Effects of adult male circumcision on premature ejaculation: results from a prospective study in China

The role of surgical therapy in the management of premature ejaculation: a narrative review

Background and Objective

Premature ejaculation (PE) is a common sexual disorder among male adults and negatively impacts a man's sexual life. Currently, the mainstay treatment of PE is still medical therapy which has drawbacks among patients as a consequence of side effects. Despite the new definitions, the evolution of medical therapy, and the consensus for the management of PE, it remains challenging to treat for many clinicians especially when medical treatment fails. However, the International Society for Sexual Medicine (ISSM) and the American Urological Association (AUA) guidelines ignored surgical therapy due to conflicting medical reports and doubts about the safety of surgical management. This article discusses the surgical management of PE based on recent guidelines, reviews, and evolving techniques.

Methods

We reviewed the literature using PubMed and searched for the following keywords: premature ejaculation, selective dorsal neurectomy, hyaluronic acid, dorsal nerve neuromodulation, cryo-ablation of the dorsal nerve and inner condom technique until May 2023. Seventeen studies were found.

Key Content and Findings

Even though the widespread use of many surgical modalities in Asia such as glans penis augmentation (GPA) using hyaluronic acid (HA) selective dorsal neurectomy (SDN), cryo-ablation of the dorsal nerve, neuromodulation of the dorsal nerve (NMDN), and circumcision are still considered as controversial for the guidelines.

Conclusions

The mainstay treatment of PE is still pharmaceutical. However, the current body of evidence on surgical treatments for PE is limited. Men considering surgical therapy for PE should be counseled well for the risks and benefits as there may be chronic disabilities. Further, well-designed trials are needed to establish safety and efficacy for the surgical treatment.

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.

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.

What is the medical evidence on non-therapeutic child circumcision?

Non-therapeutic circumcision refers to the surgical removal of part or all of the foreskin, in healthy males, where there is no medical condition requiring surgery. The arguments for and against this practice in children have been debated for many years, with conflicting and conflicted evidence presented on both sides. Here, we explore the evidence behind the claimed benefits and risks from a medical and health-related perspective. We examine the number of circumcisions which would be required to achieve each purported benefit, and set that against the reported rates of short- and long-term complications. We conclude that non-therapeutic circumcision performed on otherwise healthy infants or children has little or no high-quality medical evidence to support its overall benefit. Moreover, it is associated with rare but avoidable harm and even occasional deaths. From the perspective of the individual boy, there is no medical justification for performing a circumcision prior to an age that he can assess the known risks and potential benefits, and choose to give or withhold informed consent himself. We feel that the evidence presented in this review is essential information for all parents and practitioners considering non-therapeutic circumcisions on otherwise healthy infants and children.

Bipolar circumcision: A new technique for an old procedure with quantified cosmetic outcome

BACKGROUND

Circumcision using bipolar diathermy is well established and used widely. It seems to be superior in terms of post operative complications. The cosmetic outcome of the procedure has never been quantitatively described though.

AIMS

To describe a modification to performing circumcision with bipolar that involves applying four clamps to the foreskin as it is being amputated with the bipolar so that a consistent length of the mucosal cuff can be obtained with a single almost bloodless cut.

METHODS

Prospective case series of all patients circumcised using the 4 clamps traction and bipolar cut technique. The cosmetic outcome was assessed in terms of the length of the mucosal cuff in absolute numbers and in proportion to the penile and glanular length.

RESULTS

Seventy four patients were recruited with a median age of 3.5 months. No complications were encountered. The average length of the penis was 40 ± 13 mm and the glans 12 ± 3.6 mm. The average length of the mucosal cuff was 8.4 ± 2.9 mm, and the proportion to total penile length was 21.1% ± 4.7% and to glans length 72% ± 24.1%.

CONCLUSION

The four clamp traction method with bipolar circumcision is safe and has a satisfactory cosmetic outcome.

