This directory contains academic articles and discussions about preputial anatomy, dimensions, immunological functions, innervation, vascularity, sexual function, and the effects of circumcision. The articles are indexed in chronological order of publication.
In extensive reviews of the world medical literature, medical historian Frederick M. Hodges, D. Phil. (Oxon), revealed long forgotten European and American research starting from 1860, confirming that this information is not new, but simply has been forgotten in circumcising countries.1-7,9,10,12-18
See also Anatomy of the Penis and Mechanics of Intercourse (Circumcision Information Pages).
Musculature. The prepuce has a sheath of smooth muscle tissue inside the skin which is called the peripenic muscle.8,22,41 The muscle fibers are arranged in a whorl at the end of the foreskin to form a sphincter.8 The muscle fibers keep the foreskin snugly against the glans penis.22
Skin and mucosa. The outer surface of the prepuce is skin, however the inner surface is mucosal membrane although it resembles skin in appearance. There is a muco-cutaneous boundary just inside the tip of the prepuce. The prepuce normally covers the glans penis and protects it from foreign matter, friction, drying, and injury.
Sub-preputial moisture. The sub-preputial area is normally slightly moist. Taylor et al. reported finding no sweat or sebaceous glands;34, however, Fleiss et al. reported apocrine glands that produce cathepsin B, lysosyme chymotrypsin, neutrophil elastase, cytokine, and pheromones such an androsterone.39 Prostatic, vesicular, and urethral secretions also contribute moisture.23 Moisture may also be exuded through the mucosa of the foreskin.39 Indian scientists reported that the sub-preputial moisture contains lytic material.23 Lytic material has an anti-bacterial and anti-viral action.39 The natural oils lubricate, moisturize, and protect the mucosal covering of the glans penis and inner foreskin.41
Dimensions. The foreskin tissue of an infant male may appear to be quite small, but that tissue grows in the adult to be a substantial area. The prepuce is a folded double layer of skin and mucosa so it must be unfolded to determine its true size. The average size of the adult prepuce has been stated to be about 15 square inches or more or the size of a 3 x 5-inch index card. Taylor studied 22 prepuces taken from adult cadavers. Taylor reported a range of length from 4.8 to 9.3 cm with a mean length of 6.4 cm.34 Recently, Werker and colleagues evaluated the prepuce for use in reconstructive surgery.38 Werker studied prepuces taken from 8 cadavers. Werker reported a mean surface area of 46.7 square cm of the combined inner and outer layers with a range of 18.1 sq. cm to 67.5 sq. cm. The pedicle length ranged from 11.9 cm to 20 cm with a mean of 15.4 cm.38 He also reported two cases in which the prepuce was used in reconstructive surgery. In the first case a 65-year-old man had a prepuce measuring 8.5 x 7.5 cm. or 64 sq. cm. In the second case a 62-year-old man had a prepuce measuring 10 x 9 cm or 90 sq. cm.38 Werker's findings suggest that the dimensions of the prepuce may be somewhat greater than previously believed since Werker's living specimens were larger than those taken from cadavers.
Frenulum. The prepuce is usually tethered at the bottom by the frenulum. The frenulum's function is to provide pleasure by stretching during sexual intercourse. In fact, the frenulum is coloquially known as the "sex nerve" in France and perhaps throughout Europe. By destroying this stretching action, circumcision completely destroys this fundamental means of sexual pleasure in the human male. Taylor hypothesizes that stretching of the frenulum during coitus is provides a stimulus for ejaculation.47
Vascularization. As with other neurologic structures such as the brain, the tip of the prepuce is richly supplied with blood by important vascular structures.34 The glans penis receives blood through the frenular artery.33 The prepuce serves as a conduit for several important veins. Circumcision may contribute to erectile dysfunction by destroying these blood conduits.
