Artificial Penile Bodies-From Kama Sutra to Modern Times

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Artificial Penile Bodies—From Kama Sutra to Modern Times

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Oliver Stankov, MD, Ognen Ivanovski, MD, PhD, and Zivko Popov, MD, PhD University Clinic of Urology- Medical Faculty Skopje, University “Ss Cyril and Methodius”, Skopje, Macedonia DOI: 10.1111/j.1743-6109.2009.01230.x

ABSTRACT

Introduction. Artificial penile nodules are defined as inert objects inserted beneath the skin of the penis to enhance the pleasure of female/male sexual partners during intercourse. Aim. The aim of this article is to present our experience in dealing with artificial penile bodies. We have also reviewed the pertinent literature focusing on social, motivational, and occupational characteristics of individuals adopting this sexual practice, diagnostic dilemmas and the surgical and health side effects of the implantation of artificial penile nodules. Methods. We performed a computerized MEDLINE search followed by a manual bibliographic review of crossreferences. These reports were analyzed and the important findings summarized. Results. The phenomenon of inserting self-made artificial nodules beneath the skin of the penis was first described in the Kama Sutra, the classic Indian treatise on love. It is most commonly observed among men from Southeast Asia. The occurrence is much less common in western cultures, but it has been reported to occur in Romania, Germany, and among Fijians and Russian immigrants in Israel. Furthermore, four cases of self-inserted artificial penile bodies from our clinical practice are presented and discussed. Conclusions. The most common motive associated with foreign artificial bodies on the penis is sexual or erotic in nature and that is to enhance the pleasure of female or male sexual partners during sexual intercourse. Most of the reports involve members of low economic groups like gang members, soldiers, drug addicts, sailors, labor workers, and prisoners. Men suffer no serious side effects after insertion, although fixed beads can cause rupture of condoms. For women, the beads can cause abrasions and a few days of postcoital vaginal pain. Penis implants and inserts and other penis augmentation devices are potentially dangerous to both men and women, and of questionable value in bringing pleasure to either, and should be discouraged. Stankov O, Ivanovski O, and Popov Z. Artificial penile bodies—from Kama sutra to modern times. J Sex Med 2009;6:1543–1548. Key Words. Artificial Bodies; Penis; Sexual

Introduction

R

ecently, three comprehensive reviews were published in the Journal of Sexual Medicine concerning penile foreign bodies [1–3]. These reviews discuss different penile objects, methods of their removal, outcomes, grading of penile injury, as well as penile injection with various liquid materials used for soft-tissue augmentation. With the exception of a few case reports, data regarding solid, foreign bodies inserted under the skin of the penile shaft is lacking. Artificial penile nodules are defined as inert objects inserted beneath the skin of the penis to enhance the pleasure of female/ male sexual partners during intercourse.

© 2009 International Society for Sexual Medicine

Here we describe four cases who presented themselves to our hospital with self-introduced foreign solid bodies along their penile shafts. We have also reviewed the pertinent literature focusing on social, motivational, and occupational characteristics of individuals adopting this sexual practice, diagnostic dilemmas and the surgical and health side effects of the implantation of artificial penile nodules. Case Reports

Between September and December of 2007, four patients presented themselves to our hospital with self-introduced objects in subcutaneous locations J Sex Med 2009;6:1543–1548

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J Sex Med 2009;6:1543–1548

yes Self-made while in prison

Yes Self-madewhile in prison

Yes Self-made while in prison

Yes Self-made while in prison

16 months Dorsal side 4

7 pleasure

8 pleasure

pleasure

N/A

24 month

Nonmedical equipment in nonsterile conditions Nonmedical equipment in nonsterile conditions Non-medical equipment in nonsterile conditions Nonmedical equipment in nonsterile conditions 24 months

All circumference along penile shaft Dorsal and lateral sides Dorsal side

Not married 24 Patient 4

Prisoner

N/A 35 Patient 3

Prisoner

46 Patient 2

Prisoner

Married

To enhance sexual of his partners To enhance sexual of his partners To enhance sexual of his partners To enhance sexual of his partners Not married Prisoner 38

Age

Patient 1

Marital status

Motivation

pleasure

13

Injected paraffin Types of beads Instrument used Location

Time from placement of beads Number of beads Status at time of implantation

Characteristics of the patients with implanted penile bodies admitted at our Clinic for surgical removal of the implants Table 1

