Role of Postcircumcision Mucosal Cuff Length in Lifelong Premature Ejaculation: A Pilot Study
Seyed Reza Hosseini, MD, Sina Hospital, Hassan Abad square, Hafez Street, Tehran, 113674911, Iran. Tel: (+98) 2166701041; Fax: (+98) 2166737741; E-mail: firstname.lastname@example.org
Introduction. Premature ejaculation (PE) is the most prevalent sexual dysfunction among men. Several theories about its etiology have been made. One of the conflicting factors is the effect of circumcision on ejaculation, and there are some concerns about leaving so much mucosa during circumcision.
Aim. In our study the relationship between mucosal cuff length and PE was investigated.
Methods. Eighty-four circumcised men were studied, including 42 men with PE and 42 men without. The following data and measurements were investigated: age, education, smoking, intravaginal ejaculation latency time (IELT), circumcision timing, stretched penile, penile skin, and mucosal cuff lengths.
Main Outcome Measure. Penile, mucosal cuff, and penile skin lengths, the IELT.
Results. The mean penile, mucosal cuff, and penile skin lengths were 121.1 ± 12.8, 15.4 ± 4.8, and 80.8 ± 21.0 mm in PE men, respectively, and were 130.1 ± 10.4, 14.7 ± 3.4, and 88.7 ± 12.2 mm in the control group, respectively. No statistically significant differences were seen regarding the length of the penis (P = 0.80), mucosal cuff (P = 0.84), and penile skin (P = 0.99). The two groups were not different regarding education (P = 0.90), smoking (P = 0.70), and circumcision timing (P = 0.65).
Conclusion. Postcircumcision mucosal cuff length is not a risk factor for PE. Hosseini SR, Khazaeli MH, and Atharikia D. Role of postcircumcision mucosal cuff length in lifelong premature ejaculation: A pilot study. J Sex Med 2008;5:206–209.
Premature ejaculation (PE) is the most prevalent sexual dysfunction in every country, and a prevalence of more than 21% seems a realistic figure . Despite its prevalence, there is no consensus on the definition, etiology, and treatment. The following multivariate definition of PE is proposed: “Premature ejaculation is persistent or recurrent ejaculation with minimal stimulation before, on, or shortly after penetration and before the person wishes it, over which the sufferer has little or no voluntary control which causes the sufferer and/or his partner bother or distress”. Regarding etiology, several psychogenic and biogenic causes are proposed . Evidence supports biologic mechanisms, associated with neurotransmitters such as norepinephrine, serotonin, oxytocin, Gamma-amino-butyric acid, and nitric oxide, as well as the hormone estrogen, play central roles in ejaculation, and subsequently may mediate PE. Recent data also suggest that psychogenic factors include high level of any experience by some men with PE. The pathophysiology of both lifelong and acquired PE appears to be both neurobiogenic and psychogenic . One of the conflicting factors is the effect of circumcision on ejaculation [5–7], and there are some concerns about leaving so much mucosa during circumcision, for fear of later occurrence of PE.
Circumcision is a routine practice in Islamic countries, so we have investigated the relationship of postcircumcision mucosal cuff length and PE.
From January 2006 to June 2006, all men with the complaint of lifelong PE who came to our outpatient clinic (Sina University Hospital) were investigated. Almost all patients had sexual intercourse 1–2 times per week with no weak erection. Circumcised men with intravaginal ejaculation latency time (IELT) of less than 1 minute were included . IELT was defined as the time between the start of vaginal intromission and the start of intravaginal ejaculation. IELT was measured according to stopwatch, and women partners were responsible for recording the time. There was a baseline period during which patients and their partners were taught to record the IELT. The exclusion criteria were use of drugs with side effects on ejaculation, penis anomalies and surgeries, lower urinary tract symptoms including prostatitis, psychological diseases, and erectile dysfunction. Control age-matched men with IELT greater than 1 minute from both the inpatient and outpatient settings who recruited voluntarily were also investigated.
History, physical examination, and measurements were conducted for all men, and the following data were investigated: age; education (college educated or not); smoking; IELT according to stopwatch assessment; circumcision timing (neonatal or not); and length of the stretched penis, mucosal cuff, and penile skin. Measurement was undertaken by a 30-cm ruler, with millimeter divisions in upright position on the dorsal aspect of the fully stretched penis. Penis, mucosal cuff, and penile skin lengths were considered, respectively, from the root of the penis to the meatus, from the corona to the mucocutaneous junction, and from the mucocutaneous junction to the penis base. We did not evaluate penile sensitivity in our patients.
