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Circumcision and Premature Ejaculation!

Article · January 2017

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Samy Eleowa, MD,

Asst. Professor of Plastic Surgery

Faculty of Medicine - Al Azhar University, Cairo, Egypt.

Paper was presented in 45 annual meeting of

The ESPRS In Sharm Elshekh ,Egypt 2015

* Email: [email protected]. [email protected].

Premature ejaculation is a common sexual complaint. The causes of premature

ejaculation are unclear. Many theories have been suggested, but there is little evidence

to support any of these theories makes it good fields for research, one of these theories

are elevated penile sensitivity. So the question is what is the source of sensitive skin in

the penis? My suggestion is due to increase area of sensitive reflected inner mucosal

layer caused by mal circumcision who improved after application of local anesthesia so

my idea is to remove the sensitive skin and I replaced it by advancement of penile skin

and record the results.12 patients over 10 years period were identified and reviewed

retrospectively.All Patients were complaining of premature ejaculation, I prescribed

the local anesthetic agent for all patients as test and all patients observed good results

after that test. Removing of the Reflected internal mucosal layer and advance the

remaining skin of the penis to suturing it to remaining part of the skin at the corona.

Patients were followed up post-operative and no sexual intercourse until wound healing

was observed. Later on I asked the patients about the sexual performance especially

time and satisfaction after intercourse, and compared the effect of the operation and the

use of local anesthesia and all data were recorded. Results All patients describe a good

sexual performance as regard the time and satisfaction after intercourse. With the good

effect of the operation than the use of local anesthesia 9(75%) patients'. surgical

1
removal of sensitive reflected internal mucosal layer make it more practical with sexual

life.

Background:

What is premature ejaculation (PE)?

Ejaculatory control issues have been documented for more than 1,500 years.

The Kamasutra, the 4th century Indian sex handbook, declares: "Women love the man

whose sexual energy lasts a long time, but they resent a man whose energy ends quickly

because he stops before they reach a climax. [1, 4]

It has also been called early ejaculation, rapid ejaculation, rapid climax, premature

climax, and (historically) ejaculation praecox.

There is no uniform cut-off defining "premature," but a consensus of experts at the

International Society for Sexual Medicine (ISSM) endorsed a definition including

"ejaculation which always or nearly always occurs prior to or within about one minute.

In 2014, (ISSM) defined PE as a male sexual dysfunction characterized by: Ejaculation

which always or nearly always occurs prior to or within about 1 minute of vaginal

penetration; or inability to delay ejaculation on all; or nearly all vaginal penetrations or

negative personal consequences, such as distress, bother, frustration and/or the

avoidance of sexual encounters. [2]

Premature ejaculation is a common sexual complaint. Estimates vary, but as many as 1

out of 3 men say they experience this problem at some time. The causes of premature

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ejaculation are unclear. Many theories have been suggested, but there is little evidence

to support any of these theories. Several physiological mechanisms have been

hypothesized to contribute to causing premature ejaculation including serotonin

receptors, a genetic predisposition, elevated penile sensitivity, and nerve conduction

atypicalities.[3]

The application of local anesthetics agents to the penis to delay ejaculation, first

described over 60 years ago, continues to be used both in medical practice and as an

'over-the-counter' remedy. [4, 5]

Circumcision;

Circumcision is probably the world's most widely performed procedure, approximately

one-third of males worldwide are circumcised, most often for non-medical reasons.

Although no consensus exists among scholars regarding the origins of circumcision,

some have suggested that this procedure likely originated in Egypt some 15,000 years

ago. Egyptian mummies and wall carvings discovered in the 19th century offer some of

the earliest records of circumcision dating this procedure to at least 6000 years BC.

[6,7]

The penile skin is continuous with that of the lower abdominal wall. Distally, the penile

skin is confluent with the smooth, hairless skin covering the glans. At the corona, it is

folded on itself to form the prepuce (foreskin), which overlies the glans.[8]

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The prepuce is lined up by an external keratinized layer and an internal mucosal layer.

The prepuce provides protection to the glans from dryness and keratinization.

Innervation of the prepuce is complex, the dorsal nerve of the penis and branches of the

perineal nerve provide somatosensory input, whereas autonomic innervation comes

primarily from the pelvic plexus. [8]

Circumcision of males involves removing the fold of skin [prepuce (foreskin)] that

normally covers the glans penis. [6,7] In some situation the surgeon remove the

external keratinized layer more than internal mucosal layer so it reflected on the shaft of

the penis as in picture no (1)

Scar of Circumcision

Reflected internal mucosal

Fig (1) Topography of the penis after circumcision.

