Urologia Internationalis, Volume 75, Issue 1: Page 62-65
aDepartment of Urology, Medway Maritime Hospital, Gillingham, and bInstitute of Urology, University College London, London , UK
Key Words: Circumcision · Sexual satisfaction · Penile sensation
Objectives: Currently no consensus exists about the role of the foreskin or the effect circumcision has on penile sensitivity and overall sexual satisfaction. Our study assesses the effect of circumcision on sexually active men and the relative impact this may have on informed consent prior to surgery. Materials and Methods: One hundred and fifty men between the ages of 18 and 60 years were identified as being circumcised for benign disease between 1999 and 2002. Patients with erectile dysfunction were excluded from the study. The data was assessed using the abridged, 5-item version of the International Index of Erectile Function (IIEF-5). Questions were also asked about libido, penile sensitivity, premature ejaculation, pain during intercourse and appearance before and after circumcision. IIEF-5 data was analysed using two-tailed paired t test to compare pre-operative and post-operative score changes across the study group. For the rest of the questions, data was analysed using ‘Sign Test’, calculating two-sided p values and 95% con-fidence intervals. Results: Fifty-nine percent of patients (88/150) responded. The total mean IIEF-5 score was 22.41 8 0.94 and 21.13 8 3.17 before and after circumcision, respectively (p = 0.4). Seventy-four percent of patients had no change in their libido levels, 69% noticed less pain during intercourse (p ! 0.05), and 44% of the patients (p = 0.04) and 38% of the partners (p = 0.02) thought the penis appearance improved after circumcision. Penile sensation improved after circumcision in 38% (p = 0.01) but got worse in 18%, with the remainder having no change. Overall satisfaction was 61%. Conclusions: Penile sensitivity had variable outcomes after circumcision. The poor outcome of circumcision considered by overall satisfaction rates suggests that when we circumcise men, these outcome data should be discussed during the informed consent process.
Copyright © 2005 S. Karger AG, Basel
This file does not include tables one and two.
Circumcision was performed 15,000 years ago for unknown reasons, but was thought to be a sacrificial rite [1, 2]. It is still widely practised in the USA, although the national USA circumcision rate has dropped from 85% in 1980 to 59% in the mid 1990’s . Similarly, in the UK the pro-circumcision views were popular in the 1930’s and 1940’s, especially in the upper social classes. This concept changed in the 1950’s and 1960’s and more neutral attitudes occurred. Currently, only 1-2% of boys will need circumcision for medical reasons .
In the UK, adult circumcision is routinely performed as a day case. Generally, when the adult male is informed about circumcision, he is only told about the immediate post-operative complications, whilst the long-term adverse effects of circumcision are less detailed.
The subject of informed consent is highly topical because of clinical governance and medico-legal implications. It has been shown that training on how to obtain informed consent varies considerably . This is due to differing knowledge bases and the inconsistency amongst senior doctors. This emphasises how difficult it can be to explain even a minor procedure.
Long-term adverse effects of circumcision have been studied from the psychological impact to the loss of sexual enjoyment by the patient and his partner [6, 7]. However, there is controversy about the effect of circumcision on penile sensations and male sexual function. No consensus exists regarding the role of the foreskin in sexual performance and satisfaction. Gemmell and Boyle  found that circumcised men had significantly less penile sensation compared with non-circumcised men; however others found this loss to be favourable as it gives them more control over orgasms . Four recent studies have shown conflicting results. Three of the studies did not show any significant effect on penile sensation and sexual function in adults [10-12]. The fourth study showed that erectile function and penile sensitivity decreased but overall satisfaction improved after circumcision  .
Due to the high number of circumcisions performed in the UK and the controversy in the medical literature, we have performed the present study to assess men’s experience in our area both before and after circumcision. This was intended to help surgeons who undertake circumcision to adequately inform their patients of the outcomes related to sexual intercourse and penile sensitivity.
