In most males the foreskin and frenulum do not cause any problems but in some individuals they are a nuisance during everyday activities or sex life. The foreskin is a double fold of skin which completely covers the glans or penis head with a bit to spare in the child but usually only partially covers the glans in the adult. The frenulum or 'string' is a band of tissue which joins the inner surface of the foreskin to the glans on the under surface of the penis. If these structures cause trouble at some time during a man's life then his sons are likely to inherit the same tendency to problems though they may occur at a different age.
In susceptible individuals one can recognize a sequence of
events which can start at any age and may progress slowly or rapidly
over a period of weeks, months or years. A long foreskin is a
predisposing factor so this sequence is common in children but
usually only occurs in adults who have persistence of the long
foreskin of childhood.
1. Normal. The foreskin retracts easily with the penis
limp or erect to completely expose the glans which is quite dry.
2. Slimy. The foreskin, particularly if it is long, tends
to retain moisture making the glans and inner aspect of the foreskin
damp and often itchy.
3. Smelly. The glans and inner aspect of the foreskin become
white and sodden, particularly in the groove behind the glans,
and like any stagnant water there is an unpleasant smell.
4. Sore. Usually harmless germs multiply in the warm moist
conditions and invade the devitalized tissue causing an infection
called balanitis. The glans and foreskin become hypersensitive
with areas of redness.
The child complains of pain on passing water whilst the adult
may complain of early ejaculation, painful intercourse or inability
to have intercourse.
5. Septic. More virulent germs may invade the area causing
more acute inflammation with ulceration of the glans and swelling
of the foreskin. There is a discharge of pus from under the foreskin
so the subject thinks he has V.D.
6. Scarred. The inflammation under the foreskin damages
the tissues which heal with scar tissue. Scarring of the foreskin
spoils the elasticity so that it cannot be drawn back with the
penis erect and later this is impossible when the penis is limp,
a condition called phimosis. Similarly scarring of the glans narrows
the opening of the urethra making passing water difficult (meatal
stenosis). Phimosis and/or meatal stenosis may follow one severe
attack of balanitis, several minor attacks, or a long period of
discomfort.
Some seek advice for itching, soreness etc. before scarring occurs
whilst others present with phimosis but never complain about inflammation.
1. Taut. The frenulum becomes taut when the foreskin
is completely drawn back at full penetration during sexual intercourse.
2. Tender. If the frenulum is short it may cause discomfort
during intercourse and be tender for some time afterwards.
3. Torn. Alternatively a short frenulum may tear and further
intercourse is not possible until the raw, painful area has healed.
The accident may resolve the trouble or the frenulum may tear
and re-unite repeatedly.
4. Torrent. Sometimes a blood vessel in a short frenulum
tears and emergency treatment may be needed to stem the bleeding.
A single accident may be curative or there may be recurrent bleeding
during intercourse.
'Ballooning' or swelling of the foreskin when passing water is an absolute indication for circumcision at any age. It is caused by urine collecting under the prepuce because the foreskin opening has become smaller than the opening in the glans. The infant cries and strains while the older child may complain of pain or difficulty in passing water. If left untreated severe damage to the bladder and kidneys can also occur.
I qualified as a doctor believing that if a boy could retract
his prepuce he was perfectly normal and would never need circumcision.
I also knew virtually nothing about sex problems. As a casualty
doctor I soon had to learn how to stop bleeding from a torn frenulum
and reduce a paraphimosis. Hardly a weekend went by without at
least one patient presenting with some problem in a supposedly
normal penis. I concluded that the paediatricians were wrong and
the ability of the mature youth to retract the prepuce with the
penis erect was the criterion of normality.
I was later conscripted into the Royal Army Medical Corps and
served in West Africa where I was expected to do several jobs
including minor surgery and venerology. Uncircumcised native recruits
came to me requesting 'penis cut' because their colleagues ribbed
them as still being boys and not men. In the absence of phimosis
I initially refused to operate so they went to the native barber
and I had to deal with the ensuing bleeding or infection. I agreed
to circumcise on request and from the comments made afterwards
the soldiers were pleased with their manly appearance but they
also suggested that their sex lives were enhanced. All the uncircumcised
Africans had rather long foreskins and some degree of balanitis
which dramatically disappeared after operation and never recurred.
On returning to the U.K. I decided to see if these observations
applied here. Enquiries showed that N.H.S. circumcision in many
cases enhanced as well as restored the sex life of a man and his
partner. Routine questioning of hospital patients confirmed that
a long prepuce was associated with smelly discomfort or itching
in warm weather, or after sport. News of my interest in sex problems
was spread by my friends so I was soon being asked to see men
with problems. One of my friends knew an assistant editor of a
sex magazine so I was invited to help answer readers letters.
This naturally lead me to starting to circumcise or cut the frenulum
at my house under local anaesthesia for the usual indications.
I always investigated the effects of these procedures on sex life.
Over the years my list of indications for circumcision has grown
and I now recognize that a long foreskin which retains moisture
is best removed. The probable sequence of events is given in Appendix 1.
Readers letters and consultations have taught me a lot about sex
medicine and made me realize how often genuine troubles are ignored
or dismissed by doctors as purely psychological. For at least
the last 10 years I have been doing circumcision on request and
recording the effects of all operations in a questionnaire. One
would expect men circumcised for medical reasons to be satisfied
with the improvement in their sex lives even if the operation
was badly performed. In fact these men and their partners often
said that their sex lives were better than before the trouble
occurred. Equally one would expect patients circumcised for trivial
reasons (e.g. long prepuce, smelly in the Summer) or who were
done on the suggestion of someone else (e.g. shipping company,
fiancée) to be more critical about the operation. In practice
nearly all these patients and their partners found that their
sex lives were improved by the operation. I have been surprised
how many patients volunteered that they were more comfortable
after circumcision even though they did not complain of discomfort
before operation. Irrespective of whether circumcision was done
to cure a problem or as a preventative measure no one has ever
regretted having the operation, or found it has spoiled his sex
life. My observations on the effects of circumcision in about
1,000 cases over the last 25 years have converted me from anti-
to pro-circumcision.
In children I have pioneered the Plastibell method of circumcision
up to the age of puberty. I find it causes much less discomfort,
gives a neater result and in contrast to normal surgery most lads
are dressed and active within 24 hours. At first I would only
circumcise for medical or religious reasons but I now do it on
request. I occasionally have to remove a bell which has failed
to separate spontaneously but I have never had any of the complications
which make paediatricians oppose routine circumcision. The children,
ranging in age from a few days to nearly 14 years, were circumcised
in my surgery in the presence of their parents. None of the lads
would admit that he was upset about losing his prepuce but they
often embarrassed their parents by proudly displaying their 'new
tails' to friends and relations. Small boys are pleased to be
able to see the glans and at how far and high they can direct
a stream of urine. I am now convinced that the psychological ill
effects of circumcision are due to separation from parents whilst
in hospital and the pain caused by conventional surgery.
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