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Concept: Glans penis

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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

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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

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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

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To assess the correlation between penile hypersensitivity and premature ejaculation (PE), a total of 420 consecutive subjects attending our andrologic clinic for suspected PE were enrolled. The entire cohort was asked to complete the self-report intravaginal ejaculation latency time (IELT) by stopwatch. According to the IELT, the subjects were classified into 3 groups. Vibratory thresholds were recorded at the glans penis and penile shaft using a biothesiometer. We found that vibratory thresholds in the glans penis and penile shaft were significantly lower in both mild and severe PE group than in the control group (3.81 ± 0.57 and 3.54 ± 0.43 vs 4.73 ± 0.77 for glans penis p = 0.000; 3.64 ± 0.52 and 3.37 ± 0.50 vs 4.62 ± 0.69 for penile shaft p = 0.002). The vibratory threshold decreased as the disease aggravated. In the mild and severe PE groups, a significant positive correlation was detected between the mean values of IELT and the vibratory thresholds. Furthermore, in the receiver operating characteristics curve analysis, the area under the curve of the glans penis and penile shaft vibratory thresholds predicting severe PE were 0.852 and 0.893 respectively. Our study established a dose-dependent association between penile vibratory threshold and PE. Therefore, the vibratory threshold can serve as a potential marker for predicting the severity of PE.

Concepts: Andrology, Receiver operating characteristic, Orgasm, Ejaculation, Penis, Premature ejaculation, Glans penis, Intravaginal ejaculation latency time

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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

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Sexual transmission of HIV requires exposure to the virus and infection of activated mucosal immune cells, specifically CD4(+) T cells or dendritic cells. The foreskin is a major site of viral entry in heterosexual transmission of HIV. Although the probability of acquiring HIV from a sexual encounter is low, the risk varies even after adjusting for known HIV risk factors. The genital microbiome may account for some of the variability in risk by interacting with the host immune system to trigger inflammatory responses that mediate the infection of mucosal immune cells. We conducted a case-control study of uncircumcised participants nested within a randomized-controlled trial of male circumcision in Rakai, Uganda. Using penile (coronal sulcus) swabs collected by study personnel at trial enrollment, we characterized the penile microbiome by sequencing and real-time PCR and cytokine levels by electrochemiluminescence assays. The absolute abundances of penile anaerobes at enrollment were associated with later risk of HIV seroconversion, with a 10-fold increase in Prevotella, Dialister, Finegoldia, and Peptoniphilus increasing the odds of HIV acquisition by 54 to 63%, after controlling for other known HIV risk factors. Increased abundances of anaerobic bacteria were also correlated with increased cytokines, including interleukin-8, which can trigger an inflammatory response that recruits susceptible immune cells, suggesting a mechanism underlying the increased risk. These same anaerobic genera can be shared between heterosexual partners and are associated with increased HIV acquisition in women, pointing to anaerobic dysbiosis in the genital microbiome and an accompanying inflammatory response as a novel, independent, and transmissible risk factor for HIV infection.IMPORTANCE We found that uncircumcised men who became infected by HIV during a 2-year clinical trial had higher levels of penile anaerobes than uncircumcised men who remained HIV negative. We also found that having higher levels of penile anaerobes was also associated with higher production of immune factors that recruit HIV target cells to the foreskin, suggesting that anaerobes may modify HIV risk by triggering inflammation. These anaerobes are known to be shared by heterosexual partners and are associated with HIV risk in women. Therefore, penile anaerobes may be a sexually transmissible risk factor for HIV, and modifying the penile microbiome could potentially reduce HIV acquisition in both men and women.

Concepts: HIV, Immune system, Inflammation, Sexual intercourse, Foreskin, Penis, Circumcision, Glans penis

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PURPOSE: Men are particularly concerned about pain after circumcision. Concerns about pain can be a reason to decline surgery. Our aim was to assess the severity of postoperative pain and to investigate factors that may influence postoperative pain. MATERIALS AND METHODS: This was a prospective observational cohort study on patients undergoing circumcision. Patients were asked to fill in a questionnaire using visual analogue scales for pain (severity 0-10) on days 1,2,3,7, 21 and to record analgesia used, complications and time off work. Other data recorded were patient age, clinical indication of surgery, foreskin retractility, presence of adhesions and histology. RESULTS: 112 of 211 questionnaires were returned (53.1%). Mean age of patients was 46.4yrs. Commonest clinical indication for circumcision was phimosis (75%). Postoperative pain was scored as mild to moderate (means: 2.4 on days 1-3, 2.1 on day 7 and 0.5 on day 21). Patients younger than 35 yrs of age (p=0.025) and patients with wound infections (p=0.036) had higher pain scores. Only 11 patients (9.8%) had severe pains at any time during the recovery of which 8 had wound problems. The average time off work in the employed population was 6.6 days (SD-6.5), 5 days for light work and 11 days for heavy physical activity. CONCLUSION: Pain following adult circumcision under general anaesthetic administration with intra-operative penile block administration is mild to moderate. Severe pain is rare and mostly related to complications. Younger patients have more discomfort in general.

Concepts: Cohort study, Pain, Foreskin, Penis, Circumcision, Glans penis, Phimosis, Preputioplasty

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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

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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

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Abstract Objective. The etiology of premature ejaculation (PE) is unknown. Over the past two decades several studies have suggested that lifelong and acquired PE may be caused by somatic disorders and/or neurobiological disturbances. One controversial factor is the effect of circumcision on ejaculation. This prospective study investigated the relationship between postcircumcision penile mucosal cuff length, circumcision scar thickness and the PE syndromes. Features of PE patients were compared with those of a normal healthy control (NHC) group. Material and methods. In total, 160 circumcised men were studied: 80 men with PE and 80 men in the NHC group. The following data and measurements were evaluated: age, type of PE syndrome, intravaginal ejaculation latency time (IELT), circumcision scar thickness and postcircumcision mucosal cuff length. Results. In terms of the mean IELT, a statistically significant difference was detected between the PE syndromes (p < 0.05), and between the PE patients and the control group (p < 0.05). Among the four PE syndromes, there was no significant difference related to the mean mucosal cuff length and mean circumcision scar thickness (p > 0.05). No significant difference was observed between the two groups for mean mucosal cuff length (p > 0.05) or mean circumcision scar thickness (p > 0.05). Conclusion. In this study, no relationship was observed between PE and postcircumcision penile mucosal cuff length and circumcision scar thickness. Further studies are required to evaluate the positive and negative effects of circumcision on PE syndromes.

Concepts: Statistical significance, Foreskin, Ejaculation, Penis, Premature ejaculation, Circumcision, Glans penis, Intravaginal ejaculation latency time