Difference between revisions of "Foreskin"

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''The following content is part of the [[Circumpendium]].''
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<div class='res-img'>[[File:Infographic Foreskin.jpg|Foreskin - Anatomy and function]]</div>
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The '''foreskin''' or '''prepuce''' is the double-layered fold of smooth muscle tissue, blood vessels, neurons, [[skin]], and [[mucosa| mucous membrane]] part of the [[penis]] that creates the [[preputial sac]], while covering and protecting the [[glans penis]] and the [[urinary meatus]].
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The nature of the prepuce or foreskin, which is amputated and destroyed by circumcision, must be considered and fully understood in any discussion of male [[circumcision]].<ref name="cold-taylor1999">{{ColdCJ TaylorJR 1999}}</ref>
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Purpura et al. (2018) described the foreskin as follows:
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<blockquote>
 +
Few parts of the human anatomy can compare to the incredibly multifaceted nature of the human foreskin. At times dismissed as “just [[skin]],” the adult foreskin is, in fact, a highly vascularized and densely innervated bilayer tissue, with a surface area of up to 90 cm, and potentially larger. On average, the foreskin accounts for 51% of the total length of the penile [[shaft skin]] and serves a multitude of functions. The tissue is highly dynamic and biomechanically functions like a roller bearing; during intercourse, the foreskin “unfolds” and glides as abrasive friction is reduced and lubricating fluids are retained. The sensitive foreskin is considered to be the primary erogenous zone of the male [[penis]] and is divided into four subsections: [[Preputial mucosa|inner mucosa]], [[ridged band]], [[frenulum]], and outer foreskin; each section contributes to a vast spectrum of sensory pleasure through the [[gliding action]] of the foreskin, which mechanically stretches and stimulates the densely packed corpuscular receptors. Specialized immunological properties should be noted by the presence of [[Langerhans cells]] and other lytic materials, which defend against common microbes, and there is robust evidence supporting [[HIV]] protection. The [[glans penis| glans]] and inner [[mucosa]] are physically protected against external irritation and contaminants while maintaining a healthy, moist surface. The foreskin is also immensely vascularized and acts as a conduit for essential blood vessels within the penis, such as supplying the [[glans]] via the frenular artery.<ref>{{REFjournal
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|last=Purpura
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|first=Valeria
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|init=V
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|author-link=
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|last2=Bondioli
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|first2=Elena
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|init2=E
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|author2-link=
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|last3=Cunningham
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|first3=Eric J.
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|init3=EC
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|author3-link=
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|etal=yes
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|title=The development of a decellularized extracellular matrix–based biomaterial scaffold derived from human foreskin for the purpose of foreskin reconstruction in circumcised males
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|journal=J Tissue Eng
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|location=
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|date=2018-12-22
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|volume=
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|issue=
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|pages=
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|url=https://journals.sagepub.com/doi/full/10.1177/2041731418812613
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|quote=
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|pubmedID=30622692
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|pubmedCID=6304708
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|DOI=10.1177/2041731418812613
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|accessdate=2020-02-09
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}}</ref></blockquote>
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The medical community usually omits information on the nature and functions of the foreskin from information provided to the public and to parents.
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== Structure ==
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===Foreskin in infancy and childhood===
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Baby boys are born with the foreskin fused with the [[glans penis]] by the balanopreputial lamina, a [[synechia| synechial membrane]], which prevents retraction. In addition, the tip of the foreskin ([[acroposthion]]) is usually too narrow to allow [[retraction of the foreskin]]. The [[preputial sac]] is closed by the synechia and cannot be infected.<ref name="fleiss-hodges-vanhowe1998"/>
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Forcible attempts to retract the foreskin result in injury to the boy, so should be avoided. The first person to retract the foreskin should be the boy himself.<ref name="Wright1994">{{REFjournal
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|last=Wright
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|init=JE
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|title=Further to the "Further Fate of the Foreskin"
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|journal=Med J Aust
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|volume=160
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|issue=
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|pages=134-135
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|url=http://www.cirp.org/library/normal/wright2/
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|quote=
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|pubmedID=8295581
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|pubmedCID=
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|DOI=
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|date=1994-02-07
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|accessdate=2020-05-16
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}}</ref>
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Thorvaldsen & Meyhoff (2005) conducted a survey of 4,000 boys in [[Denmark]]. They reported that the mean age of first foreskin retraction is 10.4 years in [[Denmark]].<ref name="Thorvaldsen-meyhoff2005">{{REFjournal
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|last=Thorvaldsen
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|init=MA
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|last2=Meyhoff
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|init2=H
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|title=Patologisk eller fysiologisk fimose?
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|trans-title=Pathological or physiological phimosis?
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|language=Danish
 +
|journal=Ugeskr Læger
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|volume=167
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|issue=17
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|pages=1858-1862
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|url=http://www.cirp.org/library/normal/thorvaldsen1/
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|quote=
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|pubmedID=
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|pubmedCID=
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|DOI=
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|date=2005
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|accessdate=2019-11-14
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}}</ref>
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 +
===Foreskin in adolescence===
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The foreskin is in a transitional state during puberty and adolesence in which it is changing from the non-retractile foreskin of childhood to thh fully retractable foreskin of adulthood. Many adolescents complain of a non-retractable foreskin. Many need to do manual [[stretching]]. They usually achieve full retraction by age 16.
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===Foreskin in adulthood===
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The foreskin (also known as the ''prepuce'') is the layered fold of smooth muscle tissue, blood vessels, neurons, [[skin]], and [[Preputial mucosa|mucous membrane]] part of the [[penis]] that covers and protects the [[glans penis]] and the urinary meatus.<ref name="cold-taylor1999"/> There are four layers in the foreskin. The top layer is either epidermis in the outer foreskin or [[mucosa]], in the inner foreskin. The second layer is the lamina propria. The third layer is the [[dartos]]. The fourth layer is the dermis. It is normal for the foreskin to be darker in color than the rest of one's body after puberty. This condition is called hyperpigmentation.
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The adult foreskin measures about 3 inches by 5 inches or [[The Foreskin: 15 Square Inches of Erogenous Tissue| 15 square inches]].<ref name="taylor1996">{{TaylorJR LockwoodAP TaylorAJ 1996}}</ref> The foreskin creates the [[preputial sac]]. The two foreskin layers provide a [[skin]] reserve. When the penis becomes erect, the foreskin may wholly or partially unfold to provide the necessary [[skin]] to allow for expansion of the penis during [[erection]].
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The foreskin is the movable part of the [[penis]]. The foreskin is not attached to the underlying structure and is free to [[gliding action| glide back and forth]].<ref name="lakshmanan-prakash1980">{{REFjournal
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|last=Lakshmanan
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|init=S
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|author-link=
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|last2=Prakash
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|init2=S
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|title=Human prepuce: some aspects of structure and function
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|journal=Indian J Surg
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|date=1980
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|volume=44
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|issue=
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|pages=134-7
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|url=http://www.cirp.org/library/anatomy/lakshmanan/
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|quote=
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|accessdate=
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}}</ref> The [[gliding action]] reduces the friction of intercourse and helps to prevent abrasions, while conserving vaginal lubrication and moisture.<ref name="warren-bigelow1994">{{REFjournal
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|last=Warren
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|first=John
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|init=J
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|author-link=John Warren
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|last2=Bigelow
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|first2=Jim
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|init2=J
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|author2-link=Jim Bigelow
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|title=The case against circumcision
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|journal=Brit J Sex Med
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|date=1994-09
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|url=http://www.cirp.org/library/general/warren2/
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|quote=
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|pubmedID=
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|pubmedCID=
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|DOI=
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|accessdate=2019-10-28
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}}</ref> The foreskin is attached to the [[glans penis]] on the ventral side by the [[frenulum]], which usually limits [[Retraction of the foreskin| retraction]] to a widely variable degree. The [[ridged band]] emanates from the frenulum.<ref name="cold-taylor1999" />
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The epithelium of the outer layer of the foreskin is true [[skin]] while the epithelium of the inner layer is [[Preputial mucosa|mucosal membrane]]. There is a mucocutaneous boundary at the tip of the foreskin. The mucocutaneous junction is a specific erogenous zone,<ref name="winklemann1959">{{WinkelmannRK 1959}}</ref> Taylor et al. reported:
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<blockquote>
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The vascular ridges of the `ridged band' and its [[Meissner's corpuscles]] firmly separate preputial epithelium from true [[skin]] and place preputial [[mucosa]] amongst other mucocutaneous [[mucosa]]e. Winkelmann emphasized the structural and functional importance of junctional regions of the body and focused on mucocutaneous end-organs, or `genital corpuscles', of the [[glans penis]] and prepuce. Some of these end-organs resemble Krause end-bulbs; others resemble [[Meissner's corpuscles]]. … [[Meissner's corpuscles]] of the prepuce may be compared with similar nerve-endings in the finger-tips and lips, which respond in a fraction of a second to contact with light objects that bring about deformation of their capsules. … The prepuce provides a large and important platform for several nerves and nerve endings. The innervation of the outer [[skin]] of the prepuce is impressive; its sensitivity to light touch and pain are similar to that of the [[skin]] of the penis as a whole.<ref name="taylor1996" />
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</blockquote>
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The highly innervated [[ridged band]] area is found at the mucocutaneous junction. The ridged band area is characterized by rete ridges with [[Meissner's corpuscles]] in the ridges.<ref name="taylor1996"/>
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As with other neurologic structures such as the brain, the tip of the prepuce is richly supplied with blood by important vascular structures.<ref name="taylor1996"/> The prepuce serves as a conduit for several important veins.<ref name="fleiss-hodges-vanhowe1998">{{FleissP HodgesF VanHoweRS 1998}}</ref> The glans penis receives blood through the frenular artery.<ref>{{REFjournal
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|last=Persad
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|init=R
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|author-link=
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|last2=Sharma
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|init2=S
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|author2-link=
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|last3=McTavish
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|init3=J
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|author3-link=
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|etal=yes
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|title=Clinical presentation and pathophysiology of meatal stenosis following circumcision
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|journal=Brit J Urol
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|date=1995
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|volume=75
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|issue=1
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|pages=91-3
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|url=https://www.onlinelibrary.wiley.com/doi/abs/10.1111/j.1464-410X.1995.tb07242.x
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|quote=
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|pubmedID=7850308
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|pubmedCID=
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|DOI=10.1111/j.1464-410x.1995.tb07242.x
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|accessdate=2019-10-15
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}}</ref> The adult foreskin frequently has prominent visible veins.
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The layer of [[dartos]] muscle is contained within the foreskin.<ref name="cold-taylor1999 /> It makes the foreskin rather stretchy. The dartos muscle keeps the foreskin snugly against the [[glans]].  The fibers of the [[dartos]] muscle form a whorl at the tip that functions as a sphincter. The sphincter opens to allow [[urine]] to flow out, but closes to protect the [[penis]] from foreign matter, contaminants, and pathogens.<ref name="lakshmanan-prakash1980"/><ref>{{REFjournal
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|last=Jefferson
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|first=
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|author-link=
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|title=The peripenic muscle; some observations on the anatomy of phimosis
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|journal=Surgery, Gynecology, and Obstetrics (Chicago)
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|date=1916
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|volume=23
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|issue=2
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|pages=177-81
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|url=http://www.cirp.org/library/anatomy/jefferson/
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|quote=
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|pubmedID=
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|pubmedCID=
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|DOI=
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|accessdate=2019-10-14
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}}</ref>
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The outer foreskin usually becomes somewhat darker after puberty due to increased melanin.<ref>{{REFweb
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|url=https://medical-dictionary.thefreedictionary.com/hyperpigmentation
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|title=hyperpigmentation
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|last=
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|first=
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|init=
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|author-link=
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|publisher=Medical Dictionary for the Dental Professions
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|date=2012
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|accessdate=2024-09-25
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}}</ref>
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 +
===Foreskin length===
 +
Natural foreskins are found in all lengths from very short to very long. Most fall near the center of the range. Longer foreskins appear to perform their [[Immunological and protective function of the foreskin| protective and immunological function]] more satisfactorily. A short or inadequate foreskin may be lengthened by [[tissue expansion]] to improve function and aesthetics.
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The tapered tip of a longer foreskin that extends beyond the [[glans penis]] is known as the ''[[acroposthion]]''. A very few of the longest foreskins will not remain retracted when released, but will spontaneously [[Gliding action| glide]] forward to recover the glans penis. Longer foreskins improve protection and [[gliding action]] and do not usually create an issue. There is no recognized definition of an excessively long or so-called "redundant" foreskin.<ref name="tip2022">{{REFweb
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|url=http://acroposthion.com/the-tip-at-the-end/
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|title=The ‘Tip’ At The End
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|last=
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|first=
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|publisher=Acroposthion
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|date=2022
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|accessdate=2022-06-21
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}}</ref>
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 +
<i>See [[Development_of_retractable_foreskin#Adult_foreskin| Adult foreskin]].</i>
 +
 
