Sexual function and psychological characteristics of penile paraffinoma

Du Geon Moon¹, Jeong Woo Yoo^1, Jae Hyun Bae¹, Chang Su Han², Yong Ku Kim², Je Jong Kim¹

Keywords: paraffinoma; penis; augmentation; psychology

Abstract

Aim: To identify the sexual, emotional and psychological status of men who augmented their penis with mineral oil injection for their small penis. Methods: Men who had penile paraffin were asked to answer the semi-structured questionnaire. The questionnaire was designed to assess the motivation, method of penile injection, changes in erectile function and satisfaction after penile injection. SCL (Symptom checklist)-90-R, STAI (State and Trait Anxiety Inventory) and Zung SDS (Self-rating depression scale) were also included in the questionnaire for psychological evaluation. Results: A total of 357 men completed the questionnaire. The first-ranked motivation of the injection was recommendation by their acquaintances (48.9 %). The majority of the respondents had the procedure by non-medical person (78.0 %). Before injection, 17.2 % had a sense of inferiority in their penis and 32 % worried about their weak erectile function. After injection, 33.0 % have found relief from their sense of inferiority and 17.8 % wish to have improvement in their erectile function. Most of the respondents (91 %) were not satisfied with their penis and 74 % of them replied that they want to remove the injected material. Only 15.6 % did not experience side effects. Most of the subjects have suffered from various side effects such as inflammation, skin necrosis, pain, etc. No evidence of psychiatric pathology was found in psychological evaluation. Conclusion: The motivations of mineral oil injection were recommendation by their acquaintances or desire to be more mannish. Most of them had suffered from various side effects and only a small number of them felt improvement in their sense of inferiority, in their penis and erectile function. Increased public awareness is needed for the prevention of this physically and psychologically debilitating problem.

1 Introduction

Penile augmentation by localized injection of paraffin, vaseline (petrolatum) or any other mineral oil was widely known as inadequate medical procedure because of its severe destructive consequences [1]. Despite early warnings by many physicians, these agents continued to be used for the purpose to treat conditions ranging from hemorrhoids to wrinkles and even baldness. Medical doctors have abandoned most of these fads, but the complicating lesions have been documented as having lag times as long as 30 years [2]. Because most of the persons who had injected mineral oil at their penis undergone the procedure illegally, the exact incidence, epidemiology and their psychological status were difficult to be evaluated. We perform this study to identify the sexual, emotional and psychological status of mineral oil injected persons.

2 Materials and methods

Among the men in one local correctional institution, men who had mineral oil injection at their penis were asked to answer the questionnaire. All of them were in penal servitude. The semi-structured questionnaire was designed to assess the causes of injection, method of penile injection, erectile function change and satisfaction after the injection [Appendix]. For psychological evaluation, SCL (Symptom checklist)-90-R [3], STAI (State and Trait Anxiety Inventory) [4] and Zung SDS (Self-rating depression scale) [5] were included in the questionnaire.

3 Results

A total of 357 men completed the questionnaire. The majority of the patients had undergone the procedure of injection due to the recommendation by their acquaintances or the desire to be more mannish before imprison (Figure 1). Only 22.0 % of the respondents had the procedure by licensed medical doctor and 78.0 % by non-medical person (Figure 2). Before the procedure, 17.2 % had a sense of inferiority in their penis and 32.0 % worried about their week erectile function. After injection, 33.0 % felt improvement in their sense of inferiority and 17.8 % in their erectile function. Most of the respondents (91.0 %) were not satisfied with their mineral oil injected penis and 74.0 % wanted to remove the material. After injection, most of the subjects have suffered from inflammation (57.8 %), skin necrosis (11.1 %), pain (15.5 %), chronic discomfort (15.5 %) and difficulties in sexual intercourse. Only 15.6 % did not experience side effects (Figure 3). There were no evidences of any psychiatric pathology in the evaluation compared with 100 normal control males (Table 1).

Figure 1. The motivations of the injection were the recommendation of their acquanitances (48.9 %) or the desire to be more mannish (44.4%).

Figure 2. Only 22 % of injected persons had the procedure by medical doctor. Majority were performed by non-medical person.

Figure 3. Only 15.6 % did not experience side effects. Others have suffered from inflammation, skin necrosis, pain, chronic discomfort and difficulty in sexual intercourse.

Table 1. Mean scores of SCL-90-R, STAI and Zung SDS among paraffinoma group, compared with control group, P>0.05.

Injectable soft tissue substitutes provide an affordable, non-surgical alternative for correcting contour defects and soft tissue augmentation. Several materials have been used for this purpose, including paraffin, vaseline and other mineral oils [6, 7]. Although worldwide incidence is not well known, foreign-body injection is often attempted in order to increase the circumference of the penile shaft. Localized injection of hard and soft paraffin rose to a zenith of popularity in the early 1900s, thereafter the severe destructive consequences of such injections became widely recognized. However, these injections are still performed to a great extent by non-medical person [8]. Because these are illegal procedure, most of the patients are likely to be of low social status. Although augmentation phalloplasty is not an established procedure, some patients still need enlarging their penis. Current main procedures for augmentation phalloplasty are penile lengthening and girth enhancement by dermal-fat graft [9]. Unlike Western country, augmentation phalloplasty is very popular for subjective small penis in Asian country. Despite lack of available data, most Asian countries are paternal society and most Asian men wish to have a strong masculinity with a large penis. But the high cost of dermal-fat graft made it difficult to be performed in low socioeconomic status person. Additionally, the demand for penile augmentation continues to increase as the media display of normal male figures and advertisements create interest in corrective surgery. For these reasons, penile mineral oil injection is still performed especially in low socioeconomic group. Most persons who had augmentation phalloplasty in male clinic felt a sense of inferiority of their penile size, but only a small portion of mineral oil injected persons felt inferiority. Their main motivation of penile injection is the recommendation of their acquaintances, who already experienced injection of foreign body or the desire to be more mannish. Most of them have suffered from various side effects and want to remove the foreign material. So, penile foreign body removal is a familiar procedure to most Korean urologists. It is very difficult to diagnose penile paraffinoma for urologists unfamiliar with the disease. Soyer et al reported a case of sclerosing lipogaranuloma (paraffinoma) of the penis [10]. The clinical manifestations are very similar to those of squamous cell carcinoma of the penis. In such cases, the correct diagnosis can be made from a detailed history and the characteristic histological features and, if necessary, special chemical lipid analyses. Conclusively, increased public awareness is needed for the prevention of this physically and psychologically debilitating problem.

