Podcast Transcript: Exploring Penile Girth Enchancement Techniques

[Dr. Jose Silva]:
Penile girth enhancement. Was this something you were doing back in Iowa, or you started doing this in Miami?

[Dr. Amy Pearlman]:
I started doing this procedure in Miami, but the questions about girth enhancement, and enhancement didn't start in Miami. They started when I was in training. I think it's a common question that we get asked as urologists is, "Are there any safe ways to improve my length or girth?" I think for many of us, we're used to telling people you're within normal limits.

We think about the micro penis. That's a very small patient population. Pretty much, every man who comes to see us, is going to have a normal size penis. We're used to telling him that his penis is normal. In what other areas of our lives do we expect that people are going to be satisfied with the status quo? Cosmetics plays a role in so many other specialties, dermatology, plastic surgery, oculoplastics. Why wouldn't it make sense for us as urologists to say, if there are safe options now to offer patients, we should really be leading the charge on that.

[Dr. Jose Silva]:
No. Yes, exactly. I mean, like you mentioned, that's something that even during residency, a patient comes for a kidney stone, "Hey, do you guys know about penis enhancement. Make it bigger." It's something that comes up in the conversation at some point with patients. When you're talking about penile girth enhancement, what exactly-- What it is?

[Dr. Amy Pearlman]:
There are a lot of different options for penile girth enhancement, and we separate them out into injectable options, and then surgical options. Even within the injectable space, you name it, someone has injected it into the penis. Now, we think of things as more temporary fillers, and then more permanent fillers. To be very clear, the only option that I offer in my clinic are temporary dermal fillers.

I use a product, hyaluronic acid. It is a product that we use off-label in the penis. It is approved, FDA approved for facial uses. I tell all of my patients, "This is not an approved product for the penis." There has yet to be a single patient who has a problem with that. When we think about all the different therapies we offer as urologists and within medicine, a lot of the therapies we prescribe to our patients are actually used off-label. If we actually looked at the indications for specific treatments. We use a lot of things off-label, and patients are okay with that.

[Dr. Jose Silva]:
You mentioned, it is something that is absorbed by the body, I guess, at some point, it's non-toxic. How long does it last?

[Dr. Amy Pearlman]:
Hyaluronic acid is a naturally occurring substance in the body, and in its very simplest terms, it's a sugar molecule. The next time you go to a convenience store, if you just look down the aisle of facial products or moisturizers, you're going to see that a lot of the products have hyaluronic acid in them. Hyaluronic acid is naturally in our eyes, and in our joints, and it's a very moisturizing molecule.

It brings water to it. That's what I use in the penis. In terms of how long it lasts, that's a really good question. We're still trying to figure out that answer. I want to tell you, or I want to explain to you all why we have not been able to answer that question yet. When we look at the use of hyaluronic acid in other areas of the body, like the face, it tends to last in the lips for about 12 months, but also not all hyaluronic acid products are created equal.

It's going to depend on the exact product that someone's going to use. When it comes to the penis, I'll give you an example of a patient that might see me. He's coming in and we put the product in, and then he's reaching out to me at random times throughout his follow-up. He might come back six months later and say, "Hey, I was just driving through Miami. I would like more filler."

What I explain to my patients is really the only way for us to be able to answer that question, is if I did the filler procedure and said, "I'm going to need you to come back to see me once a year for the next 5 years or 10 years, I'm not going to give you any additional filler. I just want to measure your penis." Every single man has laughed at me when I've said that before, right?

That is the challenge, is getting these guys to come back when I'm not giving them additional treatments. The other thing is they just randomly ask for additional treatments depending on what's going on, and what their needs are. Then lastly, it depends on how much filler they want, and what their girth goals are. Now, there are several studies that have been conducted outside of the United States, and those studies put in all the filler at once.

On average, they put in about 20 units of filler at once, which is a very high volume of filler. That is not how I do that procedure under the PhalloFILL protocol. Our protocol is to inject about four to six units during each session. If someone, let's say, has three to four sessions about three to four weeks apart, and then let's say 10 weeks later has another session, again, it's a little bit challenging in terms of knowing how long it lasts.

In my personal experience though, we tend to get what we expect, and I've had patients come in six months later, and really retain a lot of that filler. I've also had patients come in less than that, a few months later, and they've lost some of the filler. It really depends on how quickly that person metabolizes. We know when it comes to Botox, the last time I had Botox, I was wrinkling my face about six weeks after, and I was like, "Darn, I didn't get three months out of it." Some people just metabolize it quicker than others.