 +
==Physiological functions==
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 +
Antique research by Alfred Kinsey (1948)<ref>{{REFbook
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|last=Kinsey
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|first=Alfred C.
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|init=
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|year=1948
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|title=Sexual behavior in the human male
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|url=
 +
|scope=
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|ISBN=
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|accessdate=2022-06-16
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}}</ref> and Masters & Johnson (1966)<ref>{{REFbook
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|last=Masters
 +
|first=William
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|init=
 +
|year=1966
 +
|title=Human sexual response
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|url=
 +
|scope=
 +
|ISBN=978-0-553-20429-2
 +
|accessdate=2022-06-16
 +
}}</ref> misled medical science into believing that the foreskin had no function. This meant the foreskin could be excised without doing harm. In actuality, the foreskin has many functions,<ref name="connors2024-02-19">{{REFweb
 +
|url=https://intactamerica.org/intact-penis/
 +
|title=6 Things You Need to Know About The Intact Penis
 +
|last=Garrett
 +
|first=Connor
 +
|init=
 +
|author-link=Connor Judson Garrett
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|publisher=Intact America
 +
|date=2024-02-19
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|accessdate=2024-10-21
 +
}}</ref> so its [[amputation]] does [[Bodily harm| great harm]].<ref name="hill2017">{{REFjournal
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|last=Hill
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|first=
 +
|init=G
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|author-link=George Hill
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|title=The case against circumcision
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|journal=Journal of Men's Health and Gender
 +
|date=2007
 +
|volume=4
 +
|issue=3
 +
|pages=318-323
 +
|url=https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=04ace5046cc27f01b8fbe4aa359c059778983912
 +
|quote=
 +
|format=PDF
 +
|accessdate=2023-10-01
 +
}}</ref>
 +
 
 +
The human race evolved over perhaps 700 millenia. The foreskin evolved its physiological functions that improve fitness for survival during that time.<ref>{{URLwikipedia|Evolution|Evolution}}</ref>
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=== Protective functions ===
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The foreskin provides physical protection to the [[glans penis]] and inner [[mucosa]],<ref>{{REFjournal
 +
|last=Morgan
 +
|first=
 +
|init=WKC
 +
|author-link=William Keith Campbell Morgan
 +
|etal=no
 +
|title=The rape of the phallus
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|trans-title=
 +
|language=
 +
|journal=JAMA
 +
|location=
 +
|date=1965-07-19
 +
|volume=193
 +
|issue=3
 +
|pages=123-4
 +
|url=https://www.cirp.org/library/general/morgan/
 +
|archived=
 +
|quote=This ritual, however, has become so widespread in the [[United States]] that it is no longer much of a status symbol, and a situation has arisen where any recently delivered mother who is eccentric enough to wish her child to retain his [[prepuce]], would be well advised to maintain permanent guard over it until such time as they both leave the hospital.
 +
|pubmedID=14310332
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|pubmedCID=
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|DOI=10.1001/jama.1965.03090030045013
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|accessdate=2024-05-21
 +
}}</ref> supplying moisture and natural oils by [[transudation]], while protecting the [[mucosa]]l tissue from pathogens, pollutants, friction, injury, [[keratinization]], de-sensitization, and drying out. The foreskin protects the glans penis and meatus of infant boys from abrasion and irritation from ammoniacal diapers.<ref name="gairdner1949">{{GairdnerDM 1949}}</ref> <ref name="dobanavacki2012">{{REFjournal
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|last=Dobanavacki
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|init=D
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|author-link=
 +
|last2=Lucić Prostran
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|init2=B
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|author2-link=
 +
|last3=Sarac
 +
|init3=D
 +
|author3-link=
 +
|etal=yes
 +
|title=Prepuce in boys and adolescents: what when, and how?
 +
|journal=Med Pregl
 +
|date=2012
 +
|volume=65
 +
|issue=7-8
 +
|pages=295-300
 +
|url=https://www.researchgate.net/publication/230746332_Prepuce_in_boys_and_adolescents_What_when_and_how
 +
|quote=
 +
|pubmedID=22924249
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|pubmedCID=
 +
|DOI=10.2298/MPNS1208295D
 +
|accessdate=2019-10-14
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}}</ref>
 +
 
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In the absence of the foreskin about ten to twenty percent of [[circumcised]] boys suffer urethral stricture ([[meatal stenosis]]) requiring further treatment.<ref name="frisch2016">{{REFjournal
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|last=Frisch
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|first=Morten
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|init=M
 +
|author-link=Morten Frisch
 +
|last2=Simonsen
 +
|init2=J
 +
|author2-link=
 +
|title=Cultural background, non-therapeutic circumcision and the risk of meatal stenosis and other urethral stricture disease: Two nationwide register-based cohort studies in Denmark 1977-2013
 +
|journal=The Surgeon
 +
|date=2016-04-01
 +
|volume=16
 +
|issue=2
 +
|pages=107-18
 +
|url=http://www.thesurgeon.net/article/S1479-666X(16)30179-2/pdf
 +
|quote=
 +
|pubmedID=28017691
 +
|pubmedCID=
 +
|DOI=10.1016/j.surge.2016.11.002
 +
|accessdate=2019-10-23
 +
}}</ref> Frisch & Simonsen (2016) reported the incidence of meatal stenosis to be 3.7 times higher in [[circumcised]] boys.<ref name="frisch2016"/>
 +
 
 +
The foreskin continues to protect the [[glans penis]] throughout life, keeping it smooth, glossy, moist, [[Foreskin sensitivity| sensitive]], and free from [[keratinization]] and loss of sensation.
 +
 
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=== Immunological functions ===
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Fleiss et al. (1998) have listed numerous immunological functions of the foreskin that help to protect the human body against [[infection]]. The foreskin maintains the moistness of the [[preputial mucosa]] and the [[glans penis]] by [[transudation]]. The sub-preputial moisture contains cathepsin B, chymotrypsin, neutrophil elastase, cytokines, and lysozyme, which has the capacity to destroy the cell walls of bacteria. The preputial muscles keep the tip of the foreskin closed to keep out pathogens.<ref name="fleiss-hodges-vanhowe1998"/>
 +
 
 +
The foreskin is highly vascularized. The high rate of blood flow helps to prevent infection.<ref name="fleiss-hodges-vanhowe1998"/>
 +
 
 +
Although claims have been made that the presence of the foreskin increases the risk of infection with [[Circumcision and HIV|human immune deficiency virus]] ([[HIV]]), that is not correct. The claims are based on the reported findings of three randomized clinical trials (RCTs) that were carried out more than a decade ago in Africa. Boyle & Hill (2011) have shown these RCTs to be have significant methodological flaws and statistical errors that render their claims invalid.<ref name="boyle-hill2011">{{BoyleGJ HillG 2011}}</ref>
 +
 
 +
Fleiss et al. noted the presence of [[Langerhans cells]] in the prepuce.<ref name="fleiss-hodges-vanhowe1998"/> De Witte et al. (2007) have discovered that Langerhans cells produce ''Langerin'', which is a "natural barrier to [[HIV]] infection".<ref>{{DeWitte etal 2007}}</ref>
 +
 
 +
For more information, see [[Immunological and protective function of the foreskin]].
 +
 
 +
=== Sexual functions ===
 +
 
 +
The foreskin is a sexual organ.<ref name="hill2017" /> It provides both mechanical and erogenous functions in sexual intercourse,<ref name="connors2024-02-19" /> as well as [[pheromone| pheromones]] for the excitement and arousal of the partner.<ref name="fleiss-hodges-vanhowe1998"/> Winkelmann (1959) classified the foreskin as ''specific erogenous tissue''.<ref name="winklemann1959" /> When the [[penis]] becomes erect, the foreskin unfolds to provide the skin necessary to allow the [[penis]] to expand to full size and length.
 +
 
