(I) Foreskin & Development

Ever since the institutionalization of circumcision in America, the foreskin has been deemed as “redundant” – a risk” rather than essential. And to this day the healthcare system gives no value to the foreskin, why its removal is equated to a benefit rather than a harm.


I.1 – Foreskin Is Not “Excess” Of Skin

Anatomy of the Intact Penis

Foreskin is the double-layered fold of skin and soft muscle tissue on the distal end of the penis that envelops the glans and meatus. Foreskin is made up of an outer layer (continuation to skin on shaft) and inner layer made up of a mucous membrane, connected by a unique structure called the ridged band (preputial ring). Another essential component is the frenelum that tethers foreskin to the underside of glans up to the meatus, while providing proper tension.

Foreskin accounts for as much as 1/2 of the entire penile skin, and a fully-developed adult foreskin (if it were spread flat) is equivalent to the size of a postcard (15 square inches)[1].

Essential For Sexual Stimulation

Foreskin is rich in blood vessels and nerve endings – 10,000 to 20,000 specialized erogenetic nerve endings to be exact, that in conjunction with the foreskin unique “gliding” mechanism are essential for sexual stimulation[2][3].

Protection

Foreskin protects the glans and meatus throughout life from mechanical and chemical irritation – from diaper use in infancy to chaffing from clothing for the remainder of life. While the mucous membrane possesses langerhans cells essential to the immune system, including the production of Langerin – a natural barrier to HIV-1[4][5].

Moisture & Lubrication

The mucous membrane provides proper hydration, while its sebaceous glands produce oils that provide moisture and natural lubrication.


I.2 – Foreskin Development

A 2004 survey of American medical textbooks found that 71% of the primary depiction of the penis was anatomically incorrect, in its circumcised form – as if it were its natural state; while the foreskin was generally cited only in the context of circumcision. The survey concluded that medical students are being miseducated on fundamental anatomy.

And such widespread distortion of the penile anatomy reflects in the  misguided advice from medical professionals on the otherwise natural foreskin development and its function.

“Non-Retractile” State

Foreskin is fused by synechia to the glans at birth – a transient state known as “non-retractile”. As the penis follows its natural development, the foreskin will widen and gradually detach from the glans – a process that can take up to puberty to settle. And unless complications arise, the foreskin shouldn’t be subject to forced dilation and certainly not circumcision – which has been the mainstay of treatment for foreskin-related conditions.

From several studies abroad (in Spain, China, Japan)[6] on thousands of boys raging from newborns to 18 years of age, found that bout 10% of boys are retractile by age 1, and that 50% become retractile by age 10. But it isn’t until puberty (as boys reach sexual maturity) that most become retractile. By age 17, 99% of boys will be fully retractile[7].

Phimosis

Phimosis is an acquired pathological condition that results in scarring of the preputial ring preventing retraction past the glans[7]. It is distinct from normal “non-retractile” state described above, and should be distinguished by the following features:

  • Obvious ring of scar tissue visible at preputial ring.
  • Previously retractable foreskin becomes non-retractable.
  • Foreskin is not retractable at the conclusion of puberty (by age 17).

The misconception in western medicine  that phimosis is physiological – meaning that males are born with it, has led to its overdiagnosis, especially in America where they believe boys must be retractile by age 3.

But even in countries like England where routine circumcision is uncommon, phimosis is often misdiagnosed. A 2000 study[8] found that although the proportion of English boys being circumcised for medical reasons fell from 35% in the early 1930’s to 6.5% by the mid-1980’s, at the time two-thirds underwent the procedure unnecessarily.

What Causes Phimosis?

One of the main known causes of phimosis is actually constant forceful foreskin retraction[7] at an early age by parents, guardians, and medical professionals seeking to “inspect” or “clean” an otherwise normal “non-retractile” foreskin that shouldn’t be tampered with, leading to injury that can cause scar tissue and adhesions.

There is also a rare infection called balanitis xerotica obliterans (BXO) – also referred as lichen sclerosus (LS), that can cause rapid scarring on the foreskin, having an inflamed appearance.