References

[1] Steffens J, Kosharskyy B, Hiebl R, Schonberger B, Rottger P, Loening S. Paraffinoma of the external genitalia after auto-injection of vaseline. Eur Urol 2000; 38: 778-81.
[2] Cohen JL, Keoleian CM, Krull EA. Penile paraffinoma: self-injection with mineral oil. J Am Acad Dermatol 2001; 45 (6 suppl): S222-4.
[3] Skilbeck WM, Acosta FX, Yamamoto J, Evans LA. Self-reported psychiatric symptoms among black, Hispanic, and white outpatients. J Clin Psychol 1984; 40: 1184-9.
[4] Allen GJ. Effect of three conditions of administration on "trait" and "state" measures of anxiety. J Consult Clin Psychol 1970;34: 355-9.
[5] Zung WW, Richards CB, Short MJ. Self-rating depression scale in an outpatient clinic. Further validation of the SDS. Arch Gen Psychiatry 1965; 13: 508-15.
[6] Barton JL, Cunliff WJ. In: Rook A, Wilkonson DB, Ebling FJG, et al., editors. Textbook of Dermatology. Oxford: Blackwell; 1986. p 1870-1.
[7] Knapp TR, Kaplan EN, Daniels JR. Injectable collagen for soft tissue augmentation. Plast Reconstruct Surg 1977; 60: 398-405.
[8] Lee T, Choi HR, Lee YT, Lee YH. Paraffinoma of the penis. Yonsei Med J 1994; 35: 344-8.
[9] Alter GJ. Augmentation phalloplasty. Urol Clin North Am 1995; 22: 887-902.
[10] Soyer HP, Petritsch P, Glavanovitz P, Kerl H. Sclerosing lipogranuloma (paraffin-induced granuloma) of the penis with a clinical picture of carcinoma. Hautarzt 1988; 39: 174-6.

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Correspondence to: Dr. Je Jong Kim, Department of Urology, Korea University Hospital, 126-1, 5-ka, Anam-dong, Sungbuk-ku, Seoul 136705, Korea.
Tel: +82-2-920 5367,  Fax: +82-2-928 7864
E-mail: jjkim98@korea.ac.kr
Received 2003-06-05  Accepted 2003-07-08

[Appendix]

Paraffinoma Questionnaire

1. Age :

2. Duration of prison life:

3. Marriage: married (  ) / not married (  ) / divorced (  ) 

4. Do you have emotional stress in prison?
(1) no (2) slightly (3) yes (4) very much

5. Do you have physical stress in prison?
(1) no (2) slightly (3) yes (4) very much

6. Do you concern about your external appearance?
(1) no (2) slightly (3) yes (4) very much

7. Do you concern about your erectile function?
(1) no (2) slightly (3) yes (4) very much

8. Did you have plastic surgery for better external appearance?
(1) no (2) once (3) more than once

9. Did you have any procedure or medication to increase your erectile function?
(1)no (2)once (3) more than once

10. If you had any surgery or medication to increase your erectile function, please check the bellows that you had.
(1) Penile augmentation - dermofat graft
(2) Penile augmentation - paraffin, Vaseline or any other mineral oil injection
(3) Penile augmentation - silicon ring insertion or any other foreign body insertion
(4) dorsal neurectomy
(5) Tattoo
(6) Intracarvernosal self injection
(7) others (  )

11. Did you have any sense of inferiority in penile size before mineral oil injection at penis?
(1) no (2) slightly (3) yes (4) very much

12. Do you have any sexual problem including week erection?
(1) no (2) slightly (3) yes (4) very much

13. Do you have any sense of inferiority in penile size after mineral oil injection?
(1) no (2) slightly (3) yes (4) very much

14. Why did you have mineral oil injection on your penis except sense of inferiority?
(1) recommendation of friend
(2) recommendation of sex partner
(3) recommendation of doctor
(4) to be more mannish
(5) just did it as others do

15. At what age did you have mineral oil injection on your penis
(  ) years old

16. By whom did you have the mineral oil injection?
(1) by a doctor
(2) by untrained person who practice medicine fraudulently
(3) by friend
(4) by myself

17. Is your erectile function improved after mineral oil injection?
(1) no (2) slightly (3) yes (4) very much

18. Is your sense of inferiority improved after mineral oil injection?
(1) no (2) slightly (3) yes (4) very much

19. Are you satisfied with your mineral oil injected penis?

20. Have you experienced any side effect of mineral oil injection?
(1) none
(2) inflammation
(3) penile skin necrosis
(4) pain
(5) chronic discomfort
(6) difficulties in sexual intercourse
(7) others (  )

21. Do you want to remove the injected material?
(1) no (2) slightly (3) yes (4) very much

22. Do you want to recommend your acquaintances to have mineral oil injection at penis?
(1) no (2) slightly (3) yes (4) very much

23. Was your sex partner satisfied with your mineral oil injected penis?
(1) no (2) slightly (3) yes (4) very much

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