 +
The [[gliding action]] provides stimulation and facilitates intromission.<ref name="warren-bigelow1994"/><ref name="morgan1965">{{REFjournal
 +
|last=Morgan
 +
|init=WKC
 +
|author-link=
 +
|title=The rape of the phallus
 +
|journal=JAMA
 +
|date=1965
 +
|volume=193
 +
|issue=
 +
|pages=123-4
 +
|url=https://jamanetwork.com/journals/jama/article-abstract/656072
 +
|quote=
 +
|pubmedID=14310332
 +
|pubmedCID=
 +
|DOI=10.1001/jama.1965.03090030045013 
 +
|accessdate=2019-10-15
 +
}}</ref> <ref name="taves2002">{{REFjournal
 +
|last=Taves
 +
|init=D
 +
|author-link=
 +
|title=The intromission function of the foreskin
 +
|journal=Med Hypotheses
 +
|date=2002
 +
|volume=59
 +
|issue=2
 +
|pages=180
 +
|url=http://www.sciencedirect.com/science/article/pii/S0306987702002505
 +
|quote=
 +
|pubmedID=12208206
 +
|pubmedCID=
 +
|DOI=10.1016/s0306-9877(02)00250-5
 +
|accessdate=2019-10-15
 +
}}</ref> At times of sexual arousal, the foreskin may be lubricated by [[pre-ejaculate]]. During the thrusting of sexual congress, the [[gliding action]] reduces abrasions and irritation in the [[Vagina| female partner]] and avoids problems with vaginal dryness.<ref name="warren-bigelow1994"/><ref name="morgan1965"/> The foreskin may protect the corona glandis from hyper-stimulation and prevent [[premature ejaculation]].
 +
 
 +
===Sensory functions===
 +
 
 +
Nature designed the foreskin to be an [[Foreskin sensitivity| erogenous sensory organ]].<ref name="hill2017" /> The foreskin has a layer of muscle called the [[dartos]] muscle sheath that provides the foreskin with elasticity, flexibility, and stretchiness, which allows full stimulation of the nerves in the [[ridged band]] that sense movement and [[stretching]] to provide [[foreskin sensitivity]]. There is a mucocutaneous region at the tip of the foreskin where outer skin changes to inner [[mucosa]]. Winkelmann (1959) identified the foreskin as a ''specific erogenous zone'' (meaning an area of acute erogenous sensation). Winklemann reported rete ridges in the foreskin with nerves set close to the surface with closely set networks.<ref name="winklemann1959"/>
 +
 
 +
Lakshamanan & Prakash (1980) report the "prepuce covers the [[glans]] completely and snugly like a hosiered material and continues to do so through the entire span of life of the male", which they explain as being caused by the smooth muscle fibers within the prepuce. The prepuce is free to [[gliding action| glide back and forth]].  When it does, it must stretch to go over the glans penis.<ref name="lakshmanan-prakash1980" />
  
−
== Anatomy and function of the foreskin in detail ==
+
Taylor et al. (1996) carried out a histological study of the foreskin. (Histology is the microscopic examination of cells and tissues.) Taylor et al. found an area of rete ridges just inside the tip of the foreskin that he called the [[ridged band]]. The ridges were found to have nerve endings at the top of the ridges. They report that the ridged band area moves to the shaft of the penis when the penis becomes erect where the nerves are subject to stimulation. They stated:
 +
<blockquote>
 +
The prepuce provides a large and important platform for several nerves and nerve endings. The innervation of the outer skin of the prepuce is impressive; its sensitivity to light touch and pain are similar to that of the skin of the penis as a whole.<ref name="taylor1996" />
 +
</blockquote>
  
−
The foreskin covers the glans, thus protecting it from pollutants, friction, injury and drying out. It consists of two superimposed layers, which are only joined together at the very end.
+
Sorrells et al. (2007) conducted a fine-touch study of the penis of both circumcised and intact men. Sorrells et al. concluded:
 +
<blockquote>
 +
In conclusion, circumcision removes the most sensitive parts of the penis and decreases the fine-touch pressure sensitivity of glans penis. The most sensitive regions in the [[uncircumcised]] penis are those parts ablated by circumcision. When compared to the most sensitive area of the circumcised penis, several locations on the [[uncircumcised]] penis (the rim of the preputial orifice, dorsal and ventral, the frenulum near the ridged band, and the frenulum at the muco-cutaneous junction) that are missing from the circumcised penis were significantly more sensitive.<ref>{{Sorrells etal 2007}}</ref>
 +
</blockquote>
  
−
While the outer foreskin layer is an extension of the penile shaft skin, the inner foreskin layer, which lies flat against the glans, is a mucous membrane. The inner layer is an extraordinarily complex tissue. It contains apocrine glands which produce Cathepsin B, lysozymes, chymotrypsin, neutrophil elastase, cytokines and pheromones such as androsterone. Indian scientists have shown that the subpreputial moisture contains lytic material which has an antibacterial and antiviral effect. The natural oils lubricate, moisten and protect the mucous membranes of both the glans and the inner foreskin layer. The tip of the foreskin is supplied with ample amounts of blood through important blood vessels.
+
Bronselaer et al. (2013) surveyed a large group of [[intact]] and [[circumcised]] men in Belgium. They reported:
−
<ref>Dr.med Wolfram Hartmann, Stellungnahme zur Anhörung am 26. November 2012 im Rechtsausschuss des Bundestages</ref>
+
<blockquote>
 +
Of the men in Group A [intact males], 90.6% rated the sexual pleasure provided when the foreskin was stimulated by themselves or their partners from ‘mild’ to ‘very strong’ and 61.9% the respective orgasm from ‘mild’ to ‘very strong’.
  
−
The foreskin serves as a pathway for many significant veins. In addition the foreskin is saturated with very many nerve endings and tactile corpuscles, the same receptors that exist in the fingertips. The enormous density of nerves and mechanoreceptors make the foreskin the most sensitive part of the body, approximately 10 times more sensitive than the fingertips. This also distinguishes the human penis from those of other mammals, which in contrast have the main concentration of nerves in the glans, and not in the foreskin.
+
For the [[glans penis]], men in Group B [circumcised males] reported significantly less sexual pleasure than men in Group A at the dorsal side (P ≤ 0.001), and the lateral (P ≤ 0.001) and ventral sides (P = 0.02). Orgasm was less intense in Group B at the dorsal side (P = 0.006) and at the lateral sides (P = 0.02). Group B required more effort in achieving orgasm at the lateral sides (P = 0.04). Furthermore, a larger percentage of men in this group reported numbness at the dorsal, lateral, and ventral sides (all P ≤ 0.001), as well as unusual sensations (burning, prickling, itching, or tingling) at the lateral sides (P = 0.02) and at the ventral side (P = 0.003) of the glans.<ref>{{REFjournal
 +
|last=Bronselaer
 +
|first=Guy
 +
|init=G
 +
|author-link=
 +
|last2=Schoeber
 +
|first2=Justine M.
 +
|init2=JM
 +
|author2-link=
 +
|last3=Meyer-Bahlburg
 +
|init3=HM
 +
|author3-link=
 +
|last4=T'Sjoen
 +
|first4=Guy
 +
|init4=G
 +
|author4-link=
 +
|last5=Vlietinck
 +
|first5=Robert
 +
|init5=R
 +
|author5-link=
 +
|last6=Hoebeke
 +
|first6=Piet B.
 +
|init6=PB
 +
|author6-link=
 +
|etal=no
 +
|title=Male circumcision decreases penile sensitivity as measured in a large cohort
 +
|journal=BJU Int
 +
|location=
 +
|date=2013-05
 +
|volume=111
 +
|issue=5
 +
|pages=820-7
 +
|url=https://onlinelibrary.wiley.com/doi/full/10.1111/j.1464-410X.2012.11761.x
 +
|quote=
 +
|pubmedID=
 +
|pubmedCID=
 +
|DOI=10.1111/j.1464-410X.2012.11761.x
 +
|accessdate=2019-10-23
 +
}}</ref>
 +
</blockquote>
  
−
The two foreskin layers provide a skin reserve, into which the growing shaft expands during an erection. Depending to the individual length of a man's foreskin, it thereby retracts more or less far. In some men, the foreskin still fully covers the glans during an erection, in others the glans is partly or completely exposed.
+
García-Mesa et al. (2021) reported the foreskin has an abundance of [[Meissner's corpuscles]] which provide pleasant sexual sensation when mechanically stimulated by motion of the foreskin.<ref name="garcía-mesa2021">{{REFjournal
 +
|last=García-Mesa
 +
|first=Yolanda
 +
|init=
 +
|author-link=
 +
|last2=García-Piqueras
 +
|first2=Jorge
 +
|init2=
 +
|author2-link=
 +
|last3=Cobo
 +
|first3=Ramón
 +
|init3=
 +
|author3-link=
 +
|last4=Martín-Cruces
 +
|first4=José
 +
|init4=
 +
|author4-link=
 +
|last5=Suazo
 +
|first5=Iván
 +
|init5=
 +
|author5-link=
 +
|last6=García-Suárez
 +
|first6=Olivia
 +
|init6=
 +
|author6-link=
 +
|last7=Feito
 +
|first7=Jorge
 +
|init7=
 +
|author7-link=
 +
|last8=
 +
|first8=Vega
 +
|init8=José A.
 +
|author8-link=
 +
|etal=no
 +
|title=Sensory innervation of the human male prepuce: Meissner's corpuscles predominate
 +
|trans-title=
 +
|language=
 +
|journal=Journal of Anatomy
 +
|location=
 +
|date=2021-10
 +
|volume=239
 +
|issue=4
 +
|article=
 +
|page=
 +
|pages=892-902
 +
|url=https://onlinelibrary.wiley.com/doi/full/10.1111/joa.13481
 +
|pubmedID=34120333
 +
|pubmedCID=8450466
 +
|DOI=10.1111/joa.13481
 +
|accessdate=2021-11-15
 +
}}</ref>
  
−
In addition, the foreskin, in combination with the shaft skin, allows a natural gliding action. During intercourse as well as masturbation the outer skin is in contact with the vagina or the hand respectively. The penile shaft moves mostly within its skin and the skin only moves at the end of its thrust. Due to this, the friction with the vagina or hand is reduced. The sexual stimulation mostly occurs through the stretching and movement of the foreskin, when it is pulled over the glans and back, as well as the direct stimulation of the inner foreskin when it is exposed and comes into direct contact with the vagina or the hand.
+
== Sexual behavior ==
  
