Asian Journal of Andrology (2021) 23, 392–395

www.asiaandro.com; www.ajandrology.com

Open Access
ORIGINAL ARTICLE

Complications and management of penile

Male Health

augmentation with hyaluronic acid injection

Yuan Quan1, Zi-Rui Gao2, Xiang Dai1, Ling Kuang3, Min Zhang4, Qing Li1, Tao Xu1, Xiao-Wei Zhang1

Hyaluronic acid injection is becoming a popular way for penile augmentation. However, only few studies and follow-ups have
investigated the various complications of hyaluronic acid injection and their corresponding management. In this study, a total of
230 patients who had penile augmentation with hyaluronic acid injection from January 2018 to December 2019 were examined on
follow-up for penile girth, complications, and their corresponding management. At 1-month, 3-month, and 6-month postoperative
follow-ups, the penile circumference had increased by 2.66 ± 1.24 cm, 2.28 ± 1.02 cm, and 1.80 ± 0.83 cm, respectively. During
the entire 6-month follow-up, 4.3% had complications such as subcutaneous bleeding, subcutaneous nodules, and infection.
There were no systemic or local allergic reactions among all the patients. All complications were treated accordingly, and no further
deterioration or severe sequelae were observed. Although complications of hyaluronic acid injections are mild and rare, these may
affect the patient’s satisfaction postoperatively. Preoperative redundant prepuce may increase the incidence of penile edema or
postoperative gel migration. Standardization of the surgery protocol and elucidation of the effects of other injection parameters are
still lacking. Nevertheless, it still highlights the importance of preoperative preparation and surgical technique.
Asian Journal of Andrology (2021) 23, 392–395; doi: 10.4103/aja.aja_78_20; published online: 29 January 2021

Keywords: complications; hyaluronic acid injection; penile augmentation

INTRODUCTION PATIENTS AND METHODS

Penile size is an important index for the measurement of sexual This is a retrospective study involving patients who underwent PA
development in men. It is perceived as a symbol of health, sexual with HA injection in Beijing Eden Hospital (Beijing, China) and
performance, and masculinity.1,2 According to some studies, penile Chengdu Kowloon Hospital (Chengdu, China) between January 2018
size is related to self-esteem, and men who underestimate their size and December 2019. The study was approved by the review board
may have a stronger tendency to exaggerate physiological defects institution of Beijing Eden Hospital (No. S2017011) and Chengdu
and express psychological distress.3,4 As a result, they are prone to Kowloon Hospital (No. An0012). The inclusion criteria were adult
feeling depressed.5 The tendency of men to exaggerate women’s penile males who (1) wanted to improve their quality of sex life, (2) were
size preference appears to drive anxiety and sexual dissatisfaction.6,7 dissatisfied with their penile size, and (3) were willing to undergo
Girth is considered more important than length.6 Due to all the surgery. The exclusion criteria were patients who (1) were over
reasons stated above, more and more men are consulting about penile 65 years of age, (2) had coagulopathy, and (3) had to take long-term
augmentation (PA) and looking for ways to increase sexual attraction anticoagulants. A total of 230 patients (average age: 30.34 years)
and satisfaction. were selected. All patients have been informed of the study and have
As the soft-tissue filling surgery becomes safer, it is also approved the collection of patient data. Photographs were taken before
becoming more popular and accepted as a micro-invasive procedure the operation and at the 1st, 3rd, and 6th month of follow-up. Penile girth,
for soft-tissue augmentation.8 Hyaluronic acid (HA) injection was self-reported satisfaction, and postsurgical discomfort were assessed.
considered to be safe in PA and can significantly improve psychological All data were analyzed using descriptive statistics (SPSS statistics
distress from small penis syndrome, a disorder where a person becomes version 20, IBM, New York, NY, USA). The results were expressed as
anxious about having a small penis in the presence of a clinically mean ± standard deviation (s.d.). All participants received previous
normal penile size.9,10 However, few complications of the surgery were counseling and signed informed consent.
described. To our knowledge, though the adverse effects of the HA The surgery was done by an experienced genital reconstructive
injection are usually mild, if any, at the least, these may cause negative surgeon (XWZ) under local anesthesia with lidocaine. An 18G
psychological effects on the patients. In this article, we discussed the cannula was used to establish an injection tunnel at the root of the
common complications after HA injections for PA and present our penis. HA (Martifill, Wuhao Biological Technology, Shanghai, China)
management after them. was injected through the tunnel between the penile superficial fascia
1
Department of Urology, Peking University People’s Hospital, Beijing 100044, China; 2Department of Dermatology and Venereology, Peking University People’s Hospital,
Beijing 100044, China; 3Department of Nephrology Division, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, Chengdu 610072, China;
4
Department of Urology, Chengdu Kowloon Hospital, Chengdu 614000, China.
Correspondence: Dr. XW Zhang (docachang@126.com)
Received: 17 June 2020; Accepted: 11 October 2020
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393

