Medical Male Circumcision Is Associated With Improvements in Pain During Intercourse and Sexual Satisfaction in Kenya

Circumcision and Sexual Medicine

INTRODUCTION

Male circumcision is one of the most frequently performed and debated urological procedures due to its possible implications for sexual health.

OBJECTIVES

The objective of this article is to review the literature on male circumcision and reconcile the scientific evidence to improve the quality of care, patient education, and clinician decision-making regarding the effects on sexual function of this procedure.

METHODS

A review of the published literature regarding male circumcision was performed on PubMed. The criteria for selecting resources prioritized systematic reviews and cohort studies pertinent to sexual dysfunction, with a preference for recent publications.

RESULTS

Despite the conflicting data reported in articles, the weight of the scientific evidence suggests there is not sufficient data to establish a direct association between male circumcision and sexual dysfunction.

CONCLUSION

This review provides clinicians with an updated summary of the best available evidence on male circumcision and sexual dysfunction for evidenced-based quality of care and patient education.

Happiness with Circumcision Status, Not Status Itself, Predicts Genital Self-Image in a Geographically Diverse Sample

Research exploring the impact of penile circumcision on aspects of body image is scarce and few studies have considered the potential roles of attitudinal factors toward one's own circumcision status. The purpose of the present study was to assess the potential relationship between one's circumcision status, happiness with circumcision status, genital self-image, and sexual functioning. The present study also examined how happiness with circumcision status varied across geographic regions. A total of 205 participants (102 circumcised, 103 not circumcised) completed a study through online recruitment methods. Participants reported being born in the United States (n = 80), Canada (n = 23), and various countries within Latin America (n = 22), Europe (n = 49), Asia (n = 13), Africa (n = 11), and Oceania (n = 7). Participants who were not circumcised reported significantly greater happiness with their circumcision status than participants who were circumcised. However, genital self-image, sexual body image, and sexual functioning did not significantly differ by circumcision status. Instead, participants who reported being happier with their circumcision status reported better genital self-image and less body exposure avoidance during sex, but sexual function did not differ by happiness. Although researchers hypothesized that happiness with circumcision status would depend on whether one fits in with the majority circumcision status within their region of origin, results did not support this. Participants who were circumcised tended to have less happiness with their circumcision status than non-circumcised participants regardless of region of birth. These findings support a small body of the literature which suggests that the psychosexual impact of penile circumcision may rely more on attitudinal factors toward circumcision status than actual circumcision status.

Factors influencing satisfaction with male circumcision in Taiwan

We aimed to investigate patient satisfaction with male circumcision in Taiwan. An online, questionnaire-based, cross-sectional study involving 376 circumcised men 20 to 40 years of age in Taiwan was conducted. Circumcision-related satisfaction was defined as a visual analogue scale score ≥ 6 (range, 1-10). Pearson's chi-square test was performed to compare differences between satisfied and unsatisfied participants. Factors predictive of participant satisfaction were analysed using multivariate logistic regression. Statistical significance was set at P < 0.05. Among 376 circumcised men, 249 (66.2%) reported satisfaction with circumcision. Satisfied participants had higher levels of education, underwent circumcision for phimosis or balanitis, underwent circumcision during adulthood, reported a larger penile size, and had fewer long-term complaints. Furthermore, 89.4% had various long-term complaints, including skin colour mismatch, changes in masturbation methods, hypertrophic scarring, excessive shortening of the prepuce, and redundant prepuce. Multivariate analysis revealed that adult circumcision and the absence of long-term conditions were predictive of satisfaction. Two-thirds of participants were satisfied with their circumcision outcome, especially those who underwent circumcision for phimosis or balanitis during adulthood. Proper preoperative patient selection and postoperative symptom prevention would improve patient satisfaction.

Psychological, psychosocial, and psychosexual aspects of penile circumcision

Policy statements on penile circumcision have focused primarily on disease, dysfunction, or sensation, with relatively little consideration of psychological and psychosocial implications of the procedure. There has also been minimal consideration of potential qualitative changes in the subjective experience of sexual activity following changes in penile anatomy (foreskin removal) or associated sexual biomechanics. We present a critical overview of literature on the psychological, psychosocial, and psychosexual implications of penile circumcision. We give consideration to differences among circumcisions performed in infancy, childhood, or adulthood. We also discuss potential psychosocial effects on parents electing, or failing to elect, circumcision for their children. We propose a framework for policy considerations and future research, recognizing that cultural context is particularly salient for the narratives individuals construct around penile circumcision, including both affected individuals and medical professionals who perform the surgeries. We argue that additional attention should be paid to the potential for long-term effects of the procedure that may not be properly considered when the patient is an infant or child.

