Andrew Siegel MD 12/30/2023
This entry was prompted by my wife forwarding me the following:
I hope she was not trying to tell me something, but simply sent this my way because she thought I would be amused from a urological perspective!
“Water Tap That Turns into a Pillar of Fire” (line coined by Eric Gill)
The possession of a penis endows man with the ability to stand to urinate and direct his urinary stream, a distinct advantage over the clumsier apparatus of the fairer sex that generates a spraying, poorly directed stream that demands sitting on a toilet seat. The advantage of being able to stand to urinate (and keep one’s body appropriately distanced from the horrors of many public toilets) is priceless.
Additionally, the ability of this flaccid piece of flesh hanging from man’s mid-section to morph into a “proud soldier,” rigidly pointing at the heavens, capable of penetration, ejaculation, and reproduction is unparalleled.
When That Water Tap Can Only Drip and the Fire Gets Extinguished
“Doc, my penis is vanishing; I can barely find it at times.”
“When I pee, it sprays and drips all over my thighs, so I have to sit like a woman.”
“My urinary stream is weak.”
“Sex is out of the question.”
The aforementioned complaints are commonly voiced by many patients who consult urologists. The long and the short of it is that aging, weight gain, poor lifestyle habits and other factors may result in men with penises that have shrunken and/or have become recessed. Coincident with the penis becoming smaller, the prostate gland generally becomes larger and capable of constricting the urinary stream. This combination of events results in the inability to generate a straight and forceful urinary stream as well as phallic incapacity with an inoperative or poorly operative shaft in terms of sexual function. Sadly, this collaboration of shrinkage, compromised urinary flow, the need to sit on the toilet like a female, and erection issues is the perfect storm resulting in emasculation, depriving man of his male role and identity.
A rifle is advantageous over a pistol because of greater power as well as the longer barrel resulting in greater accuracy. The shriveling penis (combined with the enlarging prostate that accompanies aging) functions more as a pistol than a rifle, disadvantageous in terms of power and accuracy.
Why Things Might Go South
- Weight gain: Big pannus/small penis
Poor lifestyle habits wreak havoc on the anatomy and function of the penis. Many middle-aged men typically (insidiously) gain a few pounds every year, and ultimately start developing a pubic fat pad — the male equivalent of the female mons pubis. Additionally, a pannus (“apron”) of abdominal fat often starts to become apparent. The pubic fat pad in combination with the pannus results in the penis appearing shorter and becoming an “innie” as opposed to an “outie.” In actuality, although penile shrinkage may occur, penile length is usually more-or-less preserved, with the penis merely buried within the enveloping fat creating the “turtle effect.” It is estimated that for every 35 lbs. of weight gain, there is a one-inch loss in apparent penile length.
The shorter appearing and more internalized penis can be difficult to find, and the forceful and precise urinary stream of yesteryear gives way to a spraying and dribbling-quality stream that can drip down one’s legs, spray over the floor and onto one’s feet and even at times towards the gentleman next to you at the urinal! Clearly not good. This is compounded by the enlarging prostate gland that crimps the urinary stream. Before you know it, you are sitting to urinate, joining our “stream-challenged” female companions.
Additionally, the weight gain and poor lifestyle often give rise to difficulty achieving and maintaining erections. This shorter and less functional penis and the need to sit to urinate is downright emasculating.
- Disuse atrophy: Use it or lose it
Like any other organ in the body, the penis needs to be used on a regular basis, as nature intended. If one goes too long without an erection, erectile tissues — including collagen, elastin, and smooth muscle — may be compromised, resulting in a loss of penile length and girth, and limiting one’s ability to achieve an erection. In a vicious cycle, loss of sexual function can lead to further progression of the problem as poor genital blood flow causes low oxygen levels in the genital tissues, that, in turn, can induce scarring, further compounding the problem.
