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ARTICLE Growth and Development of Male External Genitalia A Cross-sectional Study of 6200 Males Aged 0 to 19 Years Analia Tomova, MD, PhD; Fnu Deepinder, MD; Ralitsa Robeva, MD; Hristina Lalabonova, MD, PhD; Philip Kumanov, MD, PhD; Ashok Agarwal, PhD, HCLD Objective: To provide estimates of normal variations and penile circumference (measuring tape) from birth in penile measurements and testicular volumes, and to to 19 years of age. establish reference ranges for clinical use. Results: Testes did not show any increase in size until the onset of puberty at age 11 years, whereas penile growth Design: Cross-sectional, population-based study. was gradual after birth. However, both penile and testicu- lar development demonstrated peak growth from 12 to 16 Setting: Schools, kindergartens, and child care centers in different parts of Bulgaria. years of age, which coincided with the maximal male pu- bertal growth spurt. Data indicate an earlier pubertal de- Participants: A population of 6200 clinically healthy velopment for this study population than that for a simi- white males aged 0 to 19 years. lar population several decades ago. Significant differences betweenurbanandruralpopulationsregardingpenilelength Interventions: The study physician chose schools, were also noticed. kindergartens, and child care centers randomly and Conclusions: Our study provides the contemporary ref- examined children at random until he reached the erence range values for height, weight, testicular volume, required number. Each of the 20 age groups (age and penile length and circumference of males aged 0 to range, 0-19 years) had an equal number of males (ie, 19 years. Our data show that, even by the end of 20th cen- 310). tury, there is still some acceleration of male pubertal de- velopment. For the first time are reported somatic differ- Main Outcome Measures: The mean (SD) values and ences in genitalia within a population between urban and fifth, 50th, and 95th percentiles of height (Siber Hegner rural representatives. anthropometer), weight (beam balance), testicular vol- ume (Prader orchidometer), penile length (rigid tape), Arch Pediatr Adolesc Med. 2010;164(12):1152-1157 SSESSMENT OF GROWTH OF ing significant variation in the general popu- external genitalia is an es- lation. Although tables and growth charts sentialcomponentofhealth exist that provide reference ranges for the surveillance in pediatric weight and height of children and adoles- and adolescent popula- cents, data on penile and testicular mea- Ations. Because of rapid changes and great surements are available only for some popu- interindividual differences at the time of pu- lations. In the latter half of the 20th century, berty, a universal reference range of hor- among the studies conducted in Europe and mone values cannot be established at this the United States,2-10 some investigators dis- Author Affiliations: Clinical period of life. Therefore, anthropometric cussed large interindividual variations in the 5,6 Center of Endocrinology and data are quite useful for clinical evaluation onset and duration of normal puberty. Gerontology, Medical and prognosis. Medical consultations re- To establish reference ranges of various University, Sofia (Drs Tomova, lated to the size of the penis and testicles anthropometric measurements, especially Robeva, and Kumanov), and are quite common at pediatric, endocrinol- forthemaleexternalgenitalia,weconducted, Medical University, Plovdiv ogy, and urology clinics because of the as- to the best of our knowledge, the largest (Dr Lalabonova), Bulgaria; sociated medical, sexual, psychological, and cross-sectional, population-based study on Department of Endocrinology, social concerns. Aberrant growth of male male sexual growth and development. Diabetes, and Metabolism, external genitalia may be the first sign of Cedars Sinai Medical Center, an underlying biophysiologic or psychoso- Los Angeles, California 1 METHODS (Dr Deepinder); and cial illness. Reproductive Research Center, It is important to establish reference Cleveland Clinic, Cleveland, ranges of penile length and circumference Our study was approved by the institutional re- Ohio (Dr Agarwal). and of testicular volume when consider- view board of the Medical University of Sofia, (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 164 (NO. 12), DEC 2010 WWW.ARCHPEDIATRICS.COM 1152 Downloaded from www.archpediatrics.com at Cleveland Clinic Foundation, on December 14, 2011 ©2010 American Medical Association. All rights reserved. Bulgaria. In a cross-sectional, population-based study, we exam- was more uniform until 12 years of age and ranged from ined 6200 white males aged 0 to 19 years from the capital city of 1.85 to 4.34 kg among the different age groups. Among Sofia and from 4 other regions of Bulgaria. In the 4 regions, an 12- and 13-year-old boys, the difference increased sharply equal number of males were selected from urban and rural areas. to 7.12 kg and thereafter diminished