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Glans Augmentation with Hyaluronic Acid

Glans penis augmentation (GPA) with hyaluronic acid (HA) is the office injection of cross-linked HA gel into the dermis of the glans, either to enlarge a glans the patient considers small or, in premature ejaculation (PE), to reduce glans sensitivity. Kim, Moon and colleagues in Seoul reported the first human series in 2003: 2 mL of HA gel injected into the glans of 187 men increased maximal glans circumference by about 15 mm at 1 year.[1] The evidence consists mainly of small single-center series and a few small randomized trials.[2] The AUA/SMSNA guideline classes bulking-agent injection for PE as experimental, and the ISSM guideline does not recommend glans augmentation with HA for PE.[3][4]

Shaft girth enhancement, HA material properties and hyaluronidase reversal are covered on Hyaluronic Acid Filler — Penile Girth Augmentation, which also summarizes the randomized HA-versus-PLA girth trials by Dae Yul Yang and colleagues. Positioning among other male cosmetic procedures is on Male Cosmetic Genital Surgery.

Indications and patient selection​

  • Cosmetic glans enlargement. Reported targets are a subjectively small glans, glans–shaft disproportion and poor glans tumescence during erection.[5][6] Girth enhancement of the shaft can leave a thick shaft with a relatively small glans. In Kim 2003, 87 of the 187 men had a small glans after dermofat-graft girth enhancement.[6][1]
  • Glans after penile prosthesis. A small glans and lack of glans tumescence after penile prosthesis implantation are described indications for GPA.[6][5] No HA series in prosthesis patients was identified. The reported prosthesis cases used polyacrylamide gel (2 patients, short-lived effect requiring reinjection) or a dermofat graft (Shaeer's glans augmentation).[6]
  • Premature ejaculation. A review concluded that patients with lifelong PE can mainly benefit from injectable fillers rather than surgical grafting.[5] In a 2016 survey of Korean urologists who performed GPA for PE, most selected men who responded to topical anesthetics (72.7%) or had failed pharmacotherapy (59.1%).[7] Most PE trials enrolled circumcised men with lifelong PE, and several excluded men with erectile dysfunction.[8][9][10]

Screening for penile dysmorphic disorder. Men requesting cosmetic enlargement often have normal dimensions; see Small Penis Syndrome. The SMSNA 2024 position statement by Trost and colleagues (expert opinion) requires that penile dysmorphic disorder be ruled out before invasive enhancement.[11] For shaft girth, EAU 2026 recommends against HA and other soft-tissue fillers in men with penile dysmorphic disorder (strong).[12] For PE, EAU 2026 recommends treating erectile dysfunction, other sexual dysfunction or genitourinary infection first (strong).[12]

Anatomy and rationale​

The glans is covered by stratified squamous epithelium over a dense dermis-like connective tissue that blends into the tunica albuginea of the corpus spongiosum. Free nerve endings lie in almost every dermal papilla. Genital end bulbs are present throughout the glans and are most numerous at the corona and near the frenulum. The main branches of the dorsal nerve within the glans lie 3 to 6 mm from the epithelial surface.[6]

In the preclinical work, HA gel injected into the glans dermis of rabbits and dogs lay in the lamina propria (and in rabbits also the corpus spongiosum). The implants were maintained at 6 months in dogs without foreign-body reaction.[13] For PE, the proposed mechanism is a bulking barrier between tactile stimuli and the nerve terminals. Glans vibratory threshold measured by biothesiometer rose after GPA.[14][15] The originators also proposed a contribution from increased self-confidence after glans enlargement, which the studies cannot separate from the sensory effect.[6]

Technique​

No standardized protocol exists. The elements below are taken from the published series.[6][8]