−
== Medical indications and therapies ==
+
Laumann et al. (1997) reported that men who lack a foreskin "engage in a somewhat more elaborated set of sexual practices than do men who are not [[circumcised]]. For each of the practices examined, lifetime experience of various forms of oral and anal sex and [[masturbation]] frequency in the past year, [[circumcised]] men engaged in these behaviors at greater rates. The difference between [[circumcised]] men was greatest for [[masturbation]] — ironically, a practice that [[circumcision]] was once thought to limit. A total of 47% of circumcised men reported masturbating at least once a month vs 34% for their [[uncircumcised]] peers."<ref name="laumann1997>{{REFjournal
 +
|last=Laumann
 +
|init=EO
 +
|author-link=
 +
|last2=Masi
 +
|init2=CM
 +
|author2-link=
 +
|last3=Zuckerman
 +
|init3=CW
 +
|author3-link=
 +
|etal=no
 +
|title=Circumcision in the United States
 +
|journal=JAMA
 +
|location=
 +
|date=1997-04-02
 +
|volume=277
 +
|issue=13
 +
|pages=1052-7
 +
|url=http://www.cirp.org/library/general/laumann/
 +
|quote=
 +
|pubmedID=9091693
 +
|pubmedCID=
 +
|DOI=
 +
|accessdate=2019-10-23
 +
}}</ref> Dave et al. (2003) reported that men without foreskins "were more likely to report having had homosexual partner(s) (7.5% v 5.3%, p =0.012) and partners from abroad (19.7% v 13.1%, p...0.001)."<ref name="dave2003">{{REFjournal
 +
|last=Dave
 +
|init=SS
 +
|author-link=
 +
|last2=Johnson
 +
|init2=AM
 +
|author2-link=
 +
|last3=Fenton
 +
|init3=KA
 +
|author3-link=
 +
|last4=Mercer
 +
|init4=CH
 +
|author4-link=
 +
|last5=Erens
 +
|init5=B
 +
|author5-link=
 +
|last6=Wellings
 +
|init6=K
 +
|author6-link=
 +
|etal=no
 +
|title=Male circumcision in Britain: findings from a national probability sample survey
 +
|journal=Sex Trans Infect
 +
|location=
 +
|date=2003-12
 +
|volume=79
 +
|issue=
 +
|pages=499-500
 +
|url=http://www.cirp.org/library/general/dave1/
 +
|quote=
 +
|pubmedID=14663134
 +
|pubmedCID=1744763
 +
|DOI=10.1136/sti.79.6.499
 +
|accessdate=2019-10-29
 +
}}</ref>
  
−
There is a group of typical conditions of the foreskin, that can occur in more or less distinct ways.
+
Cold & Taylor (1999) commented, "The increased frequency of [[masturbation]], anal intercourse and fellatio reported by [[circumcised]] men in the [[United States of America| USA]] may possibly be due to the sensory imbalance caused by [[circumcision]]. Clearly, [[amputation]] of the prepuce causes changes in sexual behaviour in human males and females."<ref name="cold-taylor1999" />
  
−
=== Short Frenulum (frenulum breve) ===
+
Frisch et al. (2011) surveyed the sexual function and behavior of a large group of [[intact]] and [[circumcised]] men in [[Denmark]]. They reported that "[[circumcised]] men were more likely (38%) than [[uncircumcised]] men (28%) to report ≥10 sex partners."<ref name="frisch lindholm groenbaek 2011">{{FrischM LindholmM GroenbaekM 2011}}</ref>
  
−
If the frenulum is too short, it can hinder or even prohibit retraction of the foreskin. Since the underside of the glans is attached to the inner foreskin by the frenulum, it can be bent downwards due to the resulting tension when the foreskin is retracted. If the mechanical strain is too great, the frenulum can tear or rip apart. If the frenular artery, which runs within, is damaged in the process, it can lead to considerable and prolonged bleeding. When only small tears appear, it may heal spontaneously.
+
==The role of the foreskin in heterosexual relations==
  
−
To help the healing, lukewarm camomile baths or cremes containing panthenol can be applied. With a very short frenulum and previous large tears, surgical treatment is advised.
+
The knowledge of the important of the [[intact]] [[penis]] in heterosexual relations long has been known to the Jews who give us our earliest evidence of the value of the [[foreskin]] to the female partner.
  
−
There are 3 surgical variants:
+
Moses Maimonides, a Jewish rabbi and physician, stated in the 12th century:
−
<ref>http://de.wikipedia.org/wiki/Frenulum_breve</ref>
+
{{Citation
 +
|Text=It is hard for a woman with whom an [[uncircumcised]] man has had sexual intercourse to separate from him.
 +
|Author=[[Moses Maimonides]]
 +
|ref=<ref>{{REFbook
 +
|last=Maimonides
 +
|first=Moses
 +
|init=M
 +
|author-link=Moses Maimonides
 +
|year=1963
 +
|title=The Guide of the Perplexed
 +
|url=http://www.cirp.org/library/cultural/maimonides/
 +
|page=609
 +
|isbn=
 +
|accessdate=2019-10-11
 +
}}</ref>
 +
}}
  
−
* Frenectomy, the complete removal of the frenulum
+
According to the Rabbi Isaac ben Yedaiah, who lived in Southern France in the late 13th century:
−
* Frenuloplasty, where the frenulum is cut horizontally, and sewed together vertically
+
<blockquote>
−
* Elongation of the frenulum with a skin graft.
+
''She too will court the man who is [[uncircumcised]] in the flesh and lie against his breast with great passion, for he thrusts inside her a long time because of his foreskin, which is a barrier against ejaculation in intercourse. Thus she feels pleasure and reaches an orgasm first. When an [[uncircumcised]] man sleeps with her, and then resolves to return to his home, she brazenly grabs him, holding on to his genitals and says to him, "Come back, make love to me." This is because of the pleasure that she finds in intercourse with him, from the sinews of his testicles—sinew of iron—and from his ejaculation—that of a horse which he shoots like an arrow into her womb. They are united without separating, and he makes love twice and three times in one night, yet the appetite is not filled.''<ref name="saperstein1980">{{REFbook
 +
|last=Saperstein
 +
|first=Marc
 +
|init=M
 +
|year=1980
 +
|title= Decoding the Rabbis: A Thirteenth-Century Commentary on the Aggadah
 +
|url=http://www.cirp.org/library/cultural/yedaiah1/
 +
|pages=
 +
|isbn=
 +
|accessdate=2019-10-22
 +
}}</ref>
 +
</blockquote>
 +
As previously reported, the foreskin reduces the force required for penetration of the female partner's [[vagina]] by as much as ninety percent.<ref name="taves2002"/> The [[gliding action]] of the foreskin reduces friction and abrasion, while conserving vaginal lubrication.<ref name="warren-bigelow1994"/>
  
−
=== Physiological Phimosis ===
+
In a first of its kind, O'Hara & O'Hara (1999) carried out a retrospective survey of 138 women with experience of both [[intact]] and [[circumcised]] partners. The women overwhelmingly concurred that the mechanics of [[sexual intercouse| coitus]] was different for the two groups of men. Of the women, 73% reported that [[circumcised]] men tend to thrust harder and deeper, using elongated strokes, while unaltered men by comparison tended to thrust more gently, to have shorter thrusts, and tended to be in contact with the mons pubis and [[clitoris]] more, according to 71% of the respondents. Women with [[intact]] partners had a higher rate of orgasms than women with [[circumcised]] partners. O'Hara & O'Hara concluded:
 +
<blockquote>Clearly, the anatomically complete penis offers a more rewarding experience for the female partner during coitus. While this study has some obvious methodological flaws, all the differences cannot be attributed to them. It is important that these findings be confirmed by a prospective study of a randomly selected population of women with experience with both types of men. It would be useful to examine the role of the foreskin in other sexual activities. Because these findings are of interest, the negative effect of circumcision on the sexual enjoyment of the female partner needs to be part of any discussions providing '[[informed consent]]' before circumcision.<ref name="ohara1998">{{REFjournal
 +
|last=O'Hara
 +
|init=K
 +
|author-link=
 +
|last2=O'Hara
 +
|init2=J
 +
|author2-link=
 +
|etal=yes
 +
|title=The effect of male circumcision on the sexual enjoyment of the female partner
 +
|journal=BJU Int
 +
|location=
 +
|date=1999
 +
|volume=83 Suppl 1
 +
|issue=
 +
|pages=79-84
 +
|url=https://onlinelibrary.wiley.com/doi/epdf/10.1046/j.1464-410x.1999.0830s1079.x
 +
|quote=
 +
|pubmedID=10349418
 +
|pubmedCID=
 +
|DOI=10.1046/j.1464-410x.1999.0830s1079.x
 +
|accessdate=2019-10-22
 +
}}</ref>
 +
</blockquote>
  
−
Physiological phimosis can be divided into three main categories - symptom-free, in need of therapy and in need of surgery.
+
Solinis & Yiannaki (2007) concluded; "[t]here was a decrease in couple’s sexual life after circumcision indicating that [[Adolescent_and_adult_circumcision|adult circumcision]] adversely affects sexual function in many men or/and their partners, possibly because of complications of surgery and loss of nerve endings."<ref name="solinis-yiannaki2005">{{REFjournal
 +
|last=Solinis
 +
|first=
 +
|author-link=
 +
|last2=Yiannaki
 +
|first2=
 +
|author2-link=
 +
|etal=no
 +
|title=Does circumcision improve couple's sex life?
 +
|journal=Journal of Men's Health and Gender
 +
|location=
 +
|date=2007-09
 +
|volume=4
 +
|issue=3
 +
|pages=361
 +
|url=http://www.cirp.org/library/sex_function/solinis2007/
 +
|quote=
 +
|pubmedID=
 +
|pubmedCID=
 +
|DOI=
 +
|accessdate=2019-10-23
 +
}}</ref>
  
−
From a medical standpoint, an otherwise symptom-free [[phimosis]], even after dissolution of preputial adhesions, does not require any treatment before the child enters puberty. The widespread notion that full retractability has to be achieved by a certain age, derives from obsolete assumptions and studies which only covered children's development until they entered school, but not beyond that point.
+
Frisch et al. (2011) surveyed a very large group of men and women in [[Denmark]]. They concluded:
 +
<blockquote>
 +
"Circumcision was associated with frequent orgasm difficulties in Danish men and with a range of frequent sexual difficulties in women, notably orgasm difficulties, dyspareunia and a sense of incomplete sexual needs fulfilment."<ref name="frisch lindholm groenbaek 2011"/>
 +
</blockquote>
 +
<!--
 +
''The following content is part of the [[Circumpendium]].''
 +
 
 +
== Anatomy and function of the foreskin in detail ==
  
−
Even though the data from Jakob Øster's studies (see above) have been known for 45 years, some check lists for school doctors‘ examinations still erroneously refer to physiological phimosis as an abnormality.
+
The foreskin covers the glans, thus protecting it from pollutants, friction, injury and drying out. It consists of two superimposed layers, which are only joined together at the very end. The [[ridged band]] is located just inside the tip of the foreskin.
  