And a topic often dismissed is unusual masturbatory practices – such mechanical stimulation without the use of hands as well as no masturbation at all, that can negatively affect the normal foreskin development. A 1997 study[9] among males aged 18-21 found that phimosis was improved in less than a month by practicing conventional masturbation that mimicked the dynamics of coitus.

Severity Classification

Given that phimosis in itself is a vague medical term, there is no formal classification for the different types of its severity – often simply referred as “mild” or “severe” cases.

An optimal (“normal”) foreskin retraction is when there is no tightness or discomfort and foreskin sits loosely behind glans; while any degree of constricted retraction may constitute a type of phimosis. The following classification (pictured) shall serve as a general reference to identify the most common severity types (in erect state):

  • Type 1 – Full retraction, but tight behind the glans
  • Type 2 – Partial retraction (50%), with partial glans exposure
  • Type 3 – Partial retraction (25%), with minimal glans exposure
  • Type 4 – Slight retraction (10% or less), with meatus visible
  • Type 5 (not shown) – No retraction possible, with meatus barely visible – often referred as “pinhole phimosis”

This classification shouldn’t be taken as an absolute indicator for variants of phimosis, which are influenced by various factors such: anatomical features (foreskin and glans size in proportion to penis), presence of frenulum breve, cause of condition and its prominence in flaccid state.

When Treatment Is Warranted

Phimosis has been deemed as a condition that must be treated, but unless symptomatic, it should be left alone. Though if phimosis warrants treatment, there should be non-invasive options presented by a medical professional, followed up by surgery when all other options fail:[10]

  • Application of topical steroid cream (0.05% betamethasone) & gentle stretching[7][11] – aimed at thinning of scarring on the preputial ring. Cream should be applied 2-3 times a day, followed by gentle stretching. If treatment is responsive after a month’s trial, it shall continue for another two or more.
  • Manual stretching exercises[11][12] – aimed at enlarging the preputial ring by tissue expansion (known as “mitosis”). This method requires no prescription or use of creams, and should only be suitable for teenagers and adults.
  • Preputioplasty[13]minimally-invasive surgery that consists of incision(s) to enlarge the preputial ring without loss of tissue, while preserving all foreskin functionality. Unfortunately this procedure is rarely offered as an alternative to circumcision.
  • Dorsal slit[14] – as name suggests, it is a single incision to the dorsal portion of the preputial ring. Its application is mostly on cases that require emergency treatment (paraphimosis, urinary rentention due to severe balanitis) rather than long term solution. And since the incision leaves a “v-shaped” opening behind (with rather undesirable cosmetic results), its demand is minimal.

Related Conditions

Frenulum Breve – also known as “short frenulum” that can restrict foreskin retraction. In severe cases it may bend glans downwards, causing discomfort during erections. This condition is often mistaken for phimosis when foreskin isn’t fully retractile yet. But just like phimosis, the first line of treatment should be manual stretching exercises[12], followed by surgery[15] when non-invasive options fail:

  • Frenuloplastyminimally-invasive surgery that consists of incision(s) to elongate frenelum. And the results are generally satisfactory.
  • Frenulectomy (or Frenulotomy) surgery that consists of the amputation of frenulum in its entirety. Also commonly used to remove remnants of frenulums that had been injured.

Paraphimosis occurs when the foreskin becomes stuck behind the glans due to a forceful retraction when foreskin isn’t fully retractile yet. The foreskin then becomes oedematous (swollen with fluids) which makes it difficult to be retracted back over the glans.

This is a temporary condition but it is considered an urological emergency that poses a risk of preputial necrosis if left untreated. As with all foreskin-related complications, non-invasive treatment should be exhausted first before considering surgery:[7][10]

  • Manual reduction by gentle squeezing with steady pressure and held for at least 2-3 minutes. 
  • Application of ice packs to reduce swelling.
  • Firm compression bandage wrapped over the affected area, starting at tip of the penis. Must be applied for at least 10-15 minutes, and re-applied for another 15 minutes if first attempt failed.
  • Injection of hyaluronidase, which is an enzyme that helps to reduce swelling.
  • Puncturing with a needle to extract fluid, followed by manual compression.
  • Dorsal slit[14] may be used as an emergency treatment to relieve the obstruction. But no other surgery is indicated to treat paraphimosis.

