Penile size anxiety, body dysmorphic disorder, and cosmetic penile enhancement requests: a structured narrative review and expert-derived assessment framework.

INTRODUCTION: Men requesting cosmetic penile enhancement often have dimensions within the normal range, so anatomical measurement alone cannot identify the problem that requires treatment. Small penis anxiety denotes disproportionate concern that may remain below a diagnostic threshold. Penile dysmorphic disorder, a genital-focused presentation of body dysmorphic disorder, additionally involves preoccupation, repetitive behaviors, distress, or impairment. We reviewed the evidence needed to distinguish these presentations and to guide assessment before an invasive procedure. METHODS: We conducted a structured narrative review of PubMed from database inception through August 7, 2026, supplemented by Crossref metadata checks, guideline and policy repositories, publisher searches, and backward reference chaining. Search concepts covered penile enhancement procedures, penile size and measurement, small penis anxiety, penile dysmorphic disorder, body dysmorphic disorder, genital self-image, psychosexual context, and shared decision-making. Eligible sources included guidance, reviews, clinical studies, validated-instrument studies, and relevant qualitative research; nonclinical and clinically irrelevant technical reports were excluded. Selection was purposive rather than duplicate systematic screening. RESULTS: The most direct evidence concerned procedural limitations, penile measurement and differential diagnosis, body dysmorphic disorder and its penile presentation, and validated assessment instruments. Evidence linking enhancement requests to pornography, masculinity, dominance or status meanings, bondage and discipline, dominance and submission, and sadism and masochism, or sexual-role scripts was limited or indirect. In the sources reviewed, we did not identify a validated, integrated pre-procedural assessment sequence. CONCLUSIONS: We present an expert-derived and unvalidated framework that organizes assessment into anatomy, function, perception, context, and expectations. The context and expectations domains are hypothesis-generating clinical prompts rather than validated predictors. Prospective consensus work and clinical validation are required before this framework can be treated as an evidence-based decision model.