−
The growth and hormonal surge during puberty alter both the size and size ratio of the penis and penile skin significantly. Also, the first masturbations aid the process of stretching of the skin and detachment of remaining adhesions.
+
While the outer foreskin layer is an extension of the penile [[shaft skin]], the inner foreskin layer, which lies flat against the glans,<ref name="prakash1">
 +
{{REFjournal
 +
|last=Prakash
 +
|init=S
 +
|last2=Raghuram
 +
|init2=R
 +
|last3=Venkatesan
 +
|etal=yes
 +
|title=Sub-preputial wetness - Its nature
 +
|journal=Ann Nat Med Sci (India)
 +
|date=1982
 +
|volume=18
 +
|issue=3
 +
|pages=109-12
 +
|url=http://www.cirp.org/library/anatomy/prakash/
 +
|quote=
 +
|pubmedID=
 +
|pubmedCID=
 +
|DOI=
 +
|accessdate=2019-10-14
 +
}}</ref> is a mucous membrane. The inner layer is an extraordinarily complex tissue. It contains apocrine glands which produce Cathepsin B, lysozymes, chymotrypsin, neutrophil elastase, cytokines and pheromones such as androsterone.<ref name="fleiss-hodges-vanhowe1998"/> Indian scientists have shown that the subpreputial moisture contains lytic material which has an antibacterial and antiviral effect.<ref name="lakshmanan-prakash1980"/> The natural oils lubricate, moisten and protect the mucous membranes of both the glans and the inner foreskin layer.<ref name="prakash1"/> The tip of the foreskin is supplied with ample amounts of blood through important blood vessels.<ref>Dr. med. Wolfram Hartmann, Stellungnahme zur Anhörung am 26. November 2012 im Rechtsausschuss des Bundestages</ref>
  
−
If, after that, the foreskin still remains too tight, resulting in pain during sexual activities, and
+
The [[foreskin]] serves as a pathway for many significant veins. In addition the foreskin is saturated with very many nerve endings and tactile corpuscles, the same receptors that exist in the fingertips. The enormous density of nerves and mechanoreceptors make the foreskin the most sensitive part of the body, approximately 10 times more sensitive than the fingertips. This also distinguishes the human penis from those of other mammals, which in contrast have the main concentration of nerves in the [[glans]], and not in the foreskin.
−
making genital hygiene difficult, treatment is indicated. The boy himself should engage in
 
−
stretching exercises, if needed with the aid of corticosteroid cream. Depending on the active
 
−
substances, success rates of 80-90% have been documented.
 
−
<ref>Orsola A, Caffaratti J, Garat JM. Conservative treatment of [[phimosis]] in children using a topical steroid.Urology2000;56(2):307-10.</ref>
 
−
<ref>Ashfield JE, Nickel KR, Siemens DR,et al. Treatment of [[phimosis]] with topical steroids in 194 children. J Urol2003;169(3):1106-8.</ref>
 
−
<ref>Pileggi Fde O, Vicente YA. Phimotic ring topical corticoid cream (0.1% mometasone furoate) treatment in children. J Pediatr Surg. 2007 Oct;42(10):1749-52.</ref>
 
−
<ref>Ghysel C, Vander Eeckt K, Bogaert GA.Long-term efficiency of skin stretching and a topical corticoid cream application for unretractable foreskin and [[phimosis]] in prepubertal boys.Urol Int. 2009;82(1):81-8.</ref>
 
−
<ref>Reddy S, Jain V, Dubey M, Deshpande P, Singal AK.Local Steroid Therapy As The First Line Treatment For Boys
 
−
With Symptomatic [[Phimosis]] - A Long Term Prospective Study.Acta Paediatr. 2011 Nov 21. [Epub ahead of print]</ref>
 
  
−
Should those therapies not yield the desired outcomes, there is a surgical option, namely a preputioplasty.
+
The two foreskin layers provide a skin reserve, into which the growing shaft expands during an [[erection]]. Depending to the individual length of a man's foreskin, it thereby retracts more or less far. In some men, the [[foreskin]] still fully covers the glans during an [[erection]], in others the [[glans]] is partly or completely exposed.
  
−
This surgical method preserves the foreskin. A good cosmetic result and total preservation of the foreskin are achieved. The basic principle of most of those methods consists of making one or more small longitudinal incisions, and then suturing the wound or wounds transversely.
+
In addition, the foreskin, in combination with the [[shaft skin]], allows a natural [[gliding action]]. During intercourse as well as [[masturbation]] the outer skin is in contact with the [[vagina]] or the hand respectively. The penile shaft moves mostly within its skin and the skin only moves at the end of its thrust. Due to this, the friction with the [[vagina]] or hand is reduced. The sexual stimulation mostly occurs through the [[stretching]] and movement of the [[foreskin], when it is pulled over the glans and back, as well as the direct stimulation of the inner foreskin when it is exposed and comes into direct contact with the vagina or the hand. The [[frenulum]] may limit retraction.
  
−
There are several different methods:
+
The foreskin in childhood is fused with the glans penis by a [[synechia]].-->
−
<ref>http://de.wikipedia.org/wiki/Phimose#Pr.C3.A4putiumsplastik</ref>
 
  
−
* Dorsal slit with transverse suturing: this technique places a single lengthwise cut into the stenotic ring which is then closed transversely.
+
==Videos==
−
* Lateral preputioplasty: this is a refinement of the dorsal slit with transverse suturing. It consists of two lateral, longitudinal incisions sutured transversely.
+
====Why you need to pull back your foreskin.====
−
* Triple incision: this is a method of foreskin widening. It typically consists of three incisions across the tight ring. They are closed from side to side, thereby increasing the circumference of the tight ring relative to the length of the cuts. From an aesthetic view, it has results far superior to those of a dorsal slit, and usually yields a good cosmetic result.
+
<youtube>v=PcxwW4KH3Wg</youtube>
 +
====Male Foreskin is Important - Here's Why====
 +
<youtube>v=EtIYx8WnOvg</youtube>
 +
<br>
 +
Pathologist [[Ken McGrath]], Senior Lecturer in Pathology at the Faculty of Health, [https://www.aut.ac.nz/ Auckland University of Technology] and Member of the New Zealand Institute of Medical Laboratory Scientists, discusses the neurological structures in the foreskin:
  
−
If after a failed attempt to stretch the foreskin with corticosteroid cream a surgical intervention is necessary, a preputioplasty is always to be preferred over classic circumcision, due to its lower morbidity, lower rate of complications and lower costs.
+
<youtube>v=lmToXLVrZ7c</youtube>
  
−
=== Pathological Phimosis ===
+
Dr. Willam Collins explains the nature of the prepuce.
  
−
In pathological phimosis, the foreskin cannot be retracted over the glans without injury, due to a lack of elasticity caused by scarring or hardening.
+
<youtube>v=tggap0Hy1l0</youtube>
 +
<br>
 +
<youtube>v=OfeK75HWW7k</youtube>
 +
{{SEEALSO}}
 +
* [[Acroposthion]]
 +
* [[Care of intact, foreskinned boys]]
 +
* [[Circumcision - Penis SensitivityTest]]
 +
* [[Foreskin in Motion]]
 +
* [[Foreskin sensitivity]]
 +
* [[Frenulum]]
 +
* [[Gliding action]]
 +
* [[Immunological and protective function of the foreskin]]
 +
* [[Pre-ejaculate]]
 +
* [[Preputial sac]]
 +
* [[Retraction of the foreskin]]
 +
* [[Ridged band]]
 +
* [[The Foreskin and Why You Should Keep It (book)]]
 +
* [[Vagina]]
  
