Penile fillers are on the rise. But is enhancing one's manhood like this safe?

The first time Steven signed up to inject his penis with filler in 2019, he was afraid he would permanently mutilate it. There wasn’t a lot of reliable information about the procedure online, and he had come across a few horror stories about doctors injecting silicone into penises, causing their patients to lose sensation. 

Still, he had wanted his penis to be bigger for years and was finally approved for a circumcision in Canada, where he lives. This, he had read, reduced some of the risks associated with the penile filler procedure, in which a solution — anything from silicone to hyaluronic acid (HA), a natural substance found in the eyes and joints — is injected into the penis to adjust its girth and shape. With few options nearby at the time, he booked a flight to Mexico, where he had found a clinic that seemed to be reliable.

“I remember sitting on a plane … and being absolutely terrified — like, is this going to be a nightmare experience that’s going to ruin my life?” Steven, who is using a pseudonym to protect his privacy, told Salon in a phone interview. “You get scared.”

There’s not a central database that tracks the number of these procedures done, but the rise in penile augmentation in recent years has been described as a “boom,” and doctors interviewed for this story said they have been seeing a rise in the demand for it. 

Besides HA, doctors have injected several products into the penis. Permanent fillers like silicone or paraffin have been used but are not recommended, as they have been associated with long-term complications like necrosis and deformities. Other semi-permanent solutions like polymethylmethacrylate (PMMA) microspheres or fats are often used as well, although they can also cause lumps that may be harder to remove than less permanent solutions like HA.

“You name it and someone has put it in their penis, or tried to,” said Dr. Amy Pearlman, a urologist at the Prime Institute. “People are talking about [penile augmentation] and certainly a lot of patients are asking providers about it.”

In the research that has been published on these procedures, several studies show the risks are relatively low for injecting HA, which can be dissolved. However, the more permanent the filler, the higher the risk for complications and the lower the chances of being able to get it fixed, Pearlman said. Without clear guidelines on the procedure, many doctors are left to figure out best practices on their own, although Pearlman argued the evidence for using HA for penile augmentation was relatively solid at this point. 

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“We make a lot more clinical decisions based on way less robust data than we do with using hyaluronic acid for the penis,” she told Salon in a phone interview.

Dr. Luis Cassavantis, a dermatologist and the Medical Director of Avanti Derma in Mexico, says between 2008 and 2021, when he partially retired, he performed more than 5,000 penile augmentations. In a 2016 study of 729 of his patients, published in the Journal of Sexual Medicine, three patients had to have a nodule PMMA filler removed surgically, and about half of some 200 patients who responded to a questionnaire said they felt they were left with irregularities in their penis.

“The main complication that we face is irregularities,” Cassavantis told Salon in a phone interview. “Just a few of them, especially when they are uncircumcised, developed a serious deformity, but that was not only related to the lack of circumcision but also to the skills of the injector.”

Steven’s procedure was performed with PMMA in Mexico, where he had volunteered to be one of the first patients of a new practitioner training to do the procedure. He didn’t experience medical complications from the experience, but he wasn’t entirely pleased with how his penis looked afterward. A few years later, the procedures had gotten more popular and he found a doctor closer to home offering HA injections. Again, he opted to have a procedure done. Since his first visit with the new doctor in mid-2022, he has returned about a half-dozen times to get re-upped.

“I’m confident that if I’d gone down [to Mexico] for probably another one to two sessions, I would have been happy with the aesthetics overall,” Steven said. “It wasn’t bad, it just wasn’t what I wanted.”

When people first started doing these procedures around the '80s and ‘90s, many people who weren’t medical professionals were performing penile injections using baby oils, silicone and paraffin, Cassavantis said. As the years went by, doctors started offering less permanent penile augmentation options and best practices were shared to reduce the risk of complications, he said.

“Things are getting better and people are more open to talk about it, but in the early years, this was a procedure that was kind of dark,” Cassavantis said. “The number of complications that we saw in the early years were really bad.”

What drives most men to try penile augmentation is similar to what drives people to get any other cosmetic procedure done: They are unhappy with a part of their body and want to change or enhance it. In a survey of men who got the procedure, the most common reason they did it was to improve self-confidence, followed by wanting to increase sexual function. 

Social media and its proliferation of unrealistic beauty standards have been shown to impact the mental health and self-esteem of girls and young women. Of course, these standards affect everyone’s perceptions of body image and self-esteem — including men.  

Research suggests around half of men are unhappy with their penis size. Some studies have identified a form of body dysmorphia called penile dysmorphic disorder that causes long-term anxiety in a small fraction of men, though this is not a diagnosis that has been separated out from body dysmorphia disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

“If the first thing someone does in the morning is go to the bathroom and pee, that’s the first thing they see to start their day, and they’re unhappy with that part of their body, it’s going to impact their mental state throughout the day,” Pearlman said.

Many men looking to change their penis size through these procedures also have to pay a steep price. Because it’s an elective procedure, it usually costs thousands of dollars per session out of pocket. How long the temporary fillers last depends on a number of factors, like level of sexual activity, said Dr. John Leonardo, an anesthesiologist who performs the procedures. He uses a hybrid product that combines HA with Radiesse, a cosmetic filler. It’s common for patients to come back to re-up their filler before it has naturally broken down, he added.

“Most of my guys say it’s very addictive and they keep coming back to top it off,” Leonardo told Salon in a phone interview.

Some medical organizations have addressed penile augmentation as the demand for it continues to increase but don’t provide best practices for what is still considered an “experimental” procedure. The American Urological Association issued a position statement on fat injections for penile augmentation, indicating that there is not enough evidence to suggest the procedure is safe or effective. In April, the Sexual Medicine Society of North America released a position statement concluding that there wasn’t enough accurate research conducted in penile augmentation to make recommendations, although it did recommend against permanent injections like silicone.

“Specifically, without accurate information, it is not possible for clinicians or patients to make an appropriate judgment as to the true risks and benefits of a therapy,” it states. “As such, informed consent is limited, which contributes to the recommendation that some of the therapies be considered experimental at the present time.” 

Some have called for the development of national guidelines to ensure the procedure, which is increasing in prevalence, is performed safely. In one letter to the editor published in the journal Urology, a urology resident likened the lack of knowledge surrounding penile augmentation in the specialty to “a plastic surgeon [being] unfamiliar with a ‘Brazilian Butt Lift.’”

Without said guidelines, providers who want to perform these procedures are left to seek training on their own, Pearlman explained. Plus, there are no products that are approved for this use by the Food and Drug Administration (FDA). Although it’s common for doctors to use things off-label, it could improve the safety of the procedure to have a product specifically designed for penile augmentation.

“Even though a lot of people would consider the urologist to be the expert in the penis, we don’t really have much dedicated to the cosmetic aspect of that,” Pearlman said. 

Regardless, men are electing to have these cosmetic procedures to increase the size of their penises. 

“It's kind of a taboo subject, and it's not something that anybody talks about,” Steven said. “I feel like it would be better if there were more information out there for guys.”