Can circumcision be avoided in adult male with phimosis? Results of the PhimoStopTM prospective trial

Background

Circumcision as surgical treatment of adult phimosis is not devoid of complications. Efficacy of alternative non-surgical options is unclear. PhimoStop^TM is a therapeutic protocol which involves the use of appropriately shaped silicone tuboids of increasing size to obtain a non-forced dilation of the prepuce. The aim of the study was to evaluate the efficacy and durability of results of PhimoStop^TM device for the treatment of adult male phimosis.

Methods

A prospective trial was conducted between 2018 and 2020 on 85 consecutive adult male patients affected by phimosis and with an indication for circumcision. Patients were treated with PhimoStop^TM protocol and they were evaluated at baseline and after treatment through a subjective (patient self-reported information on various domains of his sexual function) and an objective assessment (evaluation of phimosis severity grade according to the Kikiros scale pre- and post-treatment, re-assessment of indication for circumcision post-treatment and validated questionnaires scores). Primary endpoint was to avoid the scheduled circumcision in 33% of the patients enrolled.

Results

Seventy-one patients (84%) completed the device usage phase as per study protocol. Median duration of tuboid application was 60 days. Thirty-seven patients (52.1%) had no indication for circumcision after treatment. Even considering patients lost to follow-up as failures, primary endpoint was reached in 43.5% of cases. There was a significant reduction of the grade of phimosis after treatment (P<0.001). Moreover IIEF-5 showed a statistically significant improvement after treatment (P<0.001). Thirty/37 patients who met the primary endpoint (81%) still have a successful resolution of their phimosis avoiding circumcision at a median follow-up of 24 months.

Conclusions

PhimoStop^TM device is effective for the treatment of adult male phimosis of Kikiros grade ≤2. The results seem to be durable in most patients at a median follow-up of 24 months. Randomized clinical trials are necessary in order to confirm our results and assess cost-efficacy.

Integration of voluntary male medical circumcision for HIV prevention into norms of masculinity: findings from Kisumu, Kenya

While it is clear that in many communities ideas about masculinity and circumcision are connected, it is still unclear how young Kenyan men in the former Nyanza province from the traditionally non-circumcising Luo people perceive voluntary medical male circumcision as connected to masculinity and the role of voluntary medical male circumcision in the transition from boyhood to manhood. The objective of this study was to explore norms of masculinity and the decision-making process among Luo young men to provide a better understanding of how circumcision and masculinity relate to cultural norms within this community. The methodology consisted of eight FGDs with male peer groups and 24 in-depth interviews to elicit young men's perceptions of masculinity and voluntary medical male circumcision. Findings from thematic analysis reveal that young men described several key characteristics of masculinity including responsibility, bravery and sexual attractiveness. For some young men, voluntary medical male circumcision has embedded itself into cultural norms of masculinity by being a step in the transition from boyhood to manhood and by being a marker of some of these masculine characteristics. In the case of voluntary medical male circumcision, there may be opportunities to integrate other programming that helps men transition into healthy adulthood.

The Contrasting Evidence Concerning the Effect of Male Circumcision on Sexual Function, Sensation, and Pleasure: A Systematic Review

INTRODUCTION

Active debate concerns whether male circumcision (MC) affects sexual function, penile sensation, or sexual pleasure.

AIM

To perform a systematic review examining the effect of MC on these parameters.

METHODS

PRISMA-compliant searches of PubMed, EMBASE, the Cochrane Library, and Google Scholar were performed, with "circumcision" used together with appropriate search terms. Articles meeting the inclusion criteria were rated for quality by the Scottish Intercollegiate Guidelines Network system.

MAIN OUTCOME MEASURE

Evidence rated by quality.

RESULTS

Searches identified 46 publications containing original data, as well as 4 systematic reviews (2 with meta-analyses), plus 29 critiques of various studies and 15 author replies, which together comprised a total of 94 publications. There was overall consistency in conclusions arising from high- and moderate-quality survey data in randomized clinical trials, systematic reviews and meta-analyses, physiological studies, large longitudinal studies, and cohort studies in diverse populations. Those studies found MC has no or minimal adverse effect on sexual function, sensation, or pleasure, with some finding improvements. A consensus from physiological and histological studies was that the glans and underside of the shaft, not the foreskin, are involved in neurological pathways mediating erogenous sensation. In contrast to the higher quality evidence, data supporting adverse effects of MC on function, sensation, or pleasure were found to be of low quality, as explained in critiques of those studies.