−
Repeated infections of the tight foreskin cause this scarring. Also, forceful attempts to retract the foreskin cause tearing with subsequential scarred [[phimosis]]. Lichen sclerosus, that first leads to adhesion and then to shrinking, can also be the cause of [[phimosis]]. This rare, non-contagious chronic skin disease is partly genetically caused and considered incurable.
+
{{LINKS}}
−
<ref>http://de.wikipedia.org/wiki/Lichen_sclerosus_et_atrophicus</ref>
+
* {{REFdocument
 +
|title=When Your Baby Boy is Not Circumcised
 +
|url=https://pool.intactiwiki.org/w/images/1982-02_Wallerstein-WhenYourBabyBoyIsNotCircumcised.pdf
 +
|language=English
 +
|last=Wallerstein
 +
|first=Edward
 +
|author-link=Edward Wallerstein
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|publisher=Pennypress
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|location=Seattle
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|format=Four-page pamphlet
 +
|date=1982-02
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|accessdate=2021-05-30
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}}
 +
* {{REFjournal
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|last=Fleiss
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|first=Paul
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|init=P
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|author-link=
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|title=The foreskin is necessary
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|journal=Mothering
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|date=1997-01
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|issue=
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|pages=36-45
 +
|url=http://www.noharmm.org/mothering.htm
 +
|accessdate=2020-06-29
 +
}}
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*{{REFweb
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|url=http://www.foreskin.org/
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|title=33 Photographs of the foreskin (Non-Pornographic)
 +
|last=Erickson
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|first=John
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|author-link=John A. Erickson
 +
|publisher=
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|website=Foreskin
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|date=1999
 +
|accessdate=2019-10-25
 +
|format=
 +
|quote=
 +
}}
 +
* {{REFbook
 +
|last=Scott
 +
|first=Steve
 +
|init=S
 +
|author-link=Steve Scott
 +
|year=1999
 +
|title=The anatomy and physiology of the human prepuce
 +
|url=https://www.coloradonocirc.org/files/handouts/Anatomy_and_Physiology.pdf
 +
|work=Male and Female Circumcision
 +
|editor=[[George C. Denniston|Denniston]] et al.
 +
|edition=
 +
|volume=
 +
|chapter=
 +
|scope=
 +
|page=
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|pages=9-18
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|location=New York
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|publisher=Kluwer Academic / Plenum Publishers
 +
|ISBN=
 +
|quote=
 +
|accessdate=2022-08-03
 +
|note=
 +
}}
 +
* {{REFweb
 +
|url=
 +
|title=Ch. 2: The Prepuce (DOC Genital Integrity Statement)
 +
|last=Hill
 +
|first=George
 +
|author-link=George Hill
 +
|publisher=[[Doctors Opposing Circumcision (D.O.C.)]]
 +
|website=Research Hub
 +
|date=2008-06-14
 +
|accessdate=2019-12-15
 +
|format=
 +
|quote=
 +
}}
 +
* {{REFweb
 +
|url=http://www.circumstitions.com/Works.html
 +
|title=NSFW Video: How the foreskin works
 +
|last=Young
 +
|first=Hugh
 +
|author-link=Hugh Young
 +
|publisher=Circumstitions
 +
|website=
 +
|date=2010
 +
|accessdate=2019-10-25
 +
|format=
 +
|quote=
 +
}}
 +
* {{REFweb
 +
|url=https://madsciencewriter.blogspot.com/2013/05/the-foreskin-why-is-it-such-secret-in.html?m=1
 +
|title=The foreskin: Why is it such a secret in North America?
 +
|last=Quine
 +
|first=Spoony
 +
|author-link=
 +
|publisher=Mad Science Writer
 +
|website=
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|date=2013-05-08
 +
|accessdate=2020-04-19
 +
|format=
 +
|quote=
 +
}}
 +
* {{REFweb
 +
|url=http://www.noharmm.org/advantage.htm
 +
|title=The Foreskin Advantage
 +
|last=Harryman
 +
|first=Gary L.
 +
|author-link=
 +
|publisher=
 +
|website=NOHARMM
 +
|date=2013-11-22
 +
|accessdate=2021-09-02
 +
|format=
 +
|quote=
 +
}}
 +
* {{REFweb
 +
|url=http://www.intactaus.org/information/functionsoftheforeskin/
 +
|title=Functions of the Foreskin
 +
|last=Helard
 +
|first=Lou
 +
|author-link=
 +
|publisher=Intact Australia
 +
|website=
 +
|date=2014-08-01
 +
|accessdate=2020-05-29
 +
|format=
 +
|quote=
 +
}}
 +
* {{REFweb
 +
|url=https://circumcision.org/functions-of-the-foreskin/
 +
|title=Functions of the Foreskin
 +
|last=Goldman
 +
|first=Ronald
 +
|author-link=Ronald Goldman
 +
|publisher=Circumcision Resource Center
 +
|website=circumcision.org
 +
|date=
 +
|accessdate=2020-07-01
 +
|format=
 +
|quote=
 +
}}
 +
* {{REFweb
 +
|url=https://www.doctorsopposingcircumcision.org/for-professionals/the-prepuce/
 +
|title=The prepuce
 +
|last=
 +
|first=
 +
|author-link=
 +
|publisher=Doctors Opposing Circumccision
 +
|website=
 +
|date=2016-07
 +
|accessdate=2019-10-16
 +
|format=
 +
|quote=To provide informed, respectful care to males with intact genitals, and to fully understand the harms of circumcision, health professionals must have a thorough grasp of the anatomy, development, and functions of the foreskin (also known as the prepuce).
 +
}}
 +
* {{REFweb
 +
|url=http://www.noharmm.org/advantage.htm
 +
|title=The Foreskin Advantage
 +
|first=Gary L
 +
|last=Harryman
 +
|publisher=NORM/Southern California
 +
|website=[[NOHARMM]]
 +
|accessdate=2020-06-30
 +
}}
 +
* {{REFweb
 +
|url=https://intactamerica.org/promoting-the-prepuce/
 +
|title=Promoting the Prepuce
 +
|last=Chapin
 +
|first=Georganne
 +
|author-link=
 +
|publisher=Intact America
 +
|website=
 +
|date=2016-05-13
 +
|accessdate=2021-04-02
 +
|format=
 +
|quote=
 +
}}
 +
* {{REFweb
 +
|url=https://15square.org.uk/male-foreskin-is-functional-5-amazing-facts/
 +
|archived=
 +
|title=Male Foreskin is Functional – 5 Amazing Facts
 +
|trans-title=
 +
|language=
 +
|last=Troy
 +
|first=Louise
 +
|author-link=
 +
|publisher=15 Square
 +
|website=
 +
|date=2022-05-24
 +
|accessdate=2022-05-24
 +
|format=
 +
|quote=The foreskin is the primary fine-touch sensory tissue of the penis.
 +
}}
 +
* {{REFweb
 +
|url=https://www.linkedin.com/pulse/circumcision-sexological-damage-erogenous-lip-tool-michel-herv%C3%A9
 +
|title=Circumcision, the sexological damage (an erogenous lip, protective of erogeneity and the tool of autosexuality, the foreskin is a sexual organ)
 +
|last=Bertaux-Navoiseau
 +
|first=Michel Hervé
 +
|init=
 +
|author-link=Michel Hervé Bertaux-Navoiseau
 +
|publisher=Linkedin
 +
|date=2022-11-06
 +
|accessdate=2022-11-16
 +
}}
 +
* {{REFweb
 +
|url=https://www.youtube.com/watch?v=09gW4TclGqY
 +
|title=The Amazing Foreskin: Learn Integral Anatomy with Gil Hedley
 +
|last=Headley
 +
|first=Gil
 +
|init=
 +
|publisher=
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|date=2022
 +
|accessdate=2022-12-03
 +
}}
 +
* {{REFweb
 +
|url=https://wikionlymen.com/does-foreskin-grow-with-age/
 +
|title=Does Foreskin Grow With Age?
 +
|last=
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|first=
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|init=
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|author-link=
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|publisher=Wiki Only Men
 +
|date=2022-06-12
 +
|accessdate=2024-10-05
 +
}}
 +
{{REF}}
  
−
Pathological phimosis requires treatment.
 
  
−
A circumcision is indicated in severe cases of pathological phimosis, where neither non-surgical methods with corticosteroid cream nor foreskin-preserving preputioplasty are promising (for example with chronic balanitis xerotica obliterans) or have failed in previous attempts.
 
  
−
== References ==
+
[[Category:Foreskin anatomy]]
−
<references />
+
[[Category:Genital]]
 +
[[Category:Parental information]]
 +
[[Category:Penile anatomy]]
 +
[[Category:Male sexuality]]
 +
[[Category:Education]]
  
−
[[Category:Genitals]]
+
[[Category:From Intactipedia]]
  
 
[[de:Vorhaut]]
 
[[de:Vorhaut]]

Latest revision as of 13:29, 22 October 2024

Foreskin - Anatomy and function

The foreskin or prepuce is the double-layered fold of smooth muscle tissue, blood vessels, neurons, skin, and mucous membrane part of the penis that creates the preputial sac, while covering and protecting the glans penis and the urinary meatus.

The nature of the prepuce or foreskin, which is amputated and destroyed by circumcision, must be considered and fully understood in any discussion of male circumcision.[1]

Purpura et al. (2018) described the foreskin as follows:

Few parts of the human anatomy can compare to the incredibly multifaceted nature of the human foreskin. At times dismissed as “just skin,” the adult foreskin is, in fact, a highly vascularized and densely innervated bilayer tissue, with a surface area of up to 90 cm, and potentially larger. On average, the foreskin accounts for 51% of the total length of the penile shaft skin and serves a multitude of functions. The tissue is highly dynamic and biomechanically functions like a roller bearing; during intercourse, the foreskin “unfolds” and glides as abrasive friction is reduced and lubricating fluids are retained. The sensitive foreskin is considered to be the primary erogenous zone of the male penis and is divided into four subsections: inner mucosa, ridged band, frenulum, and outer foreskin; each section contributes to a vast spectrum of sensory pleasure through the gliding action of the foreskin, which mechanically stretches and stimulates the densely packed corpuscular receptors. Specialized immunological properties should be noted by the presence of Langerhans cells and other lytic materials, which defend against common microbes, and there is robust evidence supporting HIV protection. The glans and inner mucosa are physically protected against external irritation and contaminants while maintaining a healthy, moist surface. The foreskin is also immensely vascularized and acts as a conduit for essential blood vessels within the penis, such as supplying the glans via the frenular artery.[2]

The medical community usually omits information on the nature and functions of the foreskin from information provided to the public and to parents.

Structure

Foreskin in infancy and childhood

Baby boys are born with the foreskin fused with the glans penis by the balanopreputial lamina, a synechial membrane, which prevents retraction. In addition, the tip of the foreskin (acroposthion) is usually too narrow to allow retraction of the foreskin. The preputial sac is closed by the synechia and cannot be infected.[3]

Forcible attempts to retract the foreskin result in injury to the boy, so should be avoided. The first person to retract the foreskin should be the boy himself.[4]

Thorvaldsen & Meyhoff (2005) conducted a survey of 4,000 boys in Denmark. They reported that the mean age of first foreskin retraction is 10.4 years in Denmark.[5]

Foreskin in adolescence

The foreskin is in a transitional state during puberty and adolesence in which it is changing from the non-retractile foreskin of childhood to thh fully retractable foreskin of adulthood. Many adolescents complain of a non-retractable foreskin. Many need to do manual stretching. They usually achieve full retraction by age 16.

Foreskin in adulthood

The foreskin (also known as the prepuce) is the layered fold of smooth muscle tissue, blood vessels, neurons, skin, and mucous membrane part of the penis that covers and protects the glans penis and the urinary meatus.[1] There are four layers in the foreskin. The top layer is either epidermis in the outer foreskin or mucosa, in the inner foreskin. The second layer is the lamina propria. The third layer is the dartos. The fourth layer is the dermis. It is normal for the foreskin to be darker in color than the rest of one's body after puberty. This condition is called hyperpigmentation.

The adult foreskin measures about 3 inches by 5 inches or 15 square inches.[6] The foreskin creates the preputial sac. The two foreskin layers provide a skin reserve. When the penis becomes erect, the foreskin may wholly or partially unfold to provide the necessary skin to allow for expansion of the penis during erection.