Misdiagnose Gone Wrong

David Reimer (1965-2004)

The most infamous case of a “phimosis” misdiagnose is the one of the identical twin brothers David and Brian Reimer[16], born August 22, 1965 in Winnipeg, Canada. Their parents concerned for what they thought was “abormal urination”, had them examined when they were just 6 months old and both were misdiagnosed with “phimosis”. Naturally circumcision was recommended, and both boys were scheduled to have surgery on April 27, 1966, when they were just seven months old. The urologist in charge chose an unconventional method of electrocauterization for the procedure, which went bizarrely wrong, burning David’s penis beyond repair. On an appearance by David’s mother Janet on the The Oprah Winfrey Show in 2000[17], she recalled David’s penis looking like a piece of “sizzling skin” the day of the accident.

Brian was spared from the surgery, and his “phimosis” resolved on its own later on. David’s parents, concerned of his future took him to Johns Hopkins Hospital in Baltimore in early 1967 to see John Money, a psychologist and pioneer of gender identity. Money and the Hopkins team persuaded David’s parents to sex reassignment surgery, and at the age of 22 months David underwent a bilateral orchidectomy; in which his testes were surgically removed and a rudimentary vulva was fashioned.

David was raised as female and given the name Brenda. Having to experience a traumatic childhood under questionable “treatments” – one of them being forced to “rehearse” sexual acts with his twin brother, to later on discover his real birth gender at the age of 14, he committed suicide by gunshot at the age of 38 in 2004. Twin brother Brian who had been battling with schizophrenia committed suicide by overdose of medication at the age of 36 in 2002.

And to think all of this tragedy was the result of a misdiagnose that led to an unnecessary botched circumcision.


References:

[1] CIRP “The Penis and Foreskin: Preputial Anatomy and Sexual Function”

[2] CIRP “Anatomy of The Penis, Mechanics of Intercourse”

[3] C.J. Cold/J.R. Taylor “The Prepuce” – British Journal of Urology, Volume 83 (January 1999)

[4] Fleiss P, Hodges F, Van Howe RS: “Immunological Functions of The Human Prepuce” – Sexually Transmitted Infections (London), Volume 74 (October 1998)

[5] “Langerin is a Natural Barrier to HIV-1 Transmission by Langerhans Cells” – Nature Medicine, Volume 13 (March 2007)

[6] Julio C. Morales Concepción: “The Need of Circumcision or Prepuce Dilation / A Study with 1200 Boys” – Archivos Españoles de Urología (July/August 2008)

Ming-he Wang: “Analysis of Shape and Retractability of the Prepuce in 1,015 Chinese Boys Aged From 0 to 18 Years Old” – Zhonghua Nan Ke Xue (March 2006)

H Kayaba: “Analysis of Shape and Retractability of the Prepuce in 603 Japanese Boys” – J Urol. (November 1996)

[7] Victorian Paediatric Clinical Network “The Penis and Foreskin”

[8] A M K Rickwood, S E Kenny, S C Donnell: “Towards Evidence Based Circumcision of English Boys: Survey of Trends in Practice” – BMJ (September 2000)

[9] Michel Beaugé (Specialist Male Sexual Medicine): “The Causes of Adolescent Phimosis” – British Journal of Sexual Medicine (September/October 1997)

[10] Doctors Opposing Circumcision “Conservative Treatment Alternatives”

[11] NHS (UK) Coventry and Rugby Clinical Commision Group “Phimosis and Circumcision (Adult)”

[12] Tight Foreskin “How To Treat My Tight Foreskin Without Surgery”

[13] Tight Foreskin “Preputioplasty”

[14] Tight Foreskin “Dorsal Slit”

[15] Tight Foreskin “Frenuloplasty/Frenulectomy”

[16] WikipediA – David Reimer

[17] The Oprah Winfrey Show (2000)