blood and remove blood stasis, regulate Qi and remove stagnation, and can optionally add products such as Gouqizi and Luju to invigorate essence and replenish Tian Gui.

　　What are some folk remedies for treating penile shortening?

　　3. Bushen Powder

　　Use 30 grams each of Shudihuang, Baizhitian, Shanyao, Gouqizi, Xianmao, Zihai, Rousenong, and Buguzhi, 15 grams each of Renshen, Danggui, and Huai niuqi, 10 grams of Chaihu, 10 strips of er, and 1.5 grams of Moshuang. Grind into fine powder. Take 1 gram per year per dose (adjust according to age), twice a day. A course of treatment is 3 months. Effects: It can reinforce kidney essence, benefit Tian Gui, nourish Qi and blood, and moisten the vital sinew.

　　This prescription is used to treat penile shortening due to insufficient kidney essence and insufficient Tian Gui, even if it can be erected, it is not firm. It may be accompanied by reduced libido, dull hair, poor development, fatigue, pale and white tongue, and deep and thin pulse.

　　4. Dihuang Decoction

　　Take 15 grams each of Shudihuang and Baizhitian, 12 grams of Shanyao, 6 grams of Shihu, 10 grams of Rousenong, 6 grams each of Wuweizi and Guanui, 10 grams of Fuling, 12 grams of Maidong, 6 grams each of Pao Fuzi, Changpu, and Yuanzhi. Grind the herbs into coarse powder, take 10-15 grams each time, add 10 grams of ginger and 5 slices of Dazao, and boil together. Take twice a day. A course of treatment is 2 months.

　　Symptoms include: small penis, poor development of secondary sexual characteristics, soreness and weakness in the lower back and knees, melancholic temperament, pale tongue with thin fur, and weak pulse.

　　Effects: It can nourish kidney yin, reinforce kidney yang, calm the mind and spirit, and open the lower orifice.

　　This prescription is used to treat penile shortening due to kidney deficiency and insufficient Tian Gui, empty brain marrow, and failure of heart and kidney to communicate.

　　5. Bushen Zhuanyuan Decoction

　　Take 6 grams of附片, 10 grams of Xianlingpi, 12 grams of Huolüba, 10 grams each of Shudihuang, Xianmao, Baizhitian, Yangqishi, Baizhu, and Danshen, 12 grams of Huaiyao, 10 grams of Lujiaoshuang, 6 grams of Rougui, and 3 grams of Gancao. Boil in water. Take one dose per day, divided into two servings. A course of treatment is 2 months.

　　Effects: It can warm the kidneys and strengthen yang.

　　This prescription is used to treat penile shortening due to insufficient kidney yang. Symptoms include small penis, poor development of secondary sexual characteristics, soreness and weakness in the lower back and knees, cold hands and feet, inability to maintain an erection, pale tongue with thin white fur, and weak pulse.

　　Secondly, Western medical treatment methods for small penis

　　For small penis and small testicles, medication should be used according to different causes.

　　For example, for patients with hypothalamic lesions but normal pituitary function, luteinizing hormone-releasing hormone should be used; if the pituitary gland has lesions but the testicular function is normal, chorionic gonadotropin should be used; only when there is a problem with the testicles can testosterone be used. If testosterone is used indiscriminately, the results are not ideal, which is the reason for this.

　　Different methods of 'penile modification' for different populations:

　　1. People with obesity, due to the thick fat layer in the lower abdomen, cause the penis to be buried in the fat layer, forming a 'turtle head' type of penis. In this case, using a fat aspiration machine to remove the fat layer in the lower abdomen or surgically removing the fat layer can have the effect of extending the length of the penis in appearance.

　　2. Simple fat injection penileoplasty: This surgical method involves extracting the patient's own fat and injecting it into the penis. The advantages are that the surgery is simple and the trauma is minimal. The disadvantages are that the survival of the injected fat is a crucial issue that is constrained by many factors, and the surgical results are not always ideal. The medical community has different views on this method, and it is still in the exploratory stage. Improving the survival rate of fat transplantation is crucial.