  1. Anesthesia. Topical lidocaine–prilocaine (EMLA) applied 30 minutes before injection is tolerated by most patients; a few need local anesthetic injection.[6] Lidocaine 2% jelly for 30 minutes was used in one randomized trial.[9]
  2. Product and needle. The originators used a large-particle HA gel (Perlane) through a 27 G needle into the deep dermis, with a small-particle gel (Restylane) through a 30 G needle to correct surface undulation.[6] Later trials used 30 G needles with other cross-linked HA products.[8][9]
  3. Plane. Deep dermis of the glans. In the authors' view, injection that is too superficial exaggerates surface undulation and can cause pressure necrosis because glans skin is inelastic, while injection that is too deep may give inadequate augmentation or sensory effect and risks deep vascular compromise.[8]
  4. Volume. Most protocols use 2 mL in one session.[1][8][9][10] To avoid discoloration or pressure necrosis from initial overinjection, Kim and colleagues recommended 2 mL initially and supplementary injection at 2 weeks.[6]
  5. Distribution. The glans surface has small folds from the underlying rete ridges, so the augmented surface is uneven at rest; the minor undulation disappears during erection.[6]

Described injection patterns​

PatternDescriptionNotes
Linear threadingMultiple linear passesAbandoned by the originators: too many punctures, with mucosal tearing, bleeding and leakage[6]
Fan (Kim 2004)Needle inserted at one-third of the distance from glans tip to coronal sulcus; gel fanned from that entryFewer punctures; ventral frenular area and coronal margin difficult to fill[6][8]
Multiple puncture (Abdallah 2012)Entry points from the proximal third along the coronal sulcus and frenulum, 0.25 mL per pointMore uniform distribution and less pain than the fan technique; longer injection time; bruising in 7 patients[6][8][16]
Two circular levels (Alahwany 2019)0.2 mL deep-dermal aliquots, 6 at the corona and 4 midway between corona and meatus, 30 G, 2 mL totalUsed in the saline-controlled crossover trial[8][17]
Three circles (Littara 2013)Three rings 1 cm apart from the glans base, each divided into quarters; 12 deep-dermal injectionsUsed in a 110-patient series[8][18]
Five puncture (Ibrahim 2024)Glans divided into five sectors; 0.4 mL per sector, 2 mL total, 30 GUsed in a randomized trial against dapoxetine[9]

No trial has shown one pattern to be more effective than another.[8]

Outcomes​

Cosmetic enlargement​

In Kim 2003, net maximal glans circumference increased by 14.93 mm in 100 men with a subjectively small glans and by 14.78 mm in 87 men with a small glans after dermofat girth grafting, measured by tape at 1 year. More than 50% of the injected volume was judged by the patients to remain in 95% and 100% of the two groups, and 77% and 69% were satisfied.[1] A 2024 meta-analysis pooled an increase in glans circumference of 14.82 mm (95% CI 12.75–16.90) across PE studies.[2]

Premature ejaculation​

StudyDesignn (HA)Follow-upIELT result
Kim 2004[14]Prospective, non-randomized; HA versus dorsal neurectomy with or without HA656 mo96.5 → 281.9 s; 75% of patients satisfied
Kwak 2008[15]Long-term follow-up series385 yrIELT and vibratory threshold lower than at 6 mo but above baseline; 76% of patients and 63% of partners satisfied
Abdallah 2012[16][6]Randomized pilot, fan versus multiple puncture49 analyzed of 603 mo2.12 → 7.71 min at 1 mo, then 5.32 min, still above baseline
Littara 2013[18]Prospective, single arm1106 mo88.3 → 293.1 s; patient satisfaction 5.3 and partner 5.1 on a 6-point scale
Alahwany 2019[17]Randomized, saline-controlled crossover (2 mL Teosyal PureSense Global Action after topical EMLA; 18-month washout before crossover from HA to saline)301 mo controlled; responders (n = 20) followed to 9 moMedian 2.6-fold increase at 1 mo versus 1.1-fold after saline. Responders (n = 20, Fig. 3), median IELT: 34 s at baseline, 44.5 s at 1 wk, 120 s at 1 mo, 105.5 s at 3 mo, 85 s at 6 mo, 45 s at 9 mo; significantly above baseline from 1 mo onward but not at 1 wk
Shebl 2021[19]Prospective, saline-controlled40 (40 controls)6 moImproved versus baseline and saline; patient satisfaction 64.9%, 70.3% and 78.4% at 1, 3 and 6 mo
Zhang 2022[20]Single-center series, fan technique184 (71 lifelong, 113 acquired)12 mo1 mo: 100.7 s in lifelong and 359.2 s in acquired PE; above baseline at 12 mo
Ibrahim 2024[9]Randomized versus on-demand dapoxetine 60 mg50 (50 dapoxetine)6 moHA 46 → 291 s at 1 mo and 192 s at 6 mo; dapoxetine 46 → 155 and 138 s
Hasan 2025[10]Randomized, open-label versus bulbospongiosus botulinum toxin A30 (30 toxin)2 moHA 1.23 → 7.30 min; toxin 1.78 → 3.87 min
Torad 2026[21]Randomized versus dapoxetine 60 mg three times weekly60 total6 moGreater improvement in IELT, IPE and QoL with HA at 1, 3 and 6 mo (p < 0.05)
Culha 2024[2]Systematic review and meta-analysis: 13 studies (4 RCTs, 8 prospective, 1 retrospective)7061 and 6 moTwo placebo-controlled RCTs: mean difference +65.44 s at 1 mo. Pre–post: +176.18 s at 1 mo (I² 83%) and +143.93 s at 6 mo (I² 82%)