and Buck’s fascia. The total amount of HA injected ranged from smaller than 1 cm can be managed by massaging for several days, only
13 ml to 25 ml (mean ± s.d.: 16.30 ± 2.46 ml) depending on the size the large nodules have to be removed surgically. Nonetheless, all of
of the patient’s penis. After injection, the doctor sutured the injection the nodules were painless, visible, and palpable (Figure 1). Infection
point with 4-0 Vicryl absorbable thread. The penis was dressed with always occurred in the unhealed wound, presenting as a sudden warm
elastic bandages for 14–21 days. Meanwhile, patients were taught to penile swelling with redness (Figure 2). The symptoms are often
massage the penis to make the HA distributed evenly under the skin. found by the patients themselves. After confirmation by the surgeon,
Patients were asked to abstain from sexual intercourse for the first the complications were managed by their corresponding treatment.
4 weeks post-surgery.
DISCUSSION
RESULTS HA is a key component of the extracellular matrix, found naturally
At the 1st, 3rd, and 6th month follow-up, the penile circumference in the human body. Because of the small chemical structure and
had increased by 2.66 ± 1.24 cm, 2.28 ± 1.02 cm, and 1.80 ± 0.83 cm similarity among all species, HA seldom causes implant rejection or
(mean ± s.d.), respectively (Table 1). During the 6-month follow-up, allergic reactions.10,11 Previous studies have shown that HA injection is
4.3% (10/230) of the patients experienced complications, most of a feasible and safe micro-invasive surgery for PA.12,13 Although injected
which were mild, namely, subcutaneous bleeding (1.3%), subcutaneous HA gel is gradually degraded after 6 months, causing a 15% decrease in
nodules (2.2%), and infection (0.9%). There were no systemic or local the maximal circumference after 5 years, it is still a long-term effective
allergic reactions among all the patients. method for PA.14,15
Subcutaneous bleeding manifested as a darkened skin on the penis, To our knowledge, there are no follow-up studies to identify the
often causing panic in patients (Figure 1). Subcutaneous nodules complications of PA using HA injection due to the low incidence. Based
presented as masses with diameters larger than 1 cm. Because nodules on the current classifications,16 the complications of filler surgery can
be classified into three types, namely, (1) basic health status of patients,
Table 1: Characteristics of all patients (2) surgical problems, and (3) filler properties. Because many studies
Variables All patients (n=230) have confirmed the safety of HA injection in penile surgery, our study
Age (year) 30.30±5.23 mainly focused on the first two types.
BMI (kg m−2) 23.70±3.17 This study has found that the complications of PA with HA
HA dosage (ml) 16.30±2.46 injection were subcutaneous nodule, penile edema, and infection. The
Penile girth (cm) timeline of these complications is summarized in Figure 3.
Preoperation 8.20±2.01
Penile subcutaneous nodule
Growth at 1-month follow-up 2.66±1.24
The most common complication of HA injection among patients is
Growth at 3-month follow-up 2.28±1.02
penile subcutaneous nodule (total incidence of 2.2%), usually occurring
Growth at 6-month follow-up 1.80±0.83
2 weeks post-surgery. The nodules we described are related to the
All data are presented as mean±s.d. s.d.: standard deviation; BMI: body mass index;
HA: hyaluronic acid accumulation of HA in one area.15 Because HA requires a certain period
of time for redistribution and shaping, elastic bands and penile massage
may be used to evenly disperse HA. However, when HA is injected too
fast, it may not distribute evenly. This may result in the development of
nodules refractory to penile massage therapy after 1–2 weeks. Although
these nodules tend to be painless, they can last for a long time if not

a b

c d
Figure 1: Subcutaneous bleeding and subcutaneous nodule. (a) The front
view of a patient who developed subcutaneous bleeding characterized by
skin darkening on the 3rd day postoperation. (b) The side view of this patient.
(c) The front view of a patient who developed subcutaneous nodules on the Figure 2: Infection in penis postoperation. The patient developed skin infection
17th day postoperation. (d) The side view picture shows that the patient had on the 50th day postoperation. The entire hyaluronic acid layer was infected,
multiple subcutaneous nodules. presenting as a total penile swelling.