gradually to 0.22 The towns and villages were chosen at random, and they are rep- kg after 17 years. For boys aged 11 to 16 years, the body resentative of the country’s population and structure. Informed consent was obtained from these males and/or their parents. All mass index had a significant positive correlation with tes- 6200 males were clinically examined by only 1 physician, who is ticular volume, penile measurements, and pubic hair an endocrinologist (P. K.). In each area, the physician chose growth. However, in boys aged 17 to 19 years, the body schools, kindergartens, and child care centers randomly and ex- mass index had only a weakly positive correlation with amined males at random until he reached the required number. testicular volume and pubic hair growth but not penile Each of the 20 age groups (age range, 0-19 years) consisted of an measurements (data not shown). equal number of males (ie, 310), and these males were included The testes begin to increase in size at the ages 8 to 9 years. in their respective age groups according to their age at the time Before the onset of puberty, the growth of testes was mini- of examination. All 6200 males were clinically healthy at the time mal: from a mean (SD) testicular volume of 1.02 (0.19) mL of examination, and they were from various strata of society. at age 1 year to 1.83 (1.31) mL at age 10 years. There was The protocol of the clinical examination comprised the following somatometric parameters: height (in centimeters), no significant difference in testicular volume between chil- weight (in kilograms), testicular volume (in milliliters), pe- dren in the first 6 months of life and children aged 6 months nile length (in centimeters), and penile circumference (in to 1 year. A marked increase in testicular volume was ob- centimeters). The Prader orchidometer was used to measure served after 10 years of age. The rate of growth, as de- the volume of the testicles; data are given separately for the picted by the slope of the growth curve, was more pro- left and right testicles. It has been demonstrated that measure- nounced from 11 to 15 years of age. After 16 years of age, ments of testicular volume determined by use of the Prader testicular growth slowed down, and the changes were small orchidometer, especially when used by an experienced exam- (Figure, A). The pubic hair (Tanner stage II) first ap- iner, correlate highly with those determined by use of ultraso- 11-13 peared at age 12 years, when the mean (SD) testicular vol- nography. Moreover, in a large population-based study ume was 5.20 (3.45) mL. Tanner stage V was reached at like our own, use of ultrasonography to measure the volume of testicles is not practical or feasible. The height of these age 15 years, when the mean (SD) volume of testes was males was measured with an anthropometer (Siber Hegner; 12.73 (3.98) mL. Zurich, Switzerland). The weight of these males was mea- Although penile length and circumference demon- sured by use of a beam balance, with each male wearing only strated gradual growth, the period of maximum growth was pants and a shirt. The stretched penile length in the flaccid approximately 12 to 16 years of age. Until age 10 years, the state was measured with a rigid tape from the pubopenile skin mean penile length remained less than 5 cm, and mean (SD) junction to the top of the penis, excluding the prepuce under penile circumference reached 5.52 (0.71) cm in the 10- maximal but not painful extension. The penile circumference year-old age group (Figure, B and C). Whereas the in- was measured at the base of the penis (close to the pubis) with crease in testicular volume at ages 11 to 16 years was more a measuring tape. For obese males, the abdominal adipose tis- steep, the changes in penile length and circumference were sue was shifted manually to one side to measure penile length and circumference. much more uniform. An increase in penile length was ob- Statistical evaluation of the data was performed by use of SPSS served 1 year after the enlargement of testes, and the changes version 11.0.1 statistical software (SPSS Inc; Chicago, Illinois). ceased to be significant after 16 years. The penile length Descriptive statistics were used to report the data in the form of increased simultaneously with penile circumference. mean (SD) values and of percentiles (ie, fifth, 50th, and 95th per- A modest though significant difference was found with centiles). The percentiles of greatest clinical importance for an- respect to penile size between urban and rural popula- thropometric measurements were used to plot graphs showing tions. On average, the children from rural regions were the distribution for all ages. The Kolmogorov-Smirnov test was born with longer penises than their urban counterparts used to determine the normality of the distribution. The non- (mean [SD] length, 3.64 [0.49] cm vs 3.49 [0.49] cm at parametric Mann-Whitney test was used to analyze whether there age 1 year; PϽ.01).

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