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Concept: Foreskin restoration

229

ABSTRACT Male circumcision reduces female-to-male HIV transmission. Hypothesized mechanisms for this protective effect include decreased HIV target cell recruitment and activation due to changes in the penis microbiome. We compared the coronal sulcus microbiota of men from a group of uncircumcised controls (n = 77) and from a circumcised intervention group (n = 79) at enrollment and year 1 follow-up in a randomized circumcision trial in Rakai, Uganda. We characterized microbiota using16S rRNA gene-based quantitative PCR (qPCR) and pyrosequencing, log response ratio (LRR), Bayesian classification, nonmetric multidimensional scaling (nMDS), and permutational multivariate analysis of variance (PerMANOVA). At baseline, men in both study arms had comparable coronal sulcus microbiota; however, by year 1, circumcision decreased the total bacterial load and reduced microbiota biodiversity. Specifically, the prevalence and absolute abundance of 12 anaerobic bacterial taxa decreased significantly in the circumcised men. While aerobic bacterial taxa also increased postcircumcision, these gains were minor. The reduction in anaerobes may partly account for the effects of circumcision on reduced HIV acquisition. IMPORTANCE The bacterial changes identified in this study may play an important role in the HIV risk reduction conferred by male circumcision. Decreasing the load of specific anaerobes could reduce HIV target cell recruitment to the foreskin. Understanding the mechanisms that underlie the benefits of male circumcision could help to identify new intervention strategies for decreasing HIV transmission, applicable to populations with high HIV prevalence where male circumcision is culturally less acceptable.

Concepts: HIV, Cellular respiration, Foreskin, Penis, Circumcision, Glans penis, Frenulum of prepuce of penis, Foreskin restoration

150

The traditional surgical approach to penile fracture is to perform a circumferential subcoronal degloving incision emergently to repair the injury. This approach necessitates circumcision to avoid foreskin complications. We present four men who had a delayed foreskin-sparing approach and discuss its advantages.

Concepts: Foreskin, Penis, Circumcision, Glans penis, Masturbation, Frenulum of prepuce of penis, Phimosis, Foreskin restoration

141

Genital injury can occur at any age of life but is most common in the pediatric population. Hair-tourniquets and circumcision procedures are the most common causes of penile injury in children. Foreskin trauma, aside from zipper related injuries, is sparsely reported. We describe the case of an 8-year-old male who presented with foreskin entrapment caused by bathing suit mesh. Management and literature review are discussed.

Concepts: Foreskin, Penis, Physical trauma, Circumcision, Glans penis, Masturbation, Frenulum of prepuce of penis, Foreskin restoration

58

WHAT’S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The sensitivity of the foreskin and its importance in erogenous sensitivity is widely debated and controversial. This is part of the actual public debate on circumcision for non-medical reason. Today some studies on the effect of circumcision on sexual function are available. However they vary widely in outcome. The present study shows in a large cohort of men, based on self-assessment, that the foreskin has erogenous sensitivity. It is shown that the foreskin is more sensitive than the uncircumcised glans mucosa, which means that after circumcision genital sensitivity is lost. In the debate on clitoral surgery the proven loss of sensitivity has been the strongest argument to change medical practice. In the present study there is strong evidence on the erogenous sensitivity of the foreskin. This knowledge hopefully can help doctors and patients in their decision on circumcision for non-medical reason. OBJECTIVES: To test the hypothesis that sensitivity of the foreskin is a substantial part of male penile sensitivity. To determine the effects of male circumcision on penile sensitivity in a large sample. SUBJECTS AND METHODS: The study aimed at a sample size of ≈1000 men. Given the intimate nature of the questions and the intended large sample size, the authors decided to create an online survey. Respondents were recruited by means of leaflets and advertising. RESULTS: The analysis sample consisted of 1059 uncircumcised and 310 circumcised men. For the glans penis, circumcised men reported decreased sexual pleasure and lower orgasm intensity. They also stated more effort was required to achieve orgasm, and a higher percentage of them experienced unusual sensations (burning, prickling, itching, or tingling and numbness of the glans penis). For the penile shaft a higher percentage of circumcised men described discomfort and pain, numbness and unusual sensations. In comparison to men circumcised before puberty, men circumcised during adolescence or later indicated less sexual pleasure at the glans penis, and a higher percentage of them reported discomfort or pain and unusual sensations at the penile shaft. CONCLUSIONS: This study confirms the importance of the foreskin for penile sensitivity, overall sexual satisfaction, and penile functioning. Furthermore, this study shows that a higher percentage of circumcised men experience discomfort or pain and unusual sensations as compared with the uncircumcised population. Before circumcision without medical indication, adult men, and parents considering circumcision of their sons, should be informed of the importance of the foreskin in male sexuality.