Chi-square, Fisher's exact test, and independent samples test were used for comparison of variables between the groups. Kolmogorov-Smirnov test was used to demonstrate normal distribution of measurements in both groups.
Eighty-four men were investigated, including 42 men (mean age 34.2 ± 10.0 years) with PE and 42 men (mean age 36.5 ± 9.1 years) without. The two groups were not different regarding age (P = 0.289, t-test). Sexual characteristics of the men with PE and men in the control group are summarized in Table 1. No statistically significant differences were seen regarding the length of the penis (mean difference = −2.05, P = 0.80, t-test), mucosal cuff (mean difference = −0.32, P = 0.84, t-test), and penile skin (mean difference = −0.03, P = 0.99, t-test). Thirty-five and 32 men had college education in case and control groups, respectively. The two groups were not different regarding education (P = 0.90, chi-square test), smoking (P = 0.70, Fisher's exact test), and circumcision timing (P = 0.65, Fisher's exact test). One-sample Kolmogorov-Smirnov test showed that the measurements in both groups have normal distribution.
Table 1. Sexual characteristics of men in PE and control groups
|Mean penile length (mm)||121.1 ± 12.8||130.1 ± 10.4||0.80|
|Mean mucosal cuff length (mm)||15.4 ± 4.8||14.7 ± 3.4||0.84|
|Mean penile skin length (mm)||80.8 ± 21.0||88.7 ± 12.2||0.99|
|Neonatal circumcision (N)||30.0||34.0||0.65|
|Median IELT (minutes)||0.5||5.7||0.001|
Premature ejaculation is one of the most prevalent male sexual dysfunctions; yet, it is frequently misdiagnosed or overlooked as a result of numerous patient and physician barriers. The diagnosis of PE is based upon sexual history of a shortened latency time, poor control over ejaculation, low satisfaction with intercourse, and distress regarding the condition . Pathophysiology of PE is not well defined. The biological causes considered are penile hypersensitivity, hyperexcitable ejaculatory reflex, increased sexual arousability, possible endocrinopathy, a genetic predisposition, and central 5-hydroxytryptamin receptor dysfunction , while several psychogenic etiologies have been proposed, including learned behavior.
Waldinger et al. formulated a new theory of the cause and genesis of lifelong PE; they postulated that lifelong rapid ejaculation is not an acquired disorder caused by initial hurried intercourse. Instead, a rapid ejaculation is postulated to be part of a normal biological variability of the IELT in men, with a possible familial genetic vulnerability [10–12].
There are conflicting studies regarding the effect of circumcision on IELT. Some reported increased and some reported decreased, and still others reported variable penile sensitivity with their own proposed mechanism and role for foreskin [13–17]. Also, there are concerns regarding the length of mucosal cuff after circumcision and its effect on IELT later in life. Taylor et al. studied “the gross and histological features of the prepuces.” They identified “a band of ridged mucosa located at the junction of true penile skin with smooth preputial mucosa.” Containing more Meissner's corpuscle than does the smooth mucosa, they considered ridged band “a specialized sensory mucosa.” Circumcision by ablating this junction mucosa can reduce penile sensitivity . Senkul et al. concluded that circumcision “does not adversely affect sexual function,” but they found an increase in the IELT . Zhang et al. found a relationship between redundant prepuce and PE, and circumcision was an effective method to treat PE . On the other hand, Zwang argues that circumcision denudes the penis and fully exposes the corona of the glans penis to direct stimulation, thereby causing circumcised men to have a greater incidence of PE . O'Hara and O'Hara, who surveyed women's preferences for the circumcised or intact penis of their men partners, concluded that women prefer uncircumcised men because of more likely occurrence of PE in circumcised men .
Absence of relationships between PE and education denies the concept that more highly educated individuals have greater incidence of PE.
Our study was based on the theory of penile hypersensitivity post circumcision. According to this theory, men with a larger mucosal cuff have a higher chance of experiencing PE. In our study, neither mucosal cuff length nor penile skin and total penis length had association with PE. Based on most studies and our results, circumcision has no deleterious effect on sexual function.
We have not found any relationship between postcircumcision mucosal cuff length and PE, and concerns about this, during circumcision, may not be justified. Also, there were no relationships between penile length, penile skin length, smoking, education, circumcision timing, and PE.
Conflict of Interest: None declared.