along the shaft of their penises (Table 1). The patients were 38, 46, 35, and 24 years old, with 13, 8, 7, and 4 objects inserted, respectfully. The penises were glossily swollen as a result of repeatedly injected paraffin, and the round objects were not visible on inspection. On palpation, the objects were rigid, mobile, nontender with rounded margins and the overlying skin was intact. No ulcers or signs of inflammation were present. All patients reported having introduced these objects while being in prison using nonmedical equipment under nonsterile conditions. The introductions were performed by using the following technique: the patient himself lifts the shaft skin while his friend makes two small parallel openings in the skin of the penile shaft using a sharp instrument. Through one of these openings, the objects are pushed into a subcutaneous location using a rod. Concerning the material of the objects, the patients reported that they have all used old toothbrushes and have carefully manufactured these objects in the mechanical workshop, taking great care with the surface of the balls in order for them to be as smooth as possible. They also reported that some Russian prisoners introduced this technique to allegedly augment the sexual pleasure of their male partners. They all presented themselves to the hospital by their own free will, with requests for surgical removal of the inserted objects and with explanations that they do not longer need it. One of them was married and reported that his wife was bothered by the objects. They all seemed pleased by the procedures and did not express any regrets. No erectile dysfunction or voiding difficulties were reported. The surgery, performed under local anesthesia, turned out to be rather difficult in terms of locating the objects along the shaft of their penises because of increased penile fibrosis as a result of paraffin injections. For that reason, the patient with self-implanted 13 foreign bodies had to be operated twice because of a single forgotten object during the first surgery (Figure 1A). In the case of this patient, surgery consisted of a circumferential incision of the penile skin just above the penile shaft, where most of the objects were located. In the case of the other three patients, first the beads were carefully palpated, located, and then fixed by the assistant. Thereafter the incision was made just above the fixed bodies, which were located mostly on the dorsal side of the penis (Table 1). By using blunt and sharp dissection through the subcutaneus fibrous tissue, the bodies were identified and dissected out. If the bodies

Stankov et al.

Artificial Penile Bodies—A Review

Figure 1 A. Patient has been previously presented in our Clinic with 13 self-introduced foreign penile bodies. After 8 months period he is presenting again due to a single forgotten object.

could not be dissected out through a single incision, a second incision was made. The patients’ recovery was quick, and they were all discharged 2 days later when the penile edema had subsided. All patients gave consent for this publication. Discussion

The phenomenon of inserting self-made artificial nodules beneath the skin of the penis is most commonly observed among men from Southeast Asia [4], including members of Yakuza in Japan [5] and prisoners in Indonesia [6]. The purpose is to enhance the pleasure of female or male sexual partners during sexual intercourse. Although some authors believe that the use of artificial penile nodules arose after World War II, the practice was actually discussed in the Kama Sutra [7], the classic Indian treatise on love. In addition, several historical records dating back centuries from Southeast Asian countries explain the existence of implants and foreign bodies under penile skin [8]. This is also shown by penis balls represented in a linga (male organ of a deity) in the 15th-century Hindu temple Candi Sukuh in Central Java [9]. Since then all the literature on artificial penile nodules consisted of only few case reports [4,10–13]. It is believed that penis inserts have persisted because of the autonomy and equality of women in Southeast Asian societies. Fang muk (Thailand), bulletus (Philipines), chagan balls (Korea), tancho balls (Japan), penis

1545 marbles (Fuji) and goli or bullet (India) are terms synonymous with the ethnosexual practices of various subcultural groups of Southeast Asian males, the terminology being specific to the geographic region. The occurrence is much less common in Western cultures, but it has been reported in Romania [14], Germany [15], and among Fijians [11] and among Russian immigrants in Israel [16]. Most of the reports involve members of low-economic groups like gang members, soldiers, drug addicts, sailors, labor workers, and prisoners, such as our patients. Data regarding the prevalence of this phenomenon among different cultures are lacking; however, Serour [16] calculated it to be 0.63% among male Russian immigrants who participated in a circumcision program in Israel. Furthermore, Thomson et al. [17] have studied the prevalence and types of penile modification in a sample of 100 young men in Chiang Mai, Thailand. He found that the prevalence of penile modification was 51%, with the most common type being inlaying with penile objects (muks) (61%). The majority of modifications in this study were performed in prison or in juvenile detention (80%), by a friend (90%) [17]. The beads are usually made from a piece of broken glass or plastic, cut and polished into required shapes and sizes. They can also be made from ivory, gems, stones, bullets, plastic, and gold. The number of beads also varies according to personal choices and economic status of the person. In the literature, up to 1–10 beads are reported [18]. Our patient reported that, in order to insert the foreign bodies, two small holes were made in the skin of the penile shaft and the nodules were then pushed into place with a rod. The reason why two holes are needed is unknown. The penile shaft is covered by a thin layer of redundant, highly mobile skin. These characteristics make the described procedure feasible. The elastic and mobile skin can be lifted off the shaft in order for the nick to be performed without damaging the underlying tunica albuginea and erectile tissues. The implanted bodies should be moveable and slippery underneath the penile skin during coitus. The loose adherence of the skin to the underlying tissues allows the introduction of sizable foreign bodies and accounts for their mobility within the subcutaneous layer. The fixed beads would lead to painful intercourse and may cause abrasion of the genital organs of both men and women. The objects are usually permanently implanted. The site of implant may be on any part of the penile J Sex Med 2009;6:1543–1548

