Adult circumcision and male sexual health: a retrospective analysis

Incidence of circumcision among insured adults in the United States

Purpose

Although circumcision is the most commonly performed surgery in males, less is known about the incidence and indications of adult circumcision. In this study, we aim to present the incidence of adult circumcision across the United States.

Methods

Using IBM MarketScan^® Commercial Database from 2015 to 2018, we obtained claims for circumcision in men between 18 and 64 years of age. We calculated the incidence of adult circumcision over the study period and across the United States. We also collected data on indications for surgery using International Classification of Diseases codes.

Results

We identified a total of 12,298 claims for adult circumcisions. The mean age was 39 (±12.9) years. The average incidence rates remained relatively constant from 98.1 per 100,000 person-years in 2015 to 98.2 per 100,000 person-years in 2018 (Δ+0.1%). The age-standardized incidence rates varied significantly across the United States (from 0 to 194.8 per 100,000 person-years) with South Dakota having the highest rate. The most common indications for adult circumcision were phimosis (52.5%), routine/ritual circumcision (28.7%), phimosis + balanitis/balanoposthitis (6.8%), balanitis (3.8%) and balanoposthitis (2.6%), and significantly varied by age groups.

Conclusion

This study suggested a wide geographic variation in rates of adult circumcision between states with highest incidences in the Northeast United States. Future studies can identify the underlying causes for the observed variations.

Immunohistological study of the density and distribution of human penile neural tissue: gradient hypothesis

Immunohistological patterns of density and distribution of neural tissue in the human penis, including the prepuce, are not fully characterized, and effects of circumcision (partial or total removal of the penile prepuce) on penile sexual sensation are controversial. This study analyzed extra- and intracavernosal innervation patterns on the main penile axes using formalin-fixed, paraffin-embedded human adult and fetal penile tissues, single- and double-staining immunohistochemistry and a variety of neural and non-neural markers, with a special emphasis on the prepuce and potential sexual effects of circumcision. Immunohistochemical profiles of neural structures were determined and the most detailed immunohistological characterizations to date of preputial nerve supply are provided. The penile prepuce has a highly organized, dense, afferent innervation pattern that is manifest early in fetal development. Autonomically, it receives noradrenergic sympathetic and nitrergic parasympathetic innervation. Cholinergic nerves are also present. We observed cutaneous and subcutaneous neural density distribution biases across our specimens towards the ventral prepuce, including a region corresponding in the adult anatomical position (penis erect) to the distal third of the ventral penile aspect. We also describe a concept of innervation gradients across the longitudinal and transverse penile axes. Results are discussed in relation to the specialized literature. An argument is made that neuroanatomic substrates underlying unusual permanent penile sensory disturbances post-circumcision are related to heightened neural levels in the distal third of the ventral penile aspect, which could potentially be compromised by deep incisions during circumcision.

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.

Self-care promotion of the intact (non-circumcised) patient: A review of available recommendations

PURPOSE

With routine infant circumcision rates declining in the United States, nurses are likely to encounter more intact (non-circumcised) male patients requiring genital hygiene, nursing interventions, and education accessing the health system. To date, a little emphasis has been placed on the care of the intact male patient in the nursing literature, resulting in ambiguity in care recommendations. The vagueness is problematic, as improper intact care, particularly in the pediatric patient, can result in forced retraction injuries, bleeding, scarring, and unnecessary intervention. In addition, with nurses conducting many of the tasks of hygiene and education for self-care, there is potential for impaired patient self-care and harm if nurses are not knowledgeable in intact care. Utilizing Orem's self-care theory as a framework, the aim of this effort is to perform a review of current recommendations on intact care to inform nursing practice with this population. As no evidence was found in the scientific literature, readily available consumer website resources were reviewed.

CONCLUSION

Themes of hygiene and age of retraction emerged. While recommendations for hygiene practices were variable, all review sources (n = 12) were clear in advising against the premature retraction of the intact foreskin and identified this as a route for injury.

PRACTICE IMPLICATIONS

With no current literature available to summarize current nursing clinical or educational practices, dissemination of these recommendations is necessary to prevent patient injury and promote appropriate patient self-care.