Who Considers Girth Procedures & How Urologists Guide Them

[Dr. Jose Silva]:
In terms of, who is a candidate, or who's not a candidate? What is the typical patient that goes to your office for this? Are they going just for this, or they're going for something else? Then, they see that you're doing this, and they start asking questions, or how does it usually happens?

[Dr. Amy Pearlman]:
Yes, good question. I don't have girth enhancements plastered on all of my walls because my mission–

[Dr. Jose Silva]:
You should, you should. You'll probably will get more.

[Dr. Amy Pearlman]:
Oh my gosh. My mission is not to introduce a confidence issue into someone who doesn't have a concern about the size of their penis. There are some things in my office that are out in the open, and other things that are a little bit more subtle. I have these demos off the side of where my desk is, that really demonstrates what someone's girth is, and what their girth goals are.

I'll have some people look around my room, and they'll say, "Oh, what's that?" That might be an opening for me to talk about girth enhancement. There are a lot of patients who come to see me that don't even know that I do it, and I don't necessarily bring it up. I found that there are-- Most of the guys that come to see me, they're either coming in specifically for girth enhancement, they're coming in with any type of sexual dysfunction, usually erectile dysfunction, or low testosterone, or Peyronie's disease.

I do bring up the size in a way that doesn't, I don't think, introduce any self-doubt, or confidence issues. I want to give you an example of a question I might ask. If I'm talking to someone with erectile dysfunction, I might simply ask him towards the end of that conversation, "Do you have any length, or girth concerns?" I don't ask him, "Do you feel like your penis is small? Do you feel like it's short?" I simply ask, "Do you have any length or girth concerns?"

A lot of people will say, "I mean, doesn't everyone?" Then I'll say, "Well, we have options. Would you like to hear more about it?" There are some guys that would like to have a larger penis, but they're just not willing to go through what it takes to get a larger penis. They're not really-- They may not even want to entertain the conversation. Then, there are a lot of guys who just didn't know that it was possible.

They are very much interested in hearing about what some of those options are. The guys that come into my office are the normal dudes walking down the streets of Coral Gables. They are truck drivers. They are accountants, investment bankers, they are businessmen. They're just-- They're retired. They're 77 years old and saying, "Hey, this has been a concern for most of my life, and I'm not dead yet. What can you do for me?" They're the normal dudes, yes.

[Dr. Jose Silva]:
You're not telling that after you examine them, right? You wait a couple of minutes.

[Dr. Amy Pearlman]:
All my patients have normal size penises, and I tell them that. They know that, they know it.

[Dr. Jose Silva]:
No, and also, a lot of patients, they always, they complain that it has shrunk in the past years just with age, or usually with the-- They're a little bit more obese, more fatty tissue there, so it looks smaller. I guess, that's also part of the conversation, "Hey, do you think it's smaller now compared to before?" Everybody had-- When they were younger, it were up to the knees. Now, it's smaller, so.

[Dr. Amy Pearlman]:
Yes. When we talk about that a lot in these conversations, you would ask the question, what does that person say to me when he walks in the door? He might be coming in for a girth enhancement conversation. I'll tell you, that conversation could be very quick. Honestly, I could say, "Where do you think you are in terms of girth? Where do you want to be? Okay, I think it's going to take this amount of filler. Let's go in the next room."

Some of those visits are pretty quick, but again, I use that as an opportunity. This is a guy who came in for a very specific reason. I actually broaden the conversation to a comprehensive men's health visit. I say, "Hey, have you ever had any hormone concerns? Have you had your testosterone checked? How are your erections? Any curvature concerns?" We end up talking about a lot of men's health issues.

In fact, I ended up managing a lot of their testosterone therapy, because I've built their trust talking about the girth enhancement. Then, they say, "Oh, she's pretty cool. I want you to manage my testosterone." I really broaden those conversations. As you mentioned, we talk about, have you always been concerned about your size, or has your size been stable throughout your adult years? Were you bigger before and have you lost length, or girth?

If they say the latter, that they've lost size, that's where, again, I'm broadening this discussion. We're talking about, might they have gained some weight to bury their penis a little bit? We'll go into that discussion. We'll talk about the use of vacuum pumps, and traction therapy. There have been several guys where I've actually said, "Look, I actually wouldn't recommend filler today. If you want to see if you can restore some size before I put filler in, why don't you try some traction and a vacuum pump?" I'll postpone their filler for another day.

[Dr. Jose Silva]:
You're also selling the traction device, and the vacuum right there in the office?