The IELT gain peaks at about 1 month and then attenuates while remaining above baseline in the series that report later visits.[16][20][9][2] In the controlled crossover trial the effect was not present at 1 week; among the 20 men who had improved at 1 month, the median IELT fell from 120 seconds at 1 month to 45 seconds at 9 months, still significantly above the 34-second baseline. Because only responders were followed beyond 1 month, these later values describe the men who benefited, not the whole cohort.[17] The only placebo-controlled pooled estimate is 65 seconds at 1 month, much smaller than the uncontrolled pre–post estimate.[2] In Zhang 2022, men with acquired PE had higher IELT and larger satisfaction gains than men with lifelong PE.[20]

Comparison with drug therapy. In randomized trials summarized by the AUA/SMSNA guideline, on-demand dapoxetine 30 or 60 mg increased IELT 2.5- to 3.0-fold. Daily paroxetine produced a mean 8.8-fold increase in a 2004 meta-analysis.[3][22] These figures come from different designs and IELT methods and are not a head-to-head comparison with the 2.6-fold median in Alahwany 2019.[17] The two randomized trials against dapoxetine both favored HA; both were small (n = 100 analyzed and n = 60).[9][21]

Durability and retreatment​

In the 5-year series (n = 38), maximal glans circumference was 15% lower than at 6 months, while the patients' visual estimate of glans size did not change (grade 3.60 versus 3.56).[15] The originators attribute the slow loss to isovolumetric degradation of cross-linked HA and describe supplementation by reinjection when volume is lost.[6] A narrative review describes reinjection every 9 to 12 months for PE.[8] A second narrative review notes that GPA requires retreatment over time, unlike selective dorsal neurectomy.[23] No standardized retreatment interval has been tested.

Complications​

Pooled rates. In the PE meta-analysis, adverse events occurred in 91 of 598 patients (15.22%): pain 7.69%, bulla or nodule 4.18% and ecchymosis 3.34%.[2] In the dapoxetine trial, injection-site pain (14%), bullae (8%) and ecchymosis (6%) resolved within 10 to 15 days.[9] In the saline-controlled crossover trial, 6 of 30 men (20%) had adverse effects 1 week after HA (local discomfort in 3, glans ecchymosis in 2 and a blanched papule from too-superficial injection in 1), all resolved by 1 month; saline caused ecchymosis in 1.[17] Glans discoloration from swelling usually resolved within 2 weeks in Kim 2003.[1]

Contour. Poor longevity and surface undulation are the main limitations of HA GPA in a review of glans augmentation complications.[24]

Sensation. The ISSM recommendation rests on possible permanent loss of sexual function.[4] In Kim 2004, no sensory loss was reported among 65 men after GPA alone, whereas numbness, paresthesia, neuroma pain or Peyronie's disease occurred in 10 of 74 men after dorsal neurectomy.[6] In the survey of Korean urologists (4,344 procedures), respondents recalled glans pain or paresthesia in 36 cases (0.8%), no erectile dysfunction and PE recurrence in 206 (4.7%).[7] These figures are recalled by the injecting surgeons, not measured.