　　3. Implantation of prosthetics: Implantation of prosthetics is originally a surgical method used in Western countries to treat organic impotence. After the implantation of the prosthesis, the penis can also be lengthened and thickened. Therefore, under the request of patients with a strong desire to increase the size and thickness of the penis, Western countries sometimes also use this method to meet their needs. Such surgery is currently rarely carried out in China.

　　4. There have been certain improvements in the treatment methods for small penis. However, androgen replacement is still the main treatment method. Since enough testosterone is provided to the patient's body, it will stimulate the development of the penis without affecting the growth and closure of the bones. Aller's recommended treatment method is to take 25mg of testosterone orally every 3 weeks, with a total dose not exceeding 100mg. The effectiveness of the treatment should be evaluated by measuring the length of the penis before and after treatment (from the pubic bone to the glans). Treatment should start from one year old. The purpose is to keep the development of the child's reproductive organs consistent with the growth of the body. If the child's penis growth is significantly worse than that of同龄 children, the above treatment should be repeated. For children with incomplete descent of the testicles, the testicle descent fixation surgery should be performed before the age of 2. LHRH can also be used to promote the development of the penis and the descent of the testicles.

　　The 'penis suspensory ligament resection' and 'penile pedicle skin flap transplantation' are considered to be the most satisfactory methods of penile reconstruction so far.

　　5. Penis Suspensory Ligament Resection

　　The principle of this surgery is that the penis visible from the body surface is only a part of the penis, and the other part is hidden in the tissue under the pubic bone, fixed by the suspensory ligament of the penis. After the suspensory ligament of the penis is removed, this part of the penis is also exposed, thereby extending the penis. Data show that in the treatment of 1347 cases of penile hypoplasia, 84% of the patients can extend the penis by 3 to 5 centimeters. The medical community abroad generally believes that this surgical operation is safe, the patient's pain is minimal, the cost is not high, and it is convenient for promotion and application. It is currently the best method in the technical field of reconstructing the penis.

　　6. Pedicled skin flap transplantation for the penis

　　Pedicled skin flap transplantation for the penis, also known as autologous dermal fat flap transplantation, is an effective method for thickening the penis. The pedicled skin flap transplantation for the penis was first carried out abroad and has been popularized in China in recent years.

　　The method to thicken the penis by using pedicled skin flap transplantation is: using skin tissue taken from the body, removing the epidermis, retaining the dermis and fat, and transplanting it to the penis to thicken the penis. To ensure the success of the transplantation, the surgery should be carried out in stages: first, take skin from the autologous donor area (inguinal or buttocks or root of the thigh), and make a pedicled flap. "Pedicled" means that the skin is not completely removed, but retains part of the "pedicle" containing blood supply to ensure the survival of the flap and make a "pedicled flap"; after confirming that the pedicled flap is successfully prepared and survives, proceed to the second step. Remove the epidermis, retain the dermis and fat, and transplant it to the penis. At this time, it is still necessary to retain the "pedicle" containing blood supply until it is confirmed that the transplanted tissue has successfully formed new blood supply in the penis, the transplanted tissue has successfully survived, and the "pedicle" no longer needs to provide blood supply before it can be removed, and the entire operation can be completed. The advantages of this operation are: it can ensure a high rate of transplant success, and ensure a more reliable thickening effect.

　　3. Prognosis

　　Patients with small penis should be followed up for a long time until adulthood to observe and understand the development of the penis, sexual behavior, and fertility. Some authors report that children with irregular or delayed hormone treatment have poor penile development, abnormal sexual behavior (homosexuality), and some require gender reassignment. Reily and Woodhouse reported that a group of patients who received early diagnosis and treatment had most of their penile length still below the normal value after adulthood, but normal sexual behavior, so proper endocrine and psychological treatment should be adopted. For patients with very small penises and no treatment possibilities, early gender reassignment surgery is the best choice.