[Dr. Amy Pearlman]:
I do, yes. That's part of that, the sexual wellness product room, what I've called a Medtail. It really makes these products convenient for patients, so that they can walk out of the door. What I also really like, I have some patients who come in with their product, and with their suitcase, we go right next door to my procedure room, and I say, "Hey, do you want me to show you how to use this device before you leave my office today?"

It is so amazing how many patients I've seen who have purchased these devices online, they don't know how to use it. They walk in the office and they say, it doesn't work, or it's painful. These devices, they do work. It's just, they don't know how to use them, and how to use them to optimize comfort. That is what part of-- I would say one of my most important roles is, is to educate people on how to use these really good products, and those would be vacuum pumps and traction devices.

[Dr. Jose Silva]:
We go, in my case, first we go back to-- I'm part of a big health system, so definitely high volume. I tell them, "Hey, go online, buy this stuff," whatever. Sometimes they know how to use it, but sometimes they come, "Hey, I bought it." Then, I take my time to help them, but because they already put me in the spot, so I need to help. It's like you mentioned. Usually, in this academic centers, health system, we don't have that time that you have to-- You're dedicating to that patient that to really help them what they need. They sometimes go through other processes, injections, maybe something as basic as a vacuum is what they need.

[Dr. Amy Pearlman]:
Yes. Here would be my advice, because I started doing this when I was at the University of Iowa, and running a busy clinic, is I just created a packet, and I didn't have the anatomy of most of my patients at the time, because the majority of my patients were men. I asked my patients, I had a patient, Dennis, who provided me a lot of feedback. I said, "Dennis, you really struggled when you were using a vacuum pump. Would you mind writing down about five bullet points of things that you've learned that I can share with the next guys? My next patients?"

I compiled a bunch of bullet points. I asked my public physical therapist, "Hey, what recommendations do you think that I can provide patients? We all have this shared message." If you're in a busy clinic, which a lot of people are, even just giving them a one or two-page document that says, "Look, this is what other guys have told me. These are the tips and tricks," that can be very beneficial.

Two, if someone prefers communicating through video, all you have to do is create a five-minute video demonstrating technique, or even just include a link to whatever product you recommend that has a good demonstration video, which a lot of times the companies already have. A good exit strategy is to say, "Look, I don't have the time to show you this in my clinic, but here's a really good link to see exactly how to use it."

[Dr. Jose Silva]:
No, and you sent me last time, you sent me the packet. I print it out, and then maybe I give it once, or twice and then, it just caught up, but I need to definitely do it. It was very good. Let's go back to that talk, to the patient, that initial talk about the enhancement, side effects. What do you talk about once the patient's already saying, "Hey, I want to do this."? How do you go about that?

[Dr. Amy Pearlman]:
Yes, I want to actually answer your other question, which you had asked me before, which is, who is a candidate, and who is not a candidate for penile girth enhancement with hyaluronic acid? Most patients are actually going to be candidates, which is great. For some of the other options, like a silicone implant, they're typically not going to implant that in someone who is uncircumcised.

We can put filler in people who are uncircumcised, so we don't require that they get a circumcision beforehand. Now, the outcomes, it's going to be a little bit trickier to put filler in, and there are some other considerations in terms of injection technique if someone is uncircumcised, but I have several patients that are uncircumcised, and they've gotten a great result. That doesn't factor into it.

Men who are on blood thinners, initially, I was nervous about doing that, and I've definitely been more strict in the past in terms of holding blood thinners. I have some patients that will just hold it, because they don't want to potentially increase the risk of a bleeding issue. I've also done the procedure with guys on antiplatelets and blood thinners, and you know what? They did fine.

I think with any sort of in-office procedure that we all have our own comfort level, but that would not be necessarily a contraindication. Penile implants, I will tell you, and this is, I don't have any research to support this other than my own anecdotal experience, I would say some of my happiest patients are guys who have inflatable penile implants in, who have great devices.

Their devices are seated extraordinarily well, their implants are working fantastically, but they just want larger girth with their implant in. The technique is a little bit different. I use smaller needles, and obviously, I'm trying to stay away. I don't want to touch that implant even with a nine-foot pole. The injection technique is a little bit different, but they are very happy patients. That doesn't really play a factor.

Then, someone-- I would say the biggest concern would be a guy with a buried penis, and not necessarily like a buried penis where you can't expose it, because obviously you're not going to be able to put filler on that guy, but someone that when he stands up, he really buries his penis. I've had to turn down a couple of guys where I've said, "I can lay you back, and the filler is going to look amazing with you laying back in this procedural chair. Once you stand up, it is just all going to go all to the tip." I've had to turn down some of those guys.

PhalloFILL’s Role in Standardizing Penile Filler Practice