One hundred and fifty men between the ages of 18 and 60 years were identified as having been circumcised between 1999 and 2002 by the sleeve technique. All these men were sexually active before and after surgery and had no history of erectile dysfunction. Patients with histological diagnosis of penile carcinoma and history of erectile dysfunction before circumcision were excluded. Ethical committee approval was obtained before conducting this study.
Patients were asked to complete the abridged, 5-item version of the International Index of Erectile Function (IIEF-5)  ( table 1 ). A modified questionnaire ( table 2 ) was also designed asking patients to compare pain during intercourse, penile sensations, libido, premature ejaculation and cosmetic appearance for the patients and the partner before and after the circumcision as well as overall satisfaction after circumcision ( table 2 ). A free text comments box was also provided. The data was collated and cross-referenced with all other patient information.
Case notes of all patients who responded to the questionnaire were reviewed to assess the indication for the procedure, grade of surgeon, any complexity at surgery, histological diagnosis and any post-operative surgical complications. The questionnaire was completed after a minimum of 3 months after circumcision.
Two-tailed paired t test was used to compare pre-operative and post-operative IIEF-5 score changes across the study group (table 1). For the modified questionnaire (table 2), the ‘Sign test’ with 95% confidence interval was used to assess the statistical difference  . The ‘Sign test’ tests the null hypothesis that, within the relevant population of men having a circumcision, the number with better outcomes is equal to the number with worse outcomes. Consequently, those who respond ‘Same’ contribute nothing to answering this question and so are ignored. The ‘two-sided’ p value was calculated, which relates to the alternative hypothesis that, within the population, the number of ‘better’ and ‘worse’ responses are unequal. Several of the tests were significant at the 5% level at least due to there being significantly more reporting ‘better’ than reporting ‘worse’ for a number of the questions.
Eighty-eight of 150 patients responded to the questionnaire (response rate 59%). Four patients were excluded because they only partially completed the questionnaire. questionnaire. Of the 84 (56%) patients included in this study, 80 patients were white British men and 4 of Asian origin. All had sexual intercourse before and after circumcision. Balanitis xerotica obliterans (BXO) and phimosis due to chronic inflammation/balanitis (histologically diagnosed) were the commonest reasons for circumcision (BXO = 39%, chronic inflammation/chronic balanitis 33%, Zoon’s balanitis 2% and for 25% the specimen was not sent for histology as the foreskin was merely tight but did not appear scarred/inflamed or grossly diseased).
The age distribution was: 18-25 years = 4.7%; 26-35 years = 23.8%; 36-45 years = 30.9%; 46-55 years = 29.7%, and 56-60 years = 10.7%.
The mean total IIEF-5 score of the 84 patients at baseline was 22.41 ± 0.94 compared to 21.13 ± 3.17 after circumcision. The difference between pre- and post-circumcision patients was not statistically significant (p = 0.4). There was a significant improvement in pain/discomfort during intercourse and erection after circumcision (p < 0.05). Only 18% of the patients complained about loss of/or altered penile sensation, whereas 38% found better sensation (p = 0.01). Libido was unaffected in 74%. Sixty-four percent had no problem with premature ejaculation before or after circumcision. Only 13% reported improvement in premature ejaculation, whereas 33% found it worse.
Forty-four percent of patients (p = 0.04) and 38% of their partners (p = 0.02) were happy with the appearance of the penis after circumcision. Sixty-one percent were satisfied with the circumcision (p = 0.04).
Fourteen patients (17%) were not satisfied with the circumcision, but only 1 patient in this group had any obvious post-operative complications (bleeding). The histological diagnosis in this group was chronic inflammation (n = 4) and BXO (n = 2). No histology was available for 8 patients.
The great majority of the men in this study had benign disease of the prepuce. The before and after comparison for most of the men compares the condition of having a diseased prepuce to the condition of having no prepuce. This study does not indicate the comparison of the condition having a healthy prepuce to the condition of having a no prepuce.