Evaluation of Male Circumcision: Retrospective Analysis of One Hundred and Ninety-eight Patients

Introduction Circumcision is the oldest and most frequently used surgical procedure. It dates back to at least 10,000 years from today. The debate on the benefits and necessity of circumcision is ongoing. In this study, we aimed to determine the complications and complication rate of circumcisions occurring in our circumcision clinic and to compare these with the complication rates in the world. Methods A total of 198 male patients circumcised between 2011 at 2019 at Bursa State Hospital was enrolled in the presented retrospective study. Demographic data of the patients were assessed and the height and weight of the patients were evaluated according to the child growth standards and weight for age percentile charts for boys of the World Health Organization (WHO). All early or late complications were noted after circumcision. Results The mean age of the patients was 93.57±40.12 (2-248) months. The mean follow-up time was 16.32±9.24 (2-35) months. Sixteen patients had bleeding, four patients had a penile hematoma, and 108 patients had penile edema. There is no statistically significant difference in the penile edema occurrence according to the weight of the patients (p=0.58).  Conclusion Circumcision is a frequently applied procedure. Like any other surgery, perioperative and postoperative complications can be observed. More importantly, a significant number of these complications can be prevented by careful surgery and postoperative care.

Circumcision does not have effect on premature ejaculation: A systematic review and meta-analysis

We attempted to evaluate whether circumcision has an effect on premature ejaculation. We searched three databases: PubMed, EMBASE and Google scholar on 1 May 2016 for eligible studies that referred to male sexual function after circumcision. No language restrictions were imposed. The Cochrane Collaboration's RevMan 5.2 software was employed for data analysis, and the fixed or the random-effect model was selected depending on the heterogeneity. Twelve studies were included in the meta-analysis, containing a total of 10019 circumcised and 11570 uncircumcised men. All studies were divided into five subgroups by types of study design to evaluate the effect of circumcision on premature ejaculation (PE). Intravaginal ejaculation latency time (IELT), difficulty of orgasm, erectile dysfunction (ED) and pain during intercourse were also assessed because PE was usually discussed along with these subjects. There were no significant differences in PE (odds ratio [OR], 0.90; 95% confidence interval (CI), 0.72-1.13; p = .37) and orgasm (OR, 1.04; 95% CI, 0.89-1.21; p = .65) between circumcised and uncircumcised group. However, IELT (OR, 0.72; 95% CI, 0.60-0.83; p < .00001), ED (OR, 0.42;95% CI, 0.22-0.78; p = .40) and pain during intercourse (OR, 0.36; 95% CI, 0.17-0.76; p = .007) favoured circumcised group. Based on these findings, circumcision does not have effect on PE.

The prevalence of an excessive prepuce and the effects of distal circumcision on premature ejaculation

OBJECTIVE

To investigate the prevalence of an excessive prepuce in patients with premature ejaculation (PE) and to evaluate the effectiveness of distal circumcision in reducing the penile hypersensitivity, which is thought to be a cause of PE.

PATIENTS AND METHODS

Men were considered to have an excessive prepuce if the foreskin exceeded the external urethral meatus by ≥1 cm in the flaccid state. The diagnosis of PE was based on the Premature Ejaculation Diagnostic Tool (PEDT) questionnaire score and on the intravaginal ejaculatory latency time (IELT). These features were evaluated at baseline and at 6 months after circumcision.

RESULTS

Lifelong PE was diagnosed in 352 patients of whom 208 (59.1%) had an excessive prepuce. We offered those with an excessive prepuce a circumcision, as a potential definitive treatment for their PE, and 27 (13%) men accepted. At 6 months after circumcision, there was an increase in the mean (SD) IELT from 40.4 (16.5) to 254 (66.8) s (P < 0.001) and the mean (SD) PEDT score decreased from 17 (2) to 6.6 (1.9) (P < 0.001). Overall, 26 of the 27 (96%) patients that had a circumcision reported an IELT increase.

CONCLUSIONS

An excessive prepuce is very common in patients affected by PE. Although accepted by only 13% of our patients, distal circumcision was shown to be a very effective surgical treatment for definitive treatment of PE. We therefore recommend assessing patients complaining of lifelong PE for an excessive prepuce and if they have an excessive prepuce to suggest that they undergo distal circumcision.