Vascular compromise. Glans ischemia after HA has been reported. A 29-year-old man developed blackening of the distal glans with a demarcation line one day after 2 mL of HA by multiple puncture (0.2 mL per injection). It reversed after hyaluronidase, aspirin 100 mg, warm saline dressings and nitroglycerin cream, without necrosis.[25] A 65-year-old man with glans necrosis and ulceration after HA injection for genital augmentation underwent partial penectomy.[26] The originators state that most glans necrosis they have seen followed non-HA or unpurified fillers or mismanagement of immediate discoloration. With HA, ischemic necrosis can follow injection that is too superficial, too large in volume or intravascular.[6]

Other fillers and grafts. Fillers that hyaluronidase cannot dissolve remove the main safety margin. Pressure necrosis followed overinjection of acellular dermal fragments, which can be neither aspirated nor digested, and complications followed suspected polyacrylamide injection.[6] Indirect GPA with dermofat grafts or scaffolds placed between the corpus spongiosum and the corporal tips forms hard, painful lumps over time in most patients, and the blunt dissection can cause glans necrosis.[24] Paraffin, silicone and other non-medical injectables can cause necrosis and autoamputation; see Non-Autologous Injectables.[27]

Suspected vascular occlusion​

No genital-specific protocol has been published. The sequence below is extrapolated from facial-filler practice, with the glans case reports as the only genital experience.[28][29][25]

  1. Recognize. Facial signs are blanching, livedo reticularis, slow capillary refill and dusky blue-red discoloration, followed days later by blisters and slough.[28]
  2. Stop injecting and start treatment at once.
  3. Hyaluronidase. The facial consensus recommends high doses (at least 200 U) without a skin test, with further hyaluronidase if there is no improvement within 60 minutes.[29] The glans originators described 75 U intradermally or 150 U, lower than the facial consensus.[6]
  4. Adjuncts. Warm compresses, massage and oral aspirin; topical nitroglycerin paste is used by some experts but is controversial.[29][28]
  5. Follow up daily. In the facial consensus, patients diagnosed and treated within 24 hours usually had the best outcomes.[29]

Hyaluronidase use for filler dissolution is off-label; product details are on the girth page.

Regulatory status and society positions​

  • FDA. HA dermal fillers are approved for specified areas of the face and hands and for HIV-associated facial lipoatrophy. The FDA recommends against injectable fillers for body contouring and enhancement. Glans injection is off-label.[30]
  • AUA/SMSNA (2020 guideline, published 2022), Statement 15. "Clinicians should inform patients that surgical management (including injection of bulking agents) for premature ejaculation should be considered experimental and only be used in the context of an ethical board-approved clinical trial" (Expert Opinion). The discussion notes that surgery could cause permanent loss of penile sensation and that the Alahwany trial was small and single-center.[3]
  • ISSM (2014 update). Selective dorsal nerve neurotomy or glans penis augmentation with HA gel "may be associated with permanent loss of sexual function and is not recommended in the management of PE."[4] The originators of GPA called this a misinterpretation of their data, since no permanent complications were reported after GPA alone.[6]
  • EAU (2026). Use HA injection with caution as a treatment option for PE compared with more established modalities (weak). The summary of evidence states that HA injections decrease penile sensitivity (level 2b). The text warns that the procedure may cause serious complications and that more safety studies are needed before it can be recommended.[12]
  • SMSNA (2024). The cosmetic penile enhancement position statement (expert opinion) addresses injectable soft-tissue fillers, describes the data as limited and requires that penile dysmorphic disorder be ruled out first.[11]
  • Reviews. Current PE guidelines do not recommend surgical interventions for PE because of safety concerns.[31][23]

Evidence gaps​

  • The meta-analysis included 4 RCTs, of which only 2 were placebo-controlled, and heterogeneity was high (I² 82–83%).[2]
  • Products, volumes, injection patterns and retreatment intervals are not standardized.[8]
  • IELT methods differ between studies. Retrospective reporting, questionnaires and open designs give far more variable ejaculation times than stopwatch measurement.[22]
  • Follow-up is mostly 12 months or less; the only 5-year data come from 38 men.[15]
  • Sensory outcomes are rarely measured objectively, and vascular events are known only from case reports.[25][26]
  • No HA data exist for glans augmentation after penile prosthesis.
  • No trial compares HA with topical anesthetics, the other first-line option that targets glans sensitivity.[3]