- Peyronie’s disease: Scar tissue in a place that needs expansion
Peyronie’s disease is scarring of the covering sheaths of the erectile chambers thought to be due to the cumulative effects of chronic penile micro-trauma. The scar tissue is hard and inelastic and prevents proper expansion of the erectile chambers, resulting in penile shortening, deformity, angulation, and pain. In the early acute phase, most men notice a painful lump or hardness in the penis when they have an erection as well as a bent or angulated erect penis. In its more mature chronic phase, the pain disappears, but the hardness and angulation persist, often accompanied by penile shortening and narrowing that gives the appearance of a “waistband.” Many men as a result of Peyronies will have difficulty obtaining and maintaining an erection.
Peyronies can also occur as a consequence of a penile fracture, an acute traumatic injury of the covering sheath of the erectile chamber. This most commonly happens from a pelvic thrusting miss-stroke during sexual intercourse when the erect penis strikes the female perineum or pubis and ruptures. This is an emergency that requires surgical repair.
- Pelvic surgery
After surgical removal of the prostate, bladder, or colon for management of cancer, it is not uncommon to experience a decrease in penile length and girth. This occurs due to damage to the nerves and blood vessels to the penis. The nerve and blood vessel damage can cause erectile dysfunction, which leads to disuse atrophy, scarring and penile shrinkage.
In particular, radical prostatectomy — surgical removal of the entire prostate gland as a treatment for prostate cancer — can cause penile shortening. The shortening is likely based on several factors. The gap in the urethra (because of the removed prostate) is bridged by sewing the bladder neck to the urethral stump, with a consequent loss of length from “telescoping.” Additionally, traumatized and impaired nerves and blood vessels vital for erections give rise to erectile dysfunction. The lack of regular erections results in less oxygen delivery to penile erectile tissue with subsequent scarring and shortening, a situation discussed above (disuse atrophy).
- Anti-testosterone treatment
Androgen deprivation therapy is a common means of suppressing the male hormone testosterone, used as a form of treatment for prostate cancer. Because testosterone is an important hormone for maintaining the health and the integrity of the penis, the low testosterone levels resulting from such therapy can result in penile atrophy and shrinkage.
Solutions
Keep one’s body (and penis) as healthy as possible via intelligent lifestyle choices is key to avoiding the enlarging pubic fat pad and the expanding pannus and will help maintain sexual and urinary function. Healthy lifestyle choices include smart eating habits; maintaining a healthy weight; engaging in exercise (including pelvic floor muscle training); obtaining adequate sleep; consuming alcohol in moderation (although the latest studies suggest avoiding alcohol entirely); avoiding tobacco; and stress reduction.
Using erectile dysfunction medications on a low-dose, daily basis can help maintain penile tumescence and help avoid the recessed penis, as well as improve urinary and sexual issues.
Numerous treatments are available for the enlarging prostate if that is determined to be contributing to the issue.
There are numerous benefits of engaging in sexual activity on a regular basis, not the least of which is to help maintain the integrity of penile tissues and helps protect against erectile dysfunction.
Peyronie’s disease as well as the penile anatomical and functional changes following radical prostatectomy are treatable.
Regarding androgen deprivation therapy, because of the resulting low testosterone levels, most men have a diminished sex drive and simply lose interest in sex and “use it or lose it” becomes challenging. Furthermore, many men on this therapy have already undergone radical prostatectomy and/or pelvic radiation therapy, so often have genital compromise even before using androgen deprivation therapy. The use of oral ED medications under this circumstance may help maintain penile stature and function.
Wishing you the best of health,
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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery. His mission is to “bridge the gap” between the public and the medical community.
He is an Assistant Clinical Professor in the Department of Urology at Hackensack Meridian School of Medicine and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. He is a urologist at New Jersey Urology, a Summit Health Company. He is the co-founder of PelvicRx and Private Gym.
Dr. Siegel is the author of several books. The newly revised second edition (June 2023) of Prostate Cancer 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families is now available in print and Kindle formats on Amazon.
Video trailer for Prostate Cancer 20/20
Preview of Prostate Cancer 20/20
Andrew Siegel MD Amazon author page
Dr. Siegel’s other books:
THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health
MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health
Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food
Our Greatest Wealth Is Health 