The foreskin is the movable part of the penis. The foreskin is not attached to the underlying structure and is free to glide back and forth.[7] The gliding action reduces the friction of intercourse and helps to prevent abrasions, while conserving vaginal lubrication and moisture.[8] The foreskin is attached to the glans penis on the ventral side by the frenulum, which usually limits retraction to a widely variable degree. The ridged band emanates from the frenulum.[1]

The epithelium of the outer layer of the foreskin is true skin while the epithelium of the inner layer is mucosal membrane. There is a mucocutaneous boundary at the tip of the foreskin. The mucocutaneous junction is a specific erogenous zone,[9] Taylor et al. reported:

The vascular ridges of the `ridged band' and its Meissner's corpuscles firmly separate preputial epithelium from true skin and place preputial mucosa amongst other mucocutaneous mucosae. Winkelmann emphasized the structural and functional importance of junctional regions of the body and focused on mucocutaneous end-organs, or `genital corpuscles', of the glans penis and prepuce. Some of these end-organs resemble Krause end-bulbs; others resemble Meissner's corpuscles. … Meissner's corpuscles of the prepuce may be compared with similar nerve-endings in the finger-tips and lips, which respond in a fraction of a second to contact with light objects that bring about deformation of their capsules. … The prepuce provides a large and important platform for several nerves and nerve endings. The innervation of the outer skin of the prepuce is impressive; its sensitivity to light touch and pain are similar to that of the skin of the penis as a whole.[6]

The highly innervated ridged band area is found at the mucocutaneous junction. The ridged band area is characterized by rete ridges with Meissner's corpuscles in the ridges.[6]

As with other neurologic structures such as the brain, the tip of the prepuce is richly supplied with blood by important vascular structures.[6] The prepuce serves as a conduit for several important veins.[3] The glans penis receives blood through the frenular artery.[10] The adult foreskin frequently has prominent visible veins.

The layer of dartos muscle is contained within the foreskin.[1] It makes the foreskin rather stretchy. The dartos muscle keeps the foreskin snugly against the glans. The fibers of the dartos muscle form a whorl at the tip that functions as a sphincter. The sphincter opens to allow urine to flow out, but closes to protect the penis from foreign matter, contaminants, and pathogens.[7][11]

The outer foreskin usually becomes somewhat darker after puberty due to increased melanin.[12]

Foreskin length

Natural foreskins are found in all lengths from very short to very long. Most fall near the center of the range. Longer foreskins appear to perform their protective and immunological function more satisfactorily. A short or inadequate foreskin may be lengthened by tissue expansion to improve function and aesthetics.

The tapered tip of a longer foreskin that extends beyond the glans penis is known as the acroposthion. A very few of the longest foreskins will not remain retracted when released, but will spontaneously glide forward to recover the glans penis. Longer foreskins improve protection and gliding action and do not usually create an issue. There is no recognized definition of an excessively long or so-called "redundant" foreskin.[13]

See Adult foreskin.

Physiological functions

Antique research by Alfred Kinsey (1948)[14] and Masters & Johnson (1966)[15] misled medical science into believing that the foreskin had no function. This meant the foreskin could be excised without doing harm. In actuality, the foreskin has many functions,[16] so its amputation does great harm.[17]

The human race evolved over perhaps 700 millenia. The foreskin evolved its physiological functions that improve fitness for survival during that time.[18]

Protective functions

The foreskin provides physical protection to the glans penis and inner mucosa,[19] supplying moisture and natural oils by transudation, while protecting the mucosal tissue from pathogens, pollutants, friction, injury, keratinization, de-sensitization, and drying out. The foreskin protects the glans penis and meatus of infant boys from abrasion and irritation from ammoniacal diapers.[20] [21]

In the absence of the foreskin about ten to twenty percent of circumcised boys suffer urethral stricture (meatal stenosis) requiring further treatment.[22] Frisch & Simonsen (2016) reported the incidence of meatal stenosis to be 3.7 times higher in circumcised boys.[22]

The foreskin continues to protect the glans penis throughout life, keeping it smooth, glossy, moist, sensitive, and free from keratinization and loss of sensation.

Immunological functions

Fleiss et al. (1998) have listed numerous immunological functions of the foreskin that help to protect the human body against infection. The foreskin maintains the moistness of the preputial mucosa and the glans penis by transudation. The sub-preputial moisture contains cathepsin B, chymotrypsin, neutrophil elastase, cytokines, and lysozyme, which has the capacity to destroy the cell walls of bacteria. The preputial muscles keep the tip of the foreskin closed to keep out pathogens.[3]

The foreskin is highly vascularized. The high rate of blood flow helps to prevent infection.[3]

Although claims have been made that the presence of the foreskin increases the risk of infection with human immune deficiency virus (HIV), that is not correct. The claims are based on the reported findings of three randomized clinical trials (RCTs) that were carried out more than a decade ago in Africa. Boyle & Hill (2011) have shown these RCTs to be have significant methodological flaws and statistical errors that render their claims invalid.[23]

Fleiss et al. noted the presence of Langerhans cells in the prepuce.[3] De Witte et al. (2007) have discovered that Langerhans cells produce Langerin, which is a "natural barrier to HIV infection".[24]

For more information, see Immunological and protective function of the foreskin.

Sexual functions

The foreskin is a sexual organ.[17] It provides both mechanical and erogenous functions in sexual intercourse,[16] as well as pheromones for the excitement and arousal of the partner.[3] Winkelmann (1959) classified the foreskin as specific erogenous tissue.[9] When the penis becomes erect, the foreskin unfolds to provide the skin necessary to allow the penis to expand to full size and length.

The gliding action provides stimulation and facilitates intromission.[8][25] [26] At times of sexual arousal, the foreskin may be lubricated by pre-ejaculate. During the thrusting of sexual congress, the gliding action reduces abrasions and irritation in the female partner and avoids problems with vaginal dryness.[8][25] The foreskin may protect the corona glandis from hyper-stimulation and prevent premature ejaculation.

Sensory functions

Nature designed the foreskin to be an erogenous sensory organ.[17] The foreskin has a layer of muscle called the dartos muscle sheath that provides the foreskin with elasticity, flexibility, and stretchiness, which allows full stimulation of the nerves in the ridged band that sense movement and stretching to provide foreskin sensitivity. There is a mucocutaneous region at the tip of the foreskin where outer skin changes to inner mucosa. Winkelmann (1959) identified the foreskin as a specific erogenous zone (meaning an area of acute erogenous sensation). Winklemann reported rete ridges in the foreskin with nerves set close to the surface with closely set networks.[9]

Lakshamanan & Prakash (1980) report the "prepuce covers the glans completely and snugly like a hosiered material and continues to do so through the entire span of life of the male", which they explain as being caused by the smooth muscle fibers within the prepuce. The prepuce is free to glide back and forth. When it does, it must stretch to go over the glans penis.[7]

Taylor et al. (1996) carried out a histological study of the foreskin. (Histology is the microscopic examination of cells and tissues.) Taylor et al. found an area of rete ridges just inside the tip of the foreskin that he called the ridged band. The ridges were found to have nerve endings at the top of the ridges. They report that the ridged band area moves to the shaft of the penis when the penis becomes erect where the nerves are subject to stimulation. They stated:

The prepuce provides a large and important platform for several nerves and nerve endings. The innervation of the outer skin of the prepuce is impressive; its sensitivity to light touch and pain are similar to that of the skin of the penis as a whole.[6]

Sorrells et al. (2007) conducted a fine-touch study of the penis of both circumcised and intact men. Sorrells et al. concluded:

In conclusion, circumcision removes the most sensitive parts of the penis and decreases the fine-touch pressure sensitivity of glans penis. The most sensitive regions in the uncircumcised penis are those parts ablated by circumcision. When compared to the most sensitive area of the circumcised penis, several locations on the uncircumcised penis (the rim of the preputial orifice, dorsal and ventral, the frenulum near the ridged band, and the frenulum at the muco-cutaneous junction) that are missing from the circumcised penis were significantly more sensitive.[27]

Bronselaer et al. (2013) surveyed a large group of intact and circumcised men in Belgium. They reported:

Of the men in Group A [intact males], 90.6% rated the sexual pleasure provided when the foreskin was stimulated by themselves or their partners from ‘mild’ to ‘very strong’ and 61.9% the respective orgasm from ‘mild’ to ‘very strong’.

For the glans penis, men in Group B [circumcised males] reported significantly less sexual pleasure than men in Group A at the dorsal side (P ≤ 0.001), and the lateral (P ≤ 0.001) and ventral sides (P = 0.02). Orgasm was less intense in Group B at the dorsal side (P = 0.006) and at the lateral sides (P = 0.02). Group B required more effort in achieving orgasm at the lateral sides (P = 0.04). Furthermore, a larger percentage of men in this group reported numbness at the dorsal, lateral, and ventral sides (all P ≤ 0.001), as well as unusual sensations (burning, prickling, itching, or tingling) at the lateral sides (P = 0.02) and at the ventral side (P = 0.003) of the glans.[28]

García-Mesa et al. (2021) reported the foreskin has an abundance of Meissner's corpuscles which provide pleasant sexual sensation when mechanically stimulated by motion of the foreskin.[29]

Sexual behavior

Laumann et al. (1997) reported that men who lack a foreskin "engage in a somewhat more elaborated set of sexual practices than do men who are not circumcised. For each of the practices examined, lifetime experience of various forms of oral and anal sex and masturbation frequency in the past year, circumcised men engaged in these behaviors at greater rates. The difference between circumcised men was greatest for masturbation — ironically, a practice that circumcision was once thought to limit. A total of 47% of circumcised men reported masturbating at least once a month vs 34% for their uncircumcised peers."[30] Dave et al. (2003) reported that men without foreskins "were more likely to report having had homosexual partner(s) (7.5% v 5.3%, p =0.012) and partners from abroad (19.7% v 13.1%, p...0.001)."[31]

Cold & Taylor (1999) commented, "The increased frequency of masturbation, anal intercourse and fellatio reported by circumcised men in the USA may possibly be due to the sensory imbalance caused by circumcision. Clearly, amputation of the prepuce causes changes in sexual behaviour in human males and females."[1]

Frisch et al. (2011) surveyed the sexual function and behavior of a large group of intact and circumcised men in Denmark. They reported that "circumcised men were more likely (38%) than uncircumcised men (28%) to report ≥10 sex partners."[32]

The role of the foreskin in heterosexual relations

The knowledge of the important of the intact penis in heterosexual relations long has been known to the Jews who give us our earliest evidence of the value of the foreskin to the female partner.