CONCLUSION

The consensus of the highest quality literature is that MC has minimal or no adverse effect, and in some studies, it has benefits on sexual functions, sensation, satisfaction, and pleasure for males circumcised neonatally or in adulthood. Morris BJ, Krieger JN. The Contrasting Evidence Concerning the Effect of Male Circumcision on Sexual Function, Sensation, and Pleasure: A Systematic Review. Sex Med 2020;8:577-598.

Male genital sensation after spinal cord injury: a review

Genital sensation (GS) is an essential component of male sexual function. Genital sensory disturbance (GSD) caused by spinal cord injury (SCI) has a severe impact on the patients' sexual function but has garnered little research focus. Under normal conditions, GS encompasses the erection, ejaculation, sexual arousal, and orgasm courses associated with physiological and psychological responses in male sexual activity. However, in SCI patients, the deficiency of GS makes the tactile stimulation of the penis unable to cause sexual arousal, disturbs the normal processes of erection and ejaculation, and decreases sexual desire and satisfaction. To provide an overview of the contemporary conception and management of male GS after SCI, we review the innervation and sexual function of male GS in this article, discuss the effects of GSD following SCI, and summarize the current diagnosis and treatment of GSD in male SCI patients.

Sexual function after voluntary medical male circumcision for human immunodeficiency virus prevention: Results from a programmatic delivery setting in Botswana

Background

Uptake of voluntary medical male circumcision (VMMC) remains modest in Botswana in spite of the government’s commitment and service provision availability. Data on sexual function post-VMMC in programmatic settings could help guide messaging tailored to Botswana.

Objectives

At 3-month post-VMMC, we evaluated changes in sexual function and satisfaction with the VMMC procedure amongst a cohort of HIV-negative, sexually active men aged 18–49 years who underwent VMMC in a public-sector clinic in Botswana.

Methods

We assessed whether each of the following domains of sexual function had improved, stayed the same or worsened since VMMC: sexual desire, ability to use condoms, ease of vaginal penetration, ease of ejaculation, ability to achieve and maintain an erection and hygiene or cleanliness.

Results

Data on sexual function were available for 378 men at 3-month post-VMMC. Median age was 27 years – 54% had a higher than secondary education, 72% were employed and 27% were married. Nearly all (96%) the men reported improvement in at least one domain of sexual function, while 19% reported improvement in all six domains. One-fourth (91/378, 24%) of the men reported that at least one domain of sexual function worsened post-VMMC. The most frequently reported domain that worsened was sexual desire (11%); in all other domains, < 10% of the men reported worsening. Men who reported any worsening sexual function were 2.3-fold as likely to be less than ‘very satisfied’ with the VMMC procedure (risk ratio 2.36, 95% confidence interval [CI] 1.66–3.34, p < 0.001).

Conclusion

Emphasising improved sexual function experienced after VMMC in demand-creation efforts could potentially increase VMMC uptake in Botswana.

Voluntary Medical Male Circumcision and Perceived Sexual Functioning, Satisfaction, and Risk Behavior: A Qualitative Study in Botswana

This article examines perceptions of sexual functioning, satisfaction, and risk-taking related to voluntary medical male circumcision (VMMC) in Botswana. Twenty-seven focus group discussions were conducted in four purposively selected communities with community leaders, men, and women. Discussions were analyzed using an inductive content analytic approach. Perceptions of VMMC's impact on sexual functioning and satisfaction varied. Increased satisfaction was attributed to improved penile health and increased ejaculatory latency time, whereas decreased satisfaction was attributed to erectile dysfunction and increased vaginal irritation during sex. Most participants thought sexual disinhibition occurred after circumcision; nevertheless, some women said they used male circumcision status as a marker of HIV status, thereby influencing sexual decision-making and partner selection. Messaging should emphasize that VMMC does not afford complete HIV protection. Optimizing VMMC's impact requires increasing uptake while minimizing behavioral disinhibition, with a balance between potential messaging of improved sexual functioning and satisfaction and the potential impact on sexual disinhibition.