Evaluation of clinical curative effects of disposable stitching instrument in redundant prepuce patients

The present study aimed to investigate the clinical curative effect of disposable stitching instrument operation in patients with redundant prepuce or phimosis. A total of 102 cases of patients with circumcision were randomly selected (from June 2013 to December 2014) from the department of plastic and aesthetic surgery of our hospital and were randomly divided into control and observation groups (n=51). Patients in the control group were treated by traditional circumcision operation, while patients in the observation group were treated by novel disposable circumcision stitching instrument. Operation time, bleeding volume, incision healing time, postoperative complications and incision aesthetic satisfaction in the groups were observed. As a result, intraoperative bleeding volume of patients in the observation group was significantly less in comparison to the control group. Operation time and incision healing time of patients in the observation group was shorter than that of the control group. Additionally, the incidence of postoperative complications of patients in the observation group was noted to be lower than that of the control group. On the other hand, the incision aesthetic satisfaction of patients in the observation group was higher than that of the control group. Blood vessel counting and nerve fiber counting of tissue specimen in the observation group were more than those of the control group. Postoperative VAS scores of patients in the observation group were significantly lower than that of the control group. Each rating scale scores of EPQ of patients in the observation group improved significantly compared with that of the control group. In conclusion, the present findings show that disposable circumcision stitching instrument operation is more advantageous in comparison to the traditional procedure along with minimal compilations and better post surgery health condition of patients.

Critical evaluation of unscientific arguments disparaging affirmative infant male circumcision policy

We evaluate recent claims opposing infant male circumcision, a procedure now supported by the evidence-based policy of the American Academy of Pediatrics. We find those criticisms depend on speculative claims about the foreskin and obfuscation of the strong scientific evidence supporting pediatric policy development. An argument that circumcision should be delayed to allow a boy to make up his own mind as an adult fails to appreciate the psychological, scheduling and financial burdens later circumcision entails, so reducing the likelihood that it will occur. In contrast, early infant circumcision is convenient, safer, quicker, lower risk, healing is faster, cosmetic outcome is routinely good and the lifetime benefits accrue immediately. Benefits include reduction in urinary tract infections, inflammatory skin conditions, foreskin problems, and, when older, substantial protection against sexually transmitted infections and genital cancers in the male and his female sexual partners. Some authorities regard the failure to offer parents early infant circumcision as unethical, just as it would be unethical to fail to encourage the vaccination of children. In conclusion, the criticisms of evidence-based infant male circumcision policy are seriously flawed and should be dismissed as unhelpful to evidence-based development and implementation of pediatric policy intended to improve public health and individual wellbeing.

Circumcision Is Unethical and Unlawful

The foreskin is a complex structure that protects and moisturizes the head of the penis, and, being the most densely innervated and sensitive portion of the penis, is essential to providing the complete sexual response. Circumcision-the removal of this structure-is non-therapeutic, painful, irreversible surgery that also risks serious physical injury, psychological sequelae, and death. Men rarely volunteer for it, and increasingly circumcised men are expressing their resentment about it.Circumcision is usually performed for religious, cultural and personal reasons. Early claims about its medical benefits have been proven false. The American Academy of Pediatrics and the Centers for Disease Prevention and Control have made many scientifically untenable claims promoting circumcision that run counter to the consensus of Western medical organizations.Circumcision violates the cardinal principles of medical ethics, to respect autonomy (self-determination), to do good, to do no harm, and to be just. Without a clear medical indication, circumcision must be deferred until the child can provide his own fully informed consent.In 2012, a German court held that circumcision constitutes criminal assault. Under existing United States law and international human rights declarations as well, circumcision already violates boys› absolute rights to equal protection, bodily integrity, autonomy, and freedom to choose their own religion. A physician has a legal duty to protect children from unnecessary interventions. Physicians who obtain parental permission through spurious claims or omissions, or rely on the American Academy of Pediatrics' position, also risk liability for misleading parents about circumcision.

Do the Benefits of Male Circumcision Outweigh the Risks? A Critique of the Proposed CDC Guidelines

The Centers for Disease Control and Prevention (CDC) have announced a set of provisional guidelines concerning male circumcision, in which they suggest that the benefits of the surgery outweigh the risks. I offer a critique of the CDC position. Among other concerns, I suggest that the CDC relies more heavily than is warranted on studies from Sub-Saharan Africa that neither translate well to North American populations nor to circumcisions performed before an age of sexual debut; that it employs an inadequate conception of risk in its benefit vs. risk analysis; that it fails to consider the anatomy and functions of the penile prepuce (i.e., the part of the penis that is removed by circumcision); that it underestimates the adverse consequences associated with circumcision by focusing on short-term surgical complications rather than long-term harms; that it portrays both the risks and benefits of circumcision in a misleading manner, thereby undermining the possibility of obtaining informed consent; that it evinces a superficial and selective analysis of the literature on sexual outcomes associated with circumcision; and that it gives less attention than is desirable to ethical issues surrounding autonomy and bodily integrity. I conclude that circumcision before an age of consent is not an appropriate health-promotion strategy.