Glans penis augmentation using hyaluronic acid for the treatment of premature ejaculation: a narrative review

Premature ejaculation (PE) is the most common self-reported male sexual disorder estimated to occur in approximately 5% of men in the general community. Penile hypersensitivity is thought to be an etiologic factor of lifelong PE. The role of glans penis augmentation using injectable hyaluronic acid (HA) for the treatment of PE is debatable and remains to be confirmed. The creation of a barrier at the level of the glans, by the bulking agent blocking accessibility and inhibiting the tactile stimuli to reach the dorsal nerve of the penis (branch of the pudendal nerve) receptors, is the theory behind the effectiveness of HA in the field of PE. We reviewed the literature using PubMed and searched for the following keywords: premature ejaculation, glans penis and HA, over the last 20 years. Five studies were found. These studies showed that HA injection could significantly increase IELT (2.43- to 4.46-fold), and this increase could persist for long term (up to 5 years). No serious adverse reactions were reported besides transient discoloration and swelling of the glans that recovered to normal within 2 weeks. Many techniques were discussed, their effectiveness remains to be proved. However, proper patient selection and mastering the esthetics of the technique, by adequate surgical training, is necessary in order to achieve the optimal results.

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.

The relationship between premature ejaculation and anogenital distance

Premature ejaculation is a common male sexual disease in andrology practice. The goal of essay is to investigate the relation of anogenital distance that predicts prenatal testosterone exposure with premature ejaculation. Between January and May 2019, 150 men were participated in the study. The patients were evaluated with anamnesis and physical examination; age, smoking, alcohol consumption, intravaginal ejaculation latency time, body mass index, premature ejaculation diagnostic tool, distance from anal point to scrotum and distance from anal point to penis were recorded. According to premature ejaculation diagnostic tool score, the patients were classified as premature ejaculation group (score ≥11) and control group (score <11). The mean of the male age was 30.73 ± 4.40 years. The mean intravaginal ejaculation latency time score was 3.42 ± 2.71 min. Two groups were compared using the distance from anal point to scrotum distance from anal point to penis. In the premature ejaculation group, the distances were found lower (77.46 ± 2.31 and 54.78 ± 2.56 mm) than the control group (81.32 ± 3.11 and 58.16 ± 3.48 mm). There were statistical differences between two groups (p < .001). It was concluded that it is likely to have a negative relationship between anogenital distance and premature ejaculation diagnostic tool score.

Muslim mothers mainly saw circumcision in terms of religion or tradition but wanted it to be carried out medical professionals

AIM

This study assessed the relationship between the education level of Muslim Turkish mothers whose sons had been circumcised and their views on circumcision.

METHODS

Interviews based on 20 close-ended questions were carried out in the Çukurova region of southern Turkey between June 2015 and September 2016. The participants were 1497 Muslim Turkish mothers whose sons had been circumcised and who were recruited using convenience sampling in schools, hospitals and public spaces.

RESULTS

Most (82%) of the mothers saw circumcision as a religious and traditional requirement, 64% mentioned the health benefits and 48% mentioned cosmetic appearance. The majority (80%) were performed by health organisations, with two-thirds (66%) expressing this preference. Most circumcisions were at school age (38%), which was about 6 years of age plus at the time of the study, and there were no complications in 79% of cases. Higher education levels were associated with views that circumcision was an important surgical procedure, it decreased the risk of urinary tract infections, it should be performed in hospitals and the foreskin did not prevent sexual intercourse.

CONCLUSION

Circumcision was mainly seen as a religious and traditional ritual, and more highly educated Turkish Muslim mothers were better informed about the health aspects.