Critical evaluation of arguments opposing male circumcision: A systematic review

OBJECTIVE

To systematically evaluate evidence against male circumcision (MC).

METHODS

We searched PubMed, Google Scholar, EMBASE and Cochrane databases.

RESULTS

Database searches retrieved 297 publications for inclusion. Bibliographies of these yielded 101 more. After evaluation we found: Claims that MC carries high risk were contradicted by low frequency of adverse events that were virtually all minor and easily treated with complete resolution. Claims that MC causes psychological harm were contradicted by studies finding no such harm. Claims that MC impairs sexual function and pleasure were contradicted by high-quality studies finding no adverse effect. Claims disputing the medical benefits of MC were contradicted by a large body of high-quality evidence indicating protection against a wide range of infections, dermatological conditions, and genital cancers in males and the female sexual partners of men. Risk-benefit analyses reported that benefits exceed risks by 100-200 to 1. To maximize benefits and minimize risks, the evidence supported early infant MC rather than arguments that the procedure should be delayed until males are old enough to decide for themselves. Claims that MC of minors is unethical were contradicted by balanced evaluations of ethical issues supporting the rights of children to be provided with low-risk, high-benefit interventions such as MC for better health. Expert evaluations of case-law supported the legality of MC of minors. Other data demonstrated that early infant MC is cost-saving to health systems.

CONCLUSIONS

Arguments opposing MC are supported mostly by low-quality evidence and opinion, and are contradicted by strong scientific evidence.

Circumcision in the paediatric patient: A review of indications, technique and complications

Circumcision is one of the most commonly performed surgical procedures in the world. Despite this, the practice of paediatric circumcision remains highly controversial, and continues to generate ongoing debate. This debate has become more relevant recently with the provisional guidelines from the Centers for Disease Control and Prevention recommending a change of practice. In this review article, we provide an overview of the history and incidence of circumcision, normal preputial development, types of phimosis, the absolute and relative indications for circumcision as well as the evidence base for its use as a preventative measure. Our aim is to provide paediatricians with a greater understanding of this common surgical procedure and the conditions it treats, to guide their clinical practice and parent counselling.

Penile coital injuries in men decline after circumcision: Results from a prospective study of recently circumcised and uncircumcised men in western Kenya

Background

Penile coital injuries are one of the suggested mechanisms behind the increased risk of HIV among uncircumcised men. We evaluated the prevalence and correlates of self-reported penile coital injuries in a longitudinal community-based cohort of young (18–24 years old), newly circumcised and uncircumcised men in Western Kenya.

Methods

Self-reported penile coital injuries were assessed at baseline, 6, 12, 18 and 24 months of follow-up, and were defined as scratches, cuts or abrasions during sex, penile soreness during sex, and skin of the penis bleeding during sex. Associations between penile coital injuries, circumcision, sexual satisfaction, and other covariates were estimated with mixed effect models.

Results

Between November 2008 and April 2010 3,186 participants were enrolled (1,588 into circumcision group and 1,598 as age-matched controls). Among 2,106 (66%) participants sexually active at baseline, 53% reported any penile injury, including 44% scratches, cuts or abrasions; 32% penile pain/soreness; and 22% penile bleeding. In multivariable modeling, risk was lower for circumcised men than uncircumcised men for scratches, cuts and abrasions (aOR = 0.39; 95% CI 0.34–0.44); penile pain/soreness (aOR = 0.58; 95% CI 0.51–0.65), penile bleeding (aOR = 0.53; 95% CI 0.46–0.62), and any penile coital injuries (aOR = 0.47; 95%CI 0.42–0.53). Other significant risk factors included increasing age, history of STIs and genital sores, and multiple sex partners, while condom use was protective. Coital injuries were significantly associated with lower levels of sexual satisfaction in longitudinal analyses (scratches, cuts or abrasions: aOR = 0.87, 95% CI: 0.76–0.98; penile pain/soreness: aOR = 0.82, 95% CI: 0.72–0.93; and penile bleeding: aOR = 0.65, 95% CI: 0.55–0.76).

Conclusions

Self-reported penile coital injuries were common and decreased significantly following circumcision. Improving sexual experience through the removal of a potential source of sexual discomfort may resonate with many men targeted for circumcision services. The role of penile coital injuries in sexual satisfaction, HIV, HSV-2, and as a motivator for seeking circumcision services should be explored further.