Moses Maimonides, a Jewish rabbi and physician, stated in the 12th century:

“ It is hard for a woman with whom an uncircumcised man has had sexual intercourse to separate from him.
– Moses Maimonides[33]

According to the Rabbi Isaac ben Yedaiah, who lived in Southern France in the late 13th century:

She too will court the man who is uncircumcised in the flesh and lie against his breast with great passion, for he thrusts inside her a long time because of his foreskin, which is a barrier against ejaculation in intercourse. Thus she feels pleasure and reaches an orgasm first. When an uncircumcised man sleeps with her, and then resolves to return to his home, she brazenly grabs him, holding on to his genitals and says to him, "Come back, make love to me." This is because of the pleasure that she finds in intercourse with him, from the sinews of his testicles—sinew of iron—and from his ejaculation—that of a horse which he shoots like an arrow into her womb. They are united without separating, and he makes love twice and three times in one night, yet the appetite is not filled.[34]

As previously reported, the foreskin reduces the force required for penetration of the female partner's vagina by as much as ninety percent.[26] The gliding action of the foreskin reduces friction and abrasion, while conserving vaginal lubrication.[8]

In a first of its kind, O'Hara & O'Hara (1999) carried out a retrospective survey of 138 women with experience of both intact and circumcised partners. The women overwhelmingly concurred that the mechanics of coitus was different for the two groups of men. Of the women, 73% reported that circumcised men tend to thrust harder and deeper, using elongated strokes, while unaltered men by comparison tended to thrust more gently, to have shorter thrusts, and tended to be in contact with the mons pubis and clitoris more, according to 71% of the respondents. Women with intact partners had a higher rate of orgasms than women with circumcised partners. O'Hara & O'Hara concluded:

Clearly, the anatomically complete penis offers a more rewarding experience for the female partner during coitus. While this study has some obvious methodological flaws, all the differences cannot be attributed to them. It is important that these findings be confirmed by a prospective study of a randomly selected population of women with experience with both types of men. It would be useful to examine the role of the foreskin in other sexual activities. Because these findings are of interest, the negative effect of circumcision on the sexual enjoyment of the female partner needs to be part of any discussions providing 'informed consent' before circumcision.[35]

Solinis & Yiannaki (2007) concluded; "[t]here was a decrease in couple’s sexual life after circumcision indicating that adult circumcision adversely affects sexual function in many men or/and their partners, possibly because of complications of surgery and loss of nerve endings."[36]

Frisch et al. (2011) surveyed a very large group of men and women in Denmark. They concluded:

"Circumcision was associated with frequent orgasm difficulties in Danish men and with a range of frequent sexual difficulties in women, notably orgasm difficulties, dyspareunia and a sense of incomplete sexual needs fulfilment."[32]

Videos

Why you need to pull back your foreskin.

Male Foreskin is Important - Here's Why


Pathologist Ken McGrath, Senior Lecturer in Pathology at the Faculty of Health, Auckland University of Technology and Member of the New Zealand Institute of Medical Laboratory Scientists, discusses the neurological structures in the foreskin:

Dr. Willam Collins explains the nature of the prepuce.


See also

External links

References

  1. ↑ a b c d e REFjournal Cold CJ, Taylor JR. The prepuce. BJU Int. January 1999; 83, Suppl. 1: 34-44. PMID. DOI. Retrieved 8 July 2021.
  2. ↑ REFjournal Purpura V, Bondioli E, Cunningham EC, et al. The development of a decellularized extracellular matrix–based biomaterial scaffold derived from human foreskin for the purpose of foreskin reconstruction in circumcised males. J Tissue Eng. 22 December 2018; PMID. PMC. DOI. Retrieved 9 February 2020.
  3. ↑ a b c d e f REFjournal Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Infect. October 1998; 74(5): 364-67. PMID. PMC. DOI. Retrieved 14 January 2022.
  4. ↑ REFjournal Wright JE. Further to the "Further Fate of the Foreskin". Med J Aust. 7 February 1994; 160: 134-135. PMID. Retrieved 16 May 2020.
  5. ↑ REFjournal Thorvaldsen MA, Meyhoff H. Patologisk eller fysiologisk fimose? [Pathological or physiological phimosis?] (Danish). Ugeskr Læger. 2005; 167(17): 1858-1862. Retrieved 14 November 2019.
  6. ↑ a b c d e REFjournal Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol. 1996; 77: 291-5. PMID. DOI. Retrieved 23 September 2019.
  7. ↑ a b c REFjournal Lakshmanan S, Prakash S. Human prepuce: some aspects of structure and function. Indian J Surg. 1980; 44: 134-7.
  8. ↑ a b c d REFjournal Warren J, Bigelow J. The case against circumcision. Brit J Sex Med. September 1994; Retrieved 28 October 2019.
  9. ↑ a b c REFjournal Winkelmann RK. The erogenous zones: their nerve supply and significance. Mayo Clin Proc. 21 January 1959; 34(3): 39-47. PMID. Retrieved 4 June 2021.
  10. ↑ REFjournal Persad R, Sharma S, McTavish J, et al. Clinical presentation and pathophysiology of meatal stenosis following circumcision. Brit J Urol. 1995; 75(1): 91-3. PMID. DOI. Retrieved 15 October 2019.
  11. ↑ REFjournal Jefferson. The peripenic muscle; some observations on the anatomy of phimosis. Surgery, Gynecology, and Obstetrics (Chicago). 1916; 23(2): 177-81. Retrieved 14 October 2019.
  12. ↑ REFweb (2012). hyperpigmentation, Medical Dictionary for the Dental Professions. Retrieved 25 September 2024.
  13. ↑ REFweb (2022). The ‘Tip’ At The End, Acroposthion. Retrieved 21 June 2022.
  14. ↑ REFbook Kinsey, Alfred C. (1948): Sexual behavior in the human male. Retrieved 16 June 2022.
  15. ↑ REFbook Masters, William (1966): Human sexual response. ISBN 978-0-553-20429-2. Retrieved 16 June 2022.
  16. ↑ a b REFweb Garrett, Connor (19 February 2024). 6 Things You Need to Know About The Intact Penis, Intact America. Retrieved 21 October 2024.
  17. ↑ a b c REFjournal Hill G. The case against circumcision PDF. Journal of Men's Health and Gender. 2007; 4(3): 318-323. Retrieved 1 October 2023.
  18. ↑ REFweb Wikipedia article: Evolution
  19. ↑ REFjournal Morgan WKC. The rape of the phallus. JAMA. 19 July 1965; 193(3): 123-4. PMID. DOI. Retrieved 21 May 2024.
    Quote: This ritual, however, has become so widespread in the United States that it is no longer much of a status symbol, and a situation has arisen where any recently delivered mother who is eccentric enough to wish her child to retain his prepuce, would be well advised to maintain permanent guard over it until such time as they both leave the hospital.
  20. ↑ REFjournal Gairdner DMT. The fate of the foreskin: a study of circumcision. British Medical Journal. 1949; 2(4642): 1433-7. PMID. PMC. DOI. Retrieved 28 October 2019.
  21. ↑ REFjournal Dobanavacki D, Lucić Prostran B, Sarac D, et al. Prepuce in boys and adolescents: what when, and how?. Med Pregl. 2012; 65(7-8): 295-300. PMID. DOI. Retrieved 14 October 2019.
  22. ↑ a b REFjournal Frisch M, Simonsen J. Cultural background, non-therapeutic circumcision and the risk of meatal stenosis and other urethral stricture disease: Two nationwide register-based cohort studies in Denmark 1977-2013. The Surgeon. 1 April 2016; 16(2): 107-18. PMID. DOI. Retrieved 23 October 2019.
  23. ↑ REFjournal Boyle GJ, Hill G. Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns PDF. Thompson Reuter. December 2011; 19(2): 316-34. PMID. Retrieved 30 December 2020.
  24. ↑ REFjournal de Witte L, Nabatov A, Pion M, Fluitsma D, de Jong MAWP, de Gruijl T, Piguet V, van Kooyk Y, Geijtenbeek TBH. Langerin is a natural barrier to HIV-1 transmission by Langerhans cells PDF. Nature Medicine. 4 March 2007; 13(3): 367-71. PMID. PMC. DOI. Retrieved 6 October 2022.
  25. ↑ a b REFjournal Morgan WKC. The rape of the phallus. JAMA. 1965; 193: 123-4. PMID. DOI. Retrieved 15 October 2019.
  26. ↑ a b REFjournal Taves D. The intromission function of the foreskin. Med Hypotheses. 2002; 59(2): 180. PMID. DOI. Retrieved 15 October 2019.
  27. ↑ REFjournal Sorrells ML, Snyder JL, Reiss MD, Eden C, Milos MF, Wilcox N, Van Howe RS. Fine‐touch pressure thresholds in the adult penis. BJUI. 19 March 2007; 99(4): 864-9. PMID. DOI. Retrieved 10 January 2021.
  28. ↑ REFjournal Bronselaer G, Schoeber JM, Meyer-Bahlburg HM, T'Sjoen G, Vlietinck R, Hoebeke PB. Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int. May 2013; 111(5): 820-7. DOI. Retrieved 23 October 2019.
  29. ↑ REFjournal García-Mesa, Yolanda, García-Piqueras, Jorge, Cobo, Ramón, Martín-Cruces, José, Suazo, Iván, García-Suárez, Olivia, Feito, Jorge. Sensory innervation of the human male prepuce: Meissner's corpuscles predominate. Journal of Anatomy. October 2021; 239(4): 892-902. PMID. PMC. DOI. Retrieved 15 November 2021.
  30. ↑ REFjournal Laumann EO, Masi CM, Zuckerman CW. Circumcision in the United States. JAMA. 2 April 1997; 277(13): 1052-7. PMID. Retrieved 23 October 2019.
  31. ↑ REFjournal Dave SS, Johnson AM, Fenton KA, Mercer CH, Erens B, Wellings K. Male circumcision in Britain: findings from a national probability sample survey. Sex Trans Infect. December 2003; 79: 499-500. PMID. PMC. DOI. Retrieved 29 October 2019.
  32. ↑ a b REFjournal Frisch M, Lindholm M, Grønbæk M. Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark. Int J Epidemiol. 14 June 2011; 40(5): 1367-81. PMID. DOI. Retrieved 26 September 2021.
  33. ↑ REFbook Maimonides M (1963): The Guide of the Perplexed. P. 609. Retrieved 11 October 2019.
  34. ↑ REFbook Saperstein M (1980): Decoding the Rabbis: A Thirteenth-Century Commentary on the Aggadah. Retrieved 22 October 2019.
  35. ↑ REFjournal O'Hara K, O'Hara J, et al. The effect of male circumcision on the sexual enjoyment of the female partner. BJU Int. 1999; 83 Suppl 1: 79-84. PMID. DOI. Retrieved 22 October 2019.
  36. ↑ REFjournal Solinis, Yiannaki. Does circumcision improve couple's sex life?. Journal of Men's Health and Gender. September 2007; 4(3): 361. Retrieved 23 October 2019.
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