Immunology. The prepuce is naturally equipped with several defenses against infection.23,39,41 The infant prepuce has a pronounced tight tip with a sphincter8,39,41 formed by the whorl of muscle tissue that stays closed to keep out foreign matter but opens to allow the outflow of urine. The sub-preputial wetness contains lyzosyme, a secretion that acts to destroy harmful microorganisms.23 The prepuce contains Langerhans cells which may provide resistance to HIV infection.39,41, Fleiss, Hodges, and Van Howe discuss the immunological functions of the prepuce in detail,39 as do Cold and Taylor.41
Innervation. The prepuce is profusely innervated especially near the tip in the ridged band area where the mucocutaneous boundary occurs. It is now understood that this junction is the most sensitive and erogenous part of the penis.17,18,26,31,32,34,39,41 Winkelmann explains the importance of the mucocutaneous boundary in human sexual response.18 He explains, "All biologic phenomena, including sensation, are the result of a certain statistical events. It is logical to anticipate that some individuals will have cutaneous hyperneuria, and also to expect eventually to find some individuals with actual diminution in organization of the cutaneous nerves for sensation. Certain pathologic states may be explicable on the basis of diminished or augmented cutaneous nerve supply."18 Thus, the accumulation of sensation triggers the ejaculation reflex.18 Diminution of the available nerve supply would make achievement of orgasm more difficult. The penile erection and ejaculation require the integration and proper sequencing of somatic, sympathetic, and parasympathetic innervation.26
Taylor's ridged band is located near the tip of the prepuce on the inner layer of the foreskin near the muco-cutanaeous boundary.33 The ridged band merges smoothly with the frenulum.32 Taylor states that the ridged band is sensitive to motion.42 The foreskin slides back and forth over the glans during foreplay and intercourse.30, 31 Typically, the ridged band area of the prepuce is stretched when it passes over the glans penis and, by this stretching action, the multitude of pleasure sensors in Taylor's ridged band are stimulated.
The ridged band area, which is stimulated by motion,42 is the most highly innervated18, 32 and pleasure producing21 region of the prepuce. They clearly have an important, but not yet well understood, function in human sexual response.18,32 Cold and Taylor (1999) confirmed the structure and innervation of the prepuce, and explained its importance in more detail.41
In comparison to the prepuce, the glans penis is much less innervated and sensitive.25,27 The corona (rim) is the most highly innervated part of the glans penis.25 Stimulation of the coronal area of the glans penis may trigger ejaculation.37 The prepuce of the typical complete male may protect the corona from direct stimulation during intercourse and so tends to prevent premature and unwanted ejaculation.
Erogeny and Sexual Function. Winkelmann states, "It is apparent in our material that all the bodies [nerve endings] present have coiled or serpentine form ... Such a form lends itself admirably to the perception of changes in pressure and tension in the tissue, as the coils are oriented in three dimensions."17 The prepuce of the human male is an elastic platform for the nerve endings composed of muscle fibers embedded within the skin, so the whole prepuce may be regarded as the principal organ for perceiving the sixth sense of erogeny.18,32,38 Milos and Macris31, and Warren and Bigelow,32 have described sexual functions of the prepuce.
See Foreskin Sexual Function for a fuller discussion.
Changes in behavior associated with a missing prepuce. Laumann et al. report that men who have lost their prepuce to circumcision tend to exhibit a "more elaborated set of sexual practices than do men who are not circumcised."35 Some have improperly interpreted this statement to mean that "circumcised men have more fun." However, Van Howe and Cold explain that circumcised men may have more difficulty in obtaining sexual satisfaction from intercourse—due to the loss of the fine-touch neuroreceptors in the prepuce—and so turn to other sexual practices.36
Effects on sexual and marital relations associated with a missing prepuce: Hughes reports a study in which intact (uncircumcised) males appear to enjoy better sexual compatibility in marriage which apparently contributes to marital happiness.29 Zwang states that it is more difficult for the partner to manually stimulate the circumcised male during foreplay.37 Depending on the individual, the permanently exposed glans may experience an excess of stimulation, or the wrong kind of stimulation, during intercourse which can lead to premature ejaculation (lack of "staying power") in the circumcised male.37 The tight foreshortened immobilized skin of the circumcised penis is more vulnerable to laceration, bleeding and pain during intercourse.37 39
Erectile dysfunction (impotence) is now known to be usually caused by circulatory problems. As noted above, circumcision inteferes with penile circulation by destroying several important blood vessels that provide circulation to the penis. Circumcision may also contribute to erectile dysfunction by destroying some of the erogenous sensory tissue in the prepuce that participates in the erectile response.
O'Hara and O'Hara surveyed 138 women who had experience with both circumcised male partners and intact complete male partners.42 20 of the 138 preferred circumcised male partners while 118 (85.5%) preferred intact male partners with anatomically complete penises over circumcised males. The respondents reported that circumcised partners tended to ejaculate prematurely more frequently than intact male partners.42 Some respondents commented that unaltered male partners appeared to enjoy coitus more than their circumcised counterparts.42
Other primates. Cold and McGrath described the variations in the prepuce between human males and females and other primate species, concluding from an evolutionary perspective that the prepuce is highly evolved and has a specialized function in each species.43
In summary, the prepuce is a unique specialized structure with important immunological, protective, mechanical, erogenous, and sexual functions. The prepuce is essential to normal copulation.41
There is an animated anatomical drawing which graphically depicts in animation the deployment of Taylor's ridged bands by retraction of the prepuce. This is located off-site. (Link to www.circumstitions.com)
There is a collection of graphic close-up photographs of the adult prepuce which depict various anatomical features of the prepuce at another website. (Link to www.foreskin.org)
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