My suggestion is due to increase area of sensitive reflected skin caused by mal

circumcision who improved after application of local anesthesia so my idea is to

remove the sensitive skin and I replaced it by advancement of penile skin and record the

results.

Patients and Methods :-

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All the patients are married and patients’ age was range between 28 to 42 years.

Patients with history of any medical problem such as blood diseases, cardiac diseases,

liver diseases, endocrine diseases, respiratory troubles, and psychological problem

were excluded from the study. All Patients were complaining of premature ejaculation

in the form of ejaculation which always or nearly always occurs prior to or within

about one minute or inability to delay ejaculation on all; or negative personal

consequences. Andrological and psychiatric consultation was done to search for other

possible cause of premature ejaculation. I prescribed the local anesthetic agent for all

patients to be used 40 minutes before intercourse as (therapeutic test) and all patients

observed good results after that test. Checking the patient’s levels of serum

testosterone (free and total) and prolactin may be appropriate if premature ejaculation

is observed in conjunction with an impotence problem. If depression or other

conditions coexist, laboratory studies specific to depression or to another medical or

psychological problem are appropriate. Other conditions that should be considered in

making the diagnosis of premature ejaculation include the following: Severely delayed

orgasm in the female partner, adverse effect from a psychotropic drug presence of

preejaculate erectile dysfunction. Informed write consent from all patient after explain

the idea and the target of the procedure.

Technique: -

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Under general anesthesia or penile block or spinal or epidural anesthesia after

sterilization: type of anesthesia done after discussion between the patients and

anesthesiologist and patients preference, marking the 0.3 to 0.5 cm from the corona of

the penis and at the previous scar of circumcision followed by removing of the skin

between the marking and degloving the penis to advance the remaining skin of the

penis and suturing it to remaining part of the skin at the corona end by dressing.

Patients were followed up post-operative and no sexual intercourse until wound healing

was observed. Later on I asked the patients about the sexual performance especially

time and satisfaction after intercourse, and compared the effect of the operation and the

use of local anesthesia and all data were recorded.

Results:

12 patients over 10 year’s period were identified and reviewed retrospectively. Under

general anesthesia one patient, penile block five patients, spinal or epidural anesthesia

six patients. There is no post-operative complication observed in all patients. With good

wound healing (no infection no dehiscence) with good acceptable scar. All patients

describe a good sexual performance as regard the time and satisfaction after intercourse.

As regard the comparison between the effect of the operation and the use of local

anesthesia 9(75%) patients' showed the effect of the operation is better than effect of

use local anesthesia cream while 3((25%) patients' showed the effect of the operation is

same effect of use local anesthesia cream.

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Case

a b c

d e f

Fig 2 a) Preoperative. b) Skin marking. {c) and d)} remove reflected internal

mucosal layer e) immediate postoperative f) 2 week postoperative

Discussion:

Premature ejaculation is the most common sexual disorder in men younger than 40

years, [1] PE can be lifelong or acquired. With lifelong PE the patient has experienced

PE since first beginning coitus, while acquired PE the patient previously had successful

coital relationships and only now has developed PE.

In this study we deal with the lifelong PE patients because the patient characteristics in

lifelong PE can include the following: Psychological difficulties; deep anxiety about

sex in patients with lifelong PE inquire about the following:- Previous psychological

difficulties, early sexual experiences, family relationships during childhood and

7
adolescence, Peer relationships, General attitude toward sex, Context of the event (eg,

marital versus non-marital), Sexual attitude and response of the female partner, level of

involvement of the sexual partner in treatment; Clues from these and similar questions

usually point toward causative factors that may be addressed specifically with therapy.