Over 20,000 circumcisions per year are performed in the National Health Service in the UK (www.menshealth forum.co.uk). Medical indications for this procedure include phimosis, paraphimosis, recurrent balanitis and posthitis (inflammation of the prepuce). Although it is a simple procedure, a patient should be counselled about the associated morbidity. Generally, patients are informed of the immediate post-operative complications, including bleeding, haematoma and infection, whereas the long-term consequences of the operation are rarely discussed. As informed consent is an integral part of health care provision, matters such as reduction of penile sensation, reduced sexual satisfaction and worsening of erectile function should all be addressed.
In 1920, Sigmund Freud  stated that circumcision was a substitute for castration, suggesting a possible connection between castration fears, neuroses and circumcision. Many studies have shown the presence of thousands of erogenous nerve endings on the inner layer of the foreskin [17, 18]. Hammond  described that circumcised men, men with intact short foreskin and those who keep their foreskin retracted have greater keratinisation of the glans epithelium. This keratinisation causes reduction of the penile sensation, hence reducing enjoyment.
Fink et al.  have recently shown that adult circumcision is associated with a significant decrease in erectile function and penile sensation. However, as with our study, approximately 62% of their patients were satisfied after a circumcision. Laumann et al.  analysed the data from a survey that included 1,410 men. They found that uncircumcised men were more likely to experience sexual dysfunction, especially later in life. Collins et al.  conducted a prospective study where 15 adult men were asked to complete a questionnaire before and 12 weeks after circumcision. They did not find any clinically important adverse effects of circumcision on sexual function.
To evaluate the effects of circumcision, Bleustein et al.  tested 36 circumcised and 43 uncircumcised men for level of vibration (Biothesiometer), pressure (Semmes-Weinstein monofilaments), spatial perception (Tactile Circumferential Discriminator), and warm and cold thermal thresholds (Physitemp NTE-2) in the large and small axon nerve fibres in the dorsal midline glans penis. They demonstrated that there were no significant differences in penile sensation between circumcised and uncircumcised men with respect to vibration, spatial perception, pressure, warm and cold thermal thresholds in patients with and without erectile dysfunction. A recently published study by Enkul et al.  has again shown that adult circumcision does not adversely affect sexual function. In our study the difference between the mean total IIEF-5 score before and after circumcision was not significant. Only 18% of our patients complained about decreased sensation after circumcision as compared to 38% who experienced improved sensation (p = 0.01), with 44% who had no change.
Circumcision affecting the sexual pleasure of the female partner has been studied by O’Hara and O’Hara . Their survey found that women preferred vaginal intercourse with an uncircumcised man. In our study 38% of female partners found improvement in cosmetic appearance after circumcision (p = 0.02) compared to 19% who found the appearance worse. Similarly, 44% of the men in this study were pleased with the appearance of their penis (p = 0.04) compared to 25% of men who were unhappy. In the present study there is significant improvement in discomfort and pain after circumcision (p = 0.04). This can be easily explained by the fact that these patients had a diseased and tight foreskin, which made intercourse painful before circumcision.
Circumcision was previously believed to improve premature ejaculation and help prolong intercourse, but we were unable to find this effect [9, 21]. Only 13% of our patients reported improvement whereas 33% found the problem had gotten worse. Sixty-one percent of our patients were satisfied and pleased (p = 0.05) with circumcision compared with 17% who were unhappy after circumcision. Of the 17% patients who were unsatisfied, 1 patient complained of a significant loss of penile sensation, commenting in retrospect that he would not have undergone surgery had he known. Of the 14 unsatisfied patients only 2 had scarred foreskins due to BXO (histological diagnosis). This demonstrates that there are fewer unsatisfied patients when the circumcision is done for diseased foreskin.
As 17% of patients in the present study were unsatisfied, we raise the important issue of informed consent. The medical literature regularly shows that incomplete information is conveyed by the surgeons or understood by the patient. Studies have shown that physicians routinely underestimate the patient’s desire for information and there is a significant discrepancy between what physicians assume a patient wants to know and what the patient actually expects .
We have demonstrated that in adults, circumcision does not appear to have significant adverse effect on sexual function. In spite of that we suggest that before circumcision, men should be warned of the long-term consequences (penile sensations and effect on erectile function) as well as be talked through the more traditional subjects (peri-operative complications).
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