See Also​

Hyaluronic Acid Filler — Penile Girth Augmentation · Male Cosmetic Genital Surgery · Small Penis Syndrome · Non-Autologous Injectables · Local Anesthetics (topical PE treatment) · Psychosexual Therapy · Penile Implants

References​

1. Kim JJ, Kwak TI, Jeon BG, Cheon J, Moon DG. Human glans penis augmentation using injectable hyaluronic acid gel. Int J Impot Res. 2003;15(6):439-443. doi:10.1038/sj.ijir.3901044

2. Culha MG, Baran C, Erkoc M. Clinical efficacy and safety of hyaluronic acid gel injection in the glans penis for treatment of premature ejaculation: systematic review and meta-analysis. J Sex Med. 2024;21(10):878-888. doi:10.1093/jsxmed/qdae090

3. Shindel AW, Althof SE, Carrier S, et al. Disorders of ejaculation: an AUA/SMSNA guideline. J Urol. 2022;207(3):504-512. doi:10.1097/JU.0000000000002392

4. Althof SE, McMahon CG, Waldinger MD, et al. An update of the International Society of Sexual Medicine's guidelines for the diagnosis and treatment of premature ejaculation (PE). Sex Med. 2014;2(2):60-90. doi:10.1002/sm2.28

5. Califano G, Arcaniolo D, Ruvolo CC, et al. Glans penis augmentation: when, how, and why? Int J Impot Res. 2022;34(4):343-346. doi:10.1038/s41443-021-00464-1

6. Moon DG, Kwak TI, Kim JJ. Glans penis augmentation using hyaluronic acid gel as an injectable filler. World J Mens Health. 2015;33(2):50-61. doi:10.5534/wjmh.2015.33.2.50

7. Jeong HG, Ahn ST, Kim JW, et al. Practice patterns among Korean urologists for glans penis augmentation using hyaluronic acid filler in the management of premature ejaculation. Sex Med. 2018;6(4):297-301. doi:10.1016/j.esxm.2018.06.005

8. Kosseifi F, Chebbi A, Raad N, et al. Glans penis augmentation using hyaluronic acid for the treatment of premature ejaculation: a narrative review. Transl Androl Urol. 2020;9(6):2814-2820. doi:10.21037/tau-20-1026

9. Ibrahim IM, Mohamed M, Kamel M, et al. Dapoxetine versus glans penis injection with hyaluronic acid gel in treatment of premature ejaculation. Arab J Urol. 2024;22(2):75-80. doi:10.1080/2090598X.2023.2245598

10. Hasan MS, Almohsen AM, Mearaj I, Abd Elsalam MT, Elsaie ML. Hyaluronic acid versus botulinum A toxin injection in the treatment of premature ejaculation: a comparative study. Sci Rep. 2025;15(1):17575. doi:10.1038/s41598-025-02466-1

11. Trost L, Watter DN, Carrier S, et al. Cosmetic penile enhancement procedures: an SMSNA position statement. J Sex Med. 2024;21(6):573-578. doi:10.1093/jsxmed/qdae045

12. Salonia A, Boeri L, Capogrosso P, et al. EAU Guidelines on Sexual and Reproductive Health. European Association of Urology; Limited Update March 2026. Sections 6.2.6.b.6, 6.2.7 and 9.3.2.d. Guideline

13. Moon DG, Kwak TI, Cho HY, et al. Augmentation of glans penis using injectable hyaluronic acid gel. Int J Impot Res. 2003;15(6):456-460. doi:10.1038/sj.ijir.3901058

14. Kim JJ, Kwak TI, Jeon BG, Cheon J, Moon DG. Effects of glans penis augmentation using hyaluronic acid gel for premature ejaculation. Int J Impot Res. 2004;16(6):547-551. doi:10.1038/sj.ijir.3901226