A bibliometric analysis of international publication trends in premature ejaculation research (2008-2018)

The incidence of premature ejaculation (PE) has been on the rise over the years. Thus, significant research efforts have been directed toward understanding the pathogenesis and hence treatment of PE. Here, we performed a comprehensive analysis of the worldwide trends in research outputs in the field of PE. This study investigated the universal findings of previous PE studies and the trending issues surrounding the condition. We employed the Web of Science Core Collection for data collection. The Excel (2016) and CiteSpace IV were used for information analysis. The information was categorized using journal names, institutions, research frontiers, citation reports, regions/countries, and authors. A sum of 886 publications concerning PE between 2008 and 2018 were identified as of July 6, 2019. The highest number of publications was identified in the Journal of Sexual Medicine published. The United States of America (USA) had the highest number of publications and H-index value. The highest co-citations were from Waldinger MD. The most common keyword was 'drug treatment'. A steady pattern was observed for PE publications done between the period of 2008-2018. Thus, the USA is at the forefront of research on PE research. The interesting advanced research frontiers were drug treatment, circumcision, and sertraline.

The Comorbidity Between Premature Ejaculation and Erectile Dysfunction-A Cross-Sectional Internet Survey

Introduction

The comorbidity between premature ejaculation (PE) and erectile dysfunction (ED) has not yet been clarified.

Aim

To assess the comorbidity between PE and ED.

Methods

Male members of a shopping club in Taiwan aged 20–60 years with stable sexual relationships were invited to complete an online questionnaire.

Main Outcome Measures

Self-estimated intravaginal ejaculatory latency time (IELT), Premature Ejaculation Diagnostic Tool, Sexual Health Inventory for Men, Self-Esteem and Relationship, and Hospital Anxiety and Depression Scale results were used.

Results

A total of 937 participants with a mean age of 41.1 ± 10.2 years were enrolled. The prevalence rates of ED (Sexual Health Inventory for Men ≤ 21), PE (Premature Ejaculation Diagnostic Tool ≥11), and IELT ≤1 minute were 24.7%, 6.3%, and 6.4%, respectively. Prevalence of acquired PE and IELT ≤1 minute increased marginally with age. Participants with ED had a greater prevalence of PE than those without ED (19.5% vs 2.0%, P < .001), and participants with PE had a greater prevalence of ED than those without PE (76.3% vs 19.4%, P < .001). Compared with participants without PE, participants with PE had greater adjusted odds of ED (odds ratio [OR] = 12.7, 95% CI = 6.7–24.2). Relative to participants without ED, participants with ED had increased adjusted odds of PE (OR = 7.2, 95% CI = 3.5–14.6 with mild ED and OR = 36.7, 95% CI = 16.2–83.0 with ED severity greater than a mild degree). Poor sexual relationships and self-esteem, depression, and anxiety were reported more frequently in those with PE or ED, especially in those with both problems compared with those without PE and ED.

Conclusions

This study confirmed a high prevalence of PE and ED coexistence, indicating a complicated relationship between the 2 conditions and the importance of screening for their co-occurrence in practice.

Tsai W-K, Chiang P-K, Lu C-C, et al. The Comorbidity Between Premature Ejaculation and Erectile Dysfunction—A Cross-Sectional Internet Survey. Sex Med 2019;7:451–458

Premature Ejaculation: From Physiology to Treatment

Objective: To review in literature about the concept of premature ejaculation from physiology to treatment. Materials and methods: A literature search conducted with Pubmed and Cochrane. Results: An accurate clinical history is the best diagnostic method, and in the majority of the cases it is enough to differentiate between primary and acquired premature ejaculation. Nowadays the treatment is not curative but is effective in increasing the Intravaginal Ejaculatory Latency Time, improving the couple's sexual satisfaction. Conclusion: Although PE is the most frequent sexual dysfunction, it is still sub-diagnosed. Combining behavioural techniques with pharmacotherapy is the best way of treatment.

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.

Prevalence and Associated Factors of Premature Ejaculation in the Anhui Male Population in China: Evidence-Based Unified Definition of Lifelong and Acquired Premature Ejaculation

Introduction

In 2014, new evidence-based definitions of lifelong premature ejaculation (LPE) and acquired premature ejaculation (APE) were proposed by the International Society for Sexual Medicine. Based on the new PE definitions, the prevalence of and factors associated with LPE and APE have not been investigated in China.