So consultation by Andrological doctors is very important.[3]

In this study all patients exhausted from medical treatment as following

Nonpharmacologic therapy which include efforts to relief of underlying pressure on the

male, Sex therapy (eg, instruction in the stop-start or squeeze-pause technique, second

attempt at coitus. Pharmacologic therapy included the following: Topical desensitizing

agents (eg, lidocaine and prilocaine) for the male which was used as test in all patients,

with significant improvement in all patients ; but become impractical .Selective

serotonin reuptake inhibitor therapy .Phosphodiesterase type 5 inhibitor therapy Other

agents (eg, pindolol or tramadol).[5]

In Korea and other areas of the Far East, SS (Super Secret) cream (a combination of 9

ingredients, mainly herbal) has been shown to desensitize the penis, decrease the

vibratory threshold, and help men with premature ejaculation to delay their ejaculatory

response significantly. [9] This preparation is not yet approved by the US Food and

Drug Administration (FDA), but simple combinations of lidocaine cream or related

topical anesthetic agents can be used with similar effects. These combinations are safe

as long as the patient has no history of allergy to the substance. [10, 11] But it is

8
impractical to use the local anesthesia every time and time interval between the

application of local anesthesia cream and effect of it may change the mood.

In this study all patients with clinical examination of the penis showed increase the area

between the corona and scar of the circumcision it takes a different color which is a

reflected internal mucosal layer after circumcision which is very sensitive and has

abundant Corpuscular receptor (Meissner corpuscle) and Schwann cells and Merkel

cells within the basal layer of the skin [8] So these patients respond well to local

anesthesia . the question is what happens when I remove the sensitive reflected skin

caused by mal circumcision and advancement of penile skin which is less sensitive?

The results showed all patients describe a good sexual performance as regard the time

and satisfaction after intercourse: the explanation of these is the possibility of remove

the sensitive skin. There is no previous data available till now about this surgical

intervention to solve the problem of PE.

As regard the comparison between the effect of the operation and the use of local

anesthesia 9(75%) patients' showed the effect of the operation is better than effect of

use local anesthesia cream while 3((25%) patients' showed the effect of the operation is

same effect of use local anesthesia cream. So with surgical removal of sensitive

reflected internal mucosal layer make it more practical with sexual life.

Conclusion: In spite of premature ejaculation is a common sexual complaint the

exact cause is unclear. This study showed that the sensitivity of reflected internal

9
mucosal layer caused by mal circumcision is a cause of premature ejaculation and with

surgical removal of this layer improve the condition and make it more practical with

sexual life. Special attention during circumcision to avoid cutting of outer skin more

than inner skin which is more sensitive and can cause premature ejaculation

References

1. Ferri FF. Ejaculation and orgasm disorders. In: Ferri's Clinical Advisor 2017.

Philadelphia, Pa.: Elsevier; 2017. https://www.clinicalkey.com. Accessed Sept.

21, 2016.

2. Sharlip, I. D., Hellstrom, W. J., & Broderick, G. A. (2008). The ISSM definition

of premature ejaculation: A contemporary, evidence-based definition. Journal of

Urology, 179(suppl), 340, abstract 988.

3. Althof SE, McMahon CG, Waldinger MD, Serefoglu EC, Shindel AW, Adaikan

PG, et al. An update of the International Society of Sexual Medicine's guidelines

for the diagnosis and treatment of premature ejaculation (PE). J Sex Med. 2014

Jun. 11 (6):1392-422

4. Graziottin, A.; S. Althof (2011). "What Does Premature Ejaculation Mean to the

Man, the Woman, and the Couple?". Journal of Sexual Medicine. 8: 304–

9. doi:10.1111/j.1743-6109.2011.02426.x. PMID 21967392.

5. Saitz TR, et al. Advances in understanding and treating premature ejaculation.

Nature Reviews Urology. 2015;12:629.

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6. Alanis MC, Lucidi RS (May 2004). "Neonatal circumcision: a review of the

world's oldest and most controversial operation". Obstet Gynecol Surv. 59(5):

379–95. doi:10.1097/00006254-200405000-00026. PMID 15097799

7. Pinto K (August 2012). "Circumcision controversies". Pediatric clinics of North

America. 59 (4): 977– 986. doi: 10.1016/j.pcl.2012.05.015. PMID 22857844.

8. Cold C.R and Taylor J.R.: the prepuce; British Journal of urology 1999;83

supple 1:34-44.

9. Choi HK, Jung GW, Moon KH, et al. Clinical study of SS-cream in patients with

lifelong premature ejaculation. Urology. 2000 Feb. 55(2):257-61.

10. Pu C, Yang L, Liu L, Yuan H, Wei Q, Han P. Topical anesthetic agents for

premature ejaculation: a systematic review and meta-analysis. Urology. 2013

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11.Busato W, Galindo CC. Topical anaesthetic use for treating premature

ejaculation: a double-blind, randomized, placebo-controlled study. BJU Int.

2004 May. 93(7):1018-21.

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