I read with interest this article by Kigozi et al. on sexual satisfaction; the article was well written and extremely interesting. However I noted that the technique used in Rakai is the sleeve method of male circumcision. The other two reported randomized control studies used the forceps-guided method [2,3]. The WHO manual for district surgery recommends the dorsal-slit method. The draft WHO training manual on male circumcision recommends all three methods as suitable for male circumcision when dealing with large populations for HIV prevention .
There is a significant anatomical difference in the technique used in the three methods which is likely to have an effect on sexual satisfaction. In Lusaka, at the University Teaching Hospital, we use the dorsal-slit method; with this technique all the layers of the skin are removed, including Buck’s fascia, and this is also true of the forceps-guided method. The sleeve method is a subcutaneous circumcision, which leaves Buck’s fascia and spares the cutaneous nerves of the dorsal nerve to the penis. This would explain the finding in the study of no significant difference in sexual satisfaction in the control and study arms. The conclusion made by the study ‘circumcision does not have any significant effect on sexual function’, although valid for the sleeve method, might not be true for the other methods. Anecdotal evidence from our site, where we have done 1800 male circumcisions by the dorsal-slit method, suggests an improvement in sexual satisfaction, particularly in premature ejaculation .