1546 skin, even though the dorsum is the most common site as observed in these four cases. The conditions under which implantation of penile bodies is usually performed are nonsterile. In addition, sharing equipment is common, as seen in our four patients. However, we have not observed any signs of present or past infection when we examined and operated on these patients. Data regarding the prevalence of infection in these patients are lacking. Interestingly, although in most of the reported cases a nonsterile technique of implantation was used, the infection rates of these patients were reported as none or minimal. No diagnostic problem to the clinician should be encountered. These objects are usually palpable as nontender, hard, subcutaneous nodules, and should not pose any diagnostic dilemma. The radiologist, however, might be baffled by the finding of penile pathologies in general and penile nodules in particular, which are uncommon in the setting of emergency room abdominal CT examinations [19]. The radiographic characteristics of the implants seem often similar to those of urinary calculi and should not be confused with these entities [19]. The differential diagnosis may include infectious processes such as syphilis, tuberculosis, ringworm infection, and bacillary angiomatosis [20]; inflammatory conditions including Peyronie’s disease, granuloma annulare [21], and sarcoidosis; benign growths including dermatofibroma, epithelial cyst, epidermal inclusion cyst [22], and schwannoma [23]; and a secondary spread of malignant diseases and primary malignant tumors of the penis including penile carcinoma, leiomyosarcoma, and epithelioid sarcoma [24]. However, it is unlikely for the densities created by these pathological processes to have the characteristics of synthetic nodules. The inserted objects do not usually give rise to symptoms, and normally they are either detected by chance or by autopsy examinations [25–27], or when the patients ask for their removal, similar to our group of patients. In addition to inserted objects our patients had multiple penile selfinjections of paraffin for penile enlargement purposes, which made the surgical procedure of extraction difficult. Namely, because of an increased penile mass mostly as a result of vacuolization of the tissue and increased fibrosis (Swiss cheese-like phenomenon), the location of the objects was not evident. For that reason one patient (the one presented with 13 inserted objects) had to be operated on twice because of a J Sex Med 2009;6:1543–1548

Stankov et al. single forgotten object. This practice, as reviewed recently [3], can cause paraffinoma, penile ulcers, voiding difficulty, and erectile dysfunction [28]. The tissue response of a host on penile objects is unknown. Allen [29] provided an excellent histological documentation of the natural human response to the injection of silicone. Essentially, natural activation of the resorption process by host tissue is triggered by foreign body injection, and penile foreign bodies should be no exception. Neutrophils and monocytes dominate the early response, followed by foreign-body giant-cell formation. At about 4 weeks, epithelioid cells and fibroblasts appear, and significant collagen deposition begins and progresses throughout the next 4 weeks. At 6 months, stable giant cells are present along with dense collagen and fibrocytes [29]. Several possible reasons and motivations can be suggested for this practice: (i) to enhance sex; (ii) peer influence, to have equality or group association; (iii) demand from female/male sexual partner; (iv) because it symbolizes manhood and potency; and (iv) for reasons of body symbolism. When interviewed, both sex and nonsex workers reported that these pearls made sex more painful, especially for women who had not experienced vaginal delivery [17]. It seems that men do not experience serious side effects after insertion although fixed penile bodies can cause rupture of condoms. In addition, men and women reported that condom use was more difficult postimplantation, as condoms were more likely to leak and were less likely to fit correctly [17]. For women, the objects may cause abrasions and a few days of vaginal pain after sexual intercourse [30]. Although this practice may or may not pose a serious public health problem, as markers of misguided or exploitative gender relations they do reveal important aspects of social psychology related to sexuality and sexual health [31]. However, as Brown, James and Ruth have noted [32] although penis inserts “may seem to be among the more bizarre human inventions, an understanding of penile inserts promises to throw light on basic features of Southeast Asian thought, on the ethnological relationships between Southeast Asia and other parts of the world, and on the relations between the sexes everywhere.” In this context it is also worth mentioning that the phenomenon of koro (in Chinese, called suo-yang)—which represents a panic anxiety state in which affected males believe that the penis is shrinking and/or retracting, and perhaps disappearing—is exclusively found in this

Artificial Penile Bodies—A Review part of the world, notably in China, Singapore, Taiwan, and Honk Kong [33]. In conclusion, penis implants and inserts and other penis augmentation devices are potentially dangerous to both men and women, and are of questionable value in bringing pleasure to either sex, and should be discouraged.

Acknowledgments

OIiver Stankov MD and Ognen Ivanovski MD, PhD, contributed equally to this article. Ognen Ivanovski MD, PhD, was a recipient of the Reintegration grant from NATO Science for Peace Program and a grant from Inoue Foundation for Science (Tokyo, Japan). Corresponding Author: Ognen Ivanovski, MD, PhD, University Clinic of Urology, Medical Faculty, University “Ss Cyril and Methodius”, Vodnjanska 17 St, 1000, Skopje, Republic of Macedonia. Tel: + (389) 2 3147 032; Fax: + (389) 2 3226 796; E-mail: [email protected] Conflict of Interest: None declared.

Statement of Authorship

Category 1 (a) Conception and Design Ognen Ivanovski (b) Acquisition of Data Ognen Ivanovski; Oliver Stankov; Zivko Popov (c) Analysis and Interpretation of Data Ognen Ivanovski

Category 2 (a) Drafting the Article Ognen Ivanovski; Oliver Stankov (b) Revising It for Intellectual Content Ognen Ivanovski; Zivko Popov

Category 3 (a) Final Approval of the Completed Article Ognen Ivanovski; Oliver Stankov; Zivko Popov

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