15. Kwak TI, Jin MH, Kim JJ, Moon DG. Long-term effects of glans penis augmentation using injectable hyaluronic acid gel for premature ejaculation. Int J Impot Res. 2008;20(4):425-428. doi:10.1038/ijir.2008.26

16. Abdallah H, Abdelnasser T, Hosny H, et al. Treatment of premature ejaculation by glans penis augmentation using hyaluronic acid gel: a pilot study. Andrologia. 2012;44 Suppl 1:650-653. doi:10.1111/j.1439-0272.2011.01244.x

17. Alahwany A, Ragab MW, Zaghloul A, Abdallah H, Mostafa T. Hyaluronic acid injection in glans penis for treatment of premature ejaculation: a randomized controlled cross-over study. Int J Impot Res. 2019;31(5):348-355. doi:10.1038/s41443-018-0104-9

18. Littara A, Palmieri B, Rottigni V, Iannitti T. A clinical study to assess the effectiveness of a hyaluronic acid-based procedure for treatment of premature ejaculation. Int J Impot Res. 2013;25(3):117-120. doi:10.1038/ijir.2013.13

19. Shebl SE, Ali S, Shokr M. Hyaluronic acid injection in the glans penis for the treatment of refractory premature ejaculation: a prospective, controlled study. Andrologia. 2021;53(7):e14084. doi:10.1111/and.14084

20. Zhang C, Quan Y, Song Y, et al. Efficacy and safety assessment of glandular augmentation with hyaluronic acid for premature ejaculation. Andrologia. 2022;54(7):e14435. doi:10.1111/and.14435

21. Torad H, Rammah AM, Elahwany A, et al. Randomized controlled trial comparing deep dermal glanular hyaluronic acid injection versus oral dapoxetine in management of premature ejaculation. Int Urol Nephrol. Published online July 20, 2026. doi:10.1007/s11255-026-05274-2

22. Waldinger MD, Zwinderman AH, Schweitzer DH, Olivier B. Relevance of methodological design for the interpretation of efficacy of drug treatment of premature ejaculation: a systematic review and meta-analysis. Int J Impot Res. 2004;16(4):369-381. doi:10.1038/sj.ijir.3901172

23. Deger MD, Gül M, Serefoglu EC. Surgical treatment of premature ejaculation: a narrative review. Int J Impot Res. 2024;36(5):474-479. doi:10.1038/s41443-023-00771-9

24. Ahn ST, Kwak TI, Park KS, Kim JJ, Moon DG. Complications of glans penis augmentation. Int J Impot Res. 2019;31(4):245-255. doi:10.1038/s41443-018-0097-4

25. Karamık K, Yıldız A, Koraş Ö, Arslan M. Glanular ischemia following glans penis augmentation: a rare case report. Urol Int. 2026;110(2):208-212. doi:10.1159/000547421

26. Yamasaki Y, Asai A, Maruta S, Sakaguchi M, Tsurusaki T. A case of glans penile necrosis due to hyaluronic acid into the penis for male genital augmentation [in Japanese]. Hinyokika Kiyo. 2021;67(8):399-401. doi:10.14989/ActaUrolJap_67_8_399

27. Pang KH, Randhawa K, Tang S, et al. Complications and outcomes following injection of foreign material into the male external genitalia for augmentation: a single-centre experience and systematic review. Int J Impot Res. 2024;36(5):498-508. doi:10.1038/s41443-023-00675-8

28. DeLorenzi C. Complications of injectable fillers, part 2: vascular complications. Aesthet Surg J. 2014;34(4):584-600. doi:10.1177/1090820X14525035

29. Cohen JL, Biesman BS, Dayan SH, et al. Treatment of hyaluronic acid filler-induced impending necrosis with hyaluronidase: consensus recommendations. Aesthet Surg J. 2015;35(7):844-849. doi:10.1093/asj/sjv018

30. U.S. Food and Drug Administration. Dermal fillers (soft tissue fillers). Content current as of July 6, 2023. FDA

31. Gul M, Bocu K, Serefoglu EC. Current and emerging treatment options for premature ejaculation. Nat Rev Urol. 2022;19(11):659-680. doi:10.1038/s41585-022-00639-5