Aim

To evaluate the prevalence of and factors associated with LPE and APE in men with the complaint of PE in China.

Methods

From December 2011 to December 2015, a cross-sectional field survey was conducted in five cities in the Anhui province of China. Questionnaire data of 3,579 men were collected in our database. The questionnaire included subjects' demographic information and medical and sexual histories. Men who were not satisfied with their time to ejaculate were accepted as having the complaint of PE. Men with the complaint of PE who met the new definition of PE were diagnosed as having LPE or APE.

Main Outcome Measures

New definition of LPE and APE.

Results

Of 3,579 men who completed the questionnaire, 34.62% complained of PE. Mean age, body mass index, and self-estimated intravaginal ejaculatory latency time for all subjects were 34.97 ± 9.02 years, 23.33 ± 3.56 kg/m², and 3.09 ± 1.36 minutes, respectively. The prevalences of LPE and APE in men with the complaint of PE were 10.98% and 21.39%, respectively. LPE and APE were associated with age, body mass index, and smoking and exercise rates (P < .001 for all comparisons). Men with APE reported more comorbidities than men with LPE, especially in the presence of hypertension, diabetes mellitus, and heart disease (P < .001 for all comparisons).

Conclusion

In this study, the prevalences of LPE and APE in men with the complaint of PE were 10.98% and 21.39%, respectively. Patients with APE were older and more likely to smoke, had more comorbidities, and had a higher body mass index than patients with LPE.

The pathophysiology of acquired premature ejaculation

The second Ad Hoc International Society for Sexual Medicine (ISSM) Committee for the Definition of Premature Ejaculation defined acquired premature ejaculation (PE) as a male sexual dysfunction characterized by a the development of a clinically significant and bothersome reduction in ejaculation latency time in men with previous normal ejaculatory experiences, often to about 3 minutes or less, the inability to delay ejaculation on all or nearly all vaginal penetrations, and the presence of negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy. The literature contains a diverse range of biological and psychological etiological theories. Acquired PE is commonly due to sexual performance anxiety, psychological or relationship problems, erectile dysfunction (ED), and occasionally prostatitis and hyperthyroidism, consistent with the predominant organic etiology of acquired PE, men with this complaint are usually older, have a higher mean BMI and a greater incidence of comorbid disease including hypertension, sexual desire disorder, diabetes mellitus, chronic prostatitis, and ED compared to lifelong, variable and subjective PE.

Pros and cons of circumcision: an evidence-based overview

Based on three large randomized controlled trials (RCTs) conducted in Africa, it can clearly be stated that circumcision lowers the risk of infection with the human immunodeficiency virus (HIV) and some sexually transmitted infections (STIs) among males in settings of high HIV and STI endemicity. Similar effects on STI risk may exist for females, although this may result from an indirect effect of decreasing risk of infection among male partners. It is unknown whether circumcision prevents HIV acquisition in men who have sex with men (MSM), although there might be a protective effect for men who engage mainly in insertive anal intercourse. When the effects of adult circumcision on sexual function and satisfaction of men are examined, high-quality evidence strongly supports lack of harm. Whether circumcision alters sexual satisfaction of female partners is not known as fewer and smaller studies reported conflicting results. Circumcision rarely causes serious complications if practiced by trained practitioners, in a sterile setting, and with a proper follow-up. These conclusions are limited by the lack of high-quality data from areas outside of Africa. RCTs have not been conducted to assess the effects of circumcising infants or MSM. Circumcision has well-proven benefits for people residing in areas with high prevalence of STIs, including HIV, and is not unethical for those who choose to be circumcised or have their children circumcised on religious, social, or cultural grounds. For many others, a definite pro or con recommendation, based on a risk-benefit ratio, cannot be made.