Concepts: Foreskin, Penis, Circumcision, Glans penis, Masturbation, Frenulum of prepuce of penis, Phimosis, Foreskin restoration

28

PURPOSE: Voluntary medical male circumcision (VMMC) has been shown to reduce men’s risk of HIV infection through heterosexual intercourse by ~60% in clinical trials and 73% in post-trial follow-up. In 2007, WHO and UNAIDS recommended countries with low circumcision rates and high HIV prevalence expand VMMC programs as part of their national HIV prevention strategies. Devices for adult/adolescent male circumcision could accelerate the pace of VMMC scale-up. Detailed penile measurements of African males are required for device development and supply size forecasting. MATERIALS AND METHODS: Consenting males undergoing VMMC at three health facilities in Tanzania’s Iringa region underwent measurement of the glans, shaft and foreskin of the penis. Age, Tanner stage, height and weight were recorded. Measurements were analyzed by age categories. Correlations between penile parameters and height, weight and body mass index (BMI) were calculated. RESULTS: In 253 Tanzanian males ages 10-47 years, the mean (SD) penile length of adults was 11.5 (1.6) cm; shaft circumference was 8.7 (0.9) cm; and glans circumference was 8.8 (0.9) cm. As expected, given the variability of puberty, measurements of younger males varied significantly. Glans circumference was highly correlated with height (r=0.80, p<.001) and weight (r=0.81, p<.001). Stretched foreskin diameter was moderately correlated with height (r=0.68, p<.001) and weight (r=0.71, p<.001). CONCLUSIONS: This descriptive study provides penile measurements of males seeking VMMC services in Iringa, Tanzania. It is the first study in a sub-Saharan African population that provides sufficiently detailed glans and foreskin dimensions to inform VMMC device development and size forecasting.

Concepts: HIV, Africa, Foreskin, Penis, Circumcision, Glans penis, Masturbation, Foreskin restoration

28

Although existing evidence is insufficient to recommend routine neonatal male circumcision, it is a procedure commonly performed in the United States. There are no commercially available infant penile models available for circumcision training. We improved the design of a low-fidelity penile model constructed of cocktail wieners following the one by Brill and Wallace (Fam Med 2007;39:241-243) and attached it to a high-fidelity infant simulator. Providing simulated movement and crying similar to what is encountered in routine newborn circumcisions create a more realistic training scenario.The study objectives were to (1) evaluate the educational experience of a simulated skill training program as perceived by participants based on a comparison scale and (2) evaluate the fidelity of the simulated model.

Concepts: Foreskin, Penis, Circumcision, Glans penis, Frenulum of prepuce of penis, Brit milah, Phimosis, Foreskin restoration

27

Plastic surgeons reconstruct hard and soft tissues in many parts of the human body. Penile reconstruction is unique in that the target tissue has to be soft but intermittently rigid. There are many ways to treat penile defects. The ideal reconstruction must take into considerations sensation, cosmesis, and erectile functions. There is limited literature available on the management of penile glans defect. In this report, we present the reconstruction of penile glans defect, after surgical excision of Bowen disease, using a bipedicled foreskin flap of bucket handle type. It is easy to perform and highly effective, and importantly, both cosmetic and functional outcomes at 1-year follow-up were quite satisfactory.

Concepts: Blood, Surgery, Foreskin, Penis, Circumcision, Glans penis, Frenulum of prepuce of penis, Foreskin restoration

27

The severe ischemia or necrosis of the glans penis is a rarely seen complication after circumcision. We report the case of a 7-year-old boy with severe glans penis ischemia occurring 24 hours after circumcision with local anesthesia (0.1% xylocaine containing ephedrine). His hemogram and levels of proteins C and S and fibrinogen were normal, but the D-dimer level was higher than normal (2.57 mg/L; normal level 0-0.5 mg/L). Normal blood flow was indicated on color Doppler ultrasonography. The severe ischemia in the glans penis was successfully treated with subcutaneous injection of enoxaparin (low-molecular-weight heparin) for 5 days, and the appearance of the glans was close to normal on the fifth day. The patient did not require any surgical intervention and was discharged without sequelae. As a result, we consider that ischemia of the glans penis may initially be managed with enoxaparin, especially in cases in which the D-dimer level is higher than normal.

Concepts: Surgery, Anesthesia, Local anesthesia, Penis, Local anesthetic, Glans penis, Foreskin restoration

26

Penile girth augmentation can be achieved by various techniques, among which are liposuction injection, synthetic grafts, and autologous grafts, with variable outcome, mostly related to viability and receptivity of the tissue used for augmentation. Flaps are considered superior to grafts considering their uninterrupted blood supply.

Concepts: Blood, Vagina, Penis, Perineum, Foreskin restoration, Penis enlargement, Phalloplasty

25

Cysts arising in the penis are uncommon and can be found anywhere from the urethral meatus to the root of the penis involving glans, foreskin, or shaft. Median raphe cysts account for the majority of penile cystic lesions reported in the literature. As their name suggests, they arise on the ventral midline of the penis that extends from the urethral meatus to the scrotum and perineum. Proposed hypotheses for their origin as well as their diverse morphology are discussed.

Concepts: Urethra, Penis, Male reproductive system, Glans penis, Erogenous zone, Foreskin restoration, Urinary meatus, Perineal raphe