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a b

c d
Figure 4: Nodule removal and purulent fluid and hyaluronic acid gel in the
Figure 3: The timeline of complications in penile augmentation. The average
infected penile skin. (a) Purulent fluid and hyaluronic acid gel discharge
time of appearance and duration of the complications.
following incision. (b) Three days after debridement. (c) Incision of a nodule
from the penile skin. (d) Removal of the subcutaneous nodule.
managed.16 Moreover, due to the thin skin of the penis, subcutaneous
nodules larger than 1 cm usually become noticeable and palpable. Injection factors such as cannula size and injection site have
As a result, patients may feel discomfort and depression during sex. a crucial role in infection. Unlike the results of Jeong et al.12 and
Moreover, these nodules cannot resolve spontaneously.
Kwak et al.,14 complications such as subcutaneous nodule and infection
Treatment options include surgery17 (Figure 4) and hyaluronidase
are more frequent in our study. In the study of Kim et al.,21 initial and
therapy.18,19 Surgery, however, may undermine PA as local HA is
supplemental HA injections at 2 weeks were done via cannulation with
removed as well. On the other hand, hyaluronidase therapy is done by
sizes of 27G and 30G, respectively, based on the HA gel used. Moreover,
fine-needle injection of an appropriate amount (usually 30 units) of
HA gel injection was done in the glans penis without suturing. In
hyaluronidase depending on the size of the nodule. It usually takes about
our study, we found that injecting the root of the penis using an 18G
3 days to take effect, and patients would not have to undergo another
cannula provides ease for the even distribution of HA. However, a
surgery. The disadvantage is that results are not instant – additional one
disadvantage is that in some of the patients, the injection sites do not
or two treatments may be required to completely eradicate a nodule.
heal spontaneously, which may be sites for infection from the pubic
These nodules, however, can be prevented by making HA
hair flora in the absence of skin preparation. As a result, suturing of
distribution more uniform. To do this, we made two adjustments,
specifically, the use of (1) low HA dose (about 0.3 ml each) and injection site was done.
(2) multi-point fan technique. Several HA gel features have been implicated in infections and
subcutaneous nodules. In our study, a mono-phasic and synthetic
Subcutaneous bleeding HA was used. Aseptic technique was strictly followed to reduce the
In the present study, subcutaneous bleeding occurred in 1.3% of all the possibilities of infection.
patients. It mainly happens 2–5 days after surgery and peaks at the first The two patients that had infection during the follow-up underwent
week. The main mechanism of subcutaneous bleeding in HA injection incision and drainage (I&D). Incision was made on the penile skin
is direct vascular puncture. Although HA injection is a micro-invasive with swelling. Due to the high internal pressure, HA and purulent
surgery, use of anti-thrombotic drugs prior to treatments must be halted fluid were discharged and drained from the incision point (Figure 4).
to decrease the risk of bleeding. Furthermore, the use of cannulas rather After I&D, intravenous antibiotics were administered for 3–5 days.
than needle has been shown to help decrease its risk.11 Reports have also Both healed without further progression and discomfort. This indicates
shown that the use of thicker needle tubes to establish a cannula may that although HA injection is safe for most of the patients, diabetics
reduce the incidence of subcutaneous bleeding. To prevent it, we used and immunocompromised patients have a higher risk for infection.
an 18G cannula to create a skin tunnel for HA injection. Subcutaneous Penile edema is characterized by swelling of the penile skin
bleeding, if any, can spontaneously resolve in a transient period. The (Figure 5). Interestingly, all the 21 patients who had penile edema after
most important thing the doctors can do is to reassure patients. PA with HA injection had the problem of redundant prepuce and did
Infection not underwent preoperative circumcision. Redundant prepuce may
Infection is a common complication in any surgical procedure. cause distal accumulation of the injected HA gel and lead to lymphatic
However, the incidence of infection following soft-tissue injection is compression.22 Penile edema can be relieved by using elastic bandage
low.20 In the present study, only two patients were reported to have for 2 weeks without severe adverse effects.
infection, both of whom are diabetic and had sexual intercourse This study is limited by patient variability, sample size, and
1–2 months post-surgery. temporal constraints, which must be addressed in future studies.
There are four main elements that can contribute to infection: Differences among patients (e.g., redundant prepuce
(1) patient characteristics, (2) intercourse, (3) injection factors, before injection) must be standardized in the succeeding studies. Our
and (4) HA gel features. Patient characteristics such as diabetes results have shown that the patients who had penile edema after the
and immunodeficiency increase the risk of developing infections, operation had redundant prepuce. In a randomized controlled trial
particularly in the genital region. Intercourse can also contribute to by Abdallah et al.23 where all the patients were circumcised prior to
infection. Bacteria, present abundantly in the vagina and pubic hair, HA gel injection, no penile edema was reported. Although there is no
may enter the unhealed wound during intercourse and cause infection. study explaining the role of redundant prepuce on the incidence of

Asian Journal of Andrology

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395

ACKNOWLEDGMENTS
This study was supported by Beijing Municipal Natural Science Foundation
(No. 7194327).

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AUTHOR CONTRIBUTIONS
premature ejaculation by glans penis augmentation using hyaluronic acid gel: a pilot
YQ participated in the surgery and follow-up and drafted the study. Andrologia 2012; 44 Suppl 1: 650–3.
manuscript. ZRG made the main follow-up work and recorded the
complications. XD arranged the data and made the statistics. LK
helped to draft the manuscript. MZ participated in the arrangement
of figures and tables. QL and TX participated in the study design.
XWZ participated in the surgeries, guided the study, and made the This is an open access journal, and articles are distributed under the terms of the
managements of all the complications. All authors read and approved Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which
the final manuscript. allows others to remix, tweak, and build upon the work non-commercially, as long
as appropriate credit is given and the new creations are licensed under the identical
COMPETING INTERESTS terms.
All authors declare no competing interests. ©The Author(s)(2021)

Asian Journal of Andrology