Professional Documents
Culture Documents
Fine-Touch Pressure Thresholds in The Uncircumcised and Circumcised Adult Penis
Fine-Touch Pressure Thresholds in The Uncircumcised and Circumcised Adult Penis
et al.
OBJECTIVE last ejaculation, ethnicity, country of birth, circumcision had lower pressure thresholds
and level of education. than the ventral scar of the circumcised penis.
To map the fine-touch pressure thresholds
of the adult penis in circumcised and CONCLUSIONS
uncircumcised men, and to compare the two RESULTS
populations. The glans of the circumcised penis is less
The glans of the uncircumcised men had sensitive to fine touch than the glans of the
significantly lower mean (SEM) pressure uncircumcised penis. The transitional region
SUBJECTS AND METHODS thresholds than that of the circumcised men, from the external to the internal prepuce
at 0.161 (0.078) g (P = 0.040) when controlled is the most sensitive region of the
Adult male volunteers with no history of for age, location of measurement, type of uncircumcised penis and more sensitive than
penile pathology or diabetes were evaluated underwear worn, and ethnicity. There were the most sensitive region of the circumcised
with a Semmes-Weinstein monofilament significant differences in pressure thresholds penis. Circumcision ablates the most sensitive
touch-test to map the fine-touch pressure by location on the penis (P < 0.001). The most parts of the penis.
thresholds of the penis. Circumcised and sensitive location on the circumcised penis
uncircumcised men were compared using was the circumcision scar on the ventral KEYWORDS
mixed models for repeated data, controlling surface. Five locations on the uncircumcised
for age, type of underwear worn, time since penis that are routinely removed at circumcision, pressure sensitivity, penis
© 2 0 07 T H E A U T H O R S
864 JOURNAL COMPILATION © 2 0 0 7 B J U I N T E R N A T I O N A L | 9 9 , 8 6 4 – 8 6 9 | doi:10.1111/j.1464-410X.2006.06685.x
FINE-TOUCH PRESSURE THRESHOLDS IN THE ADULT PENIS
FIG. 1. Locations on the dorsal penis evaluated for FIG. 2. Locations on the ventral penis evaluated for preputial orifice; (4) the muco-cutaneous
fine-touch pressure thresholds. fine-touch pressure thresholds. junction; (5) the ridged band; (6) the preputial
mucosa; (7) the coronal sulcus; (8) the coronal
1. 11. ridge; (9) the middle of dorsal aspect of the
SHAFT PROXIMAL CORONAL
TO CORONAL
glans; (10) the glans at the meatus; on the
RIDGE
RIDGE ventral surface of the penis, the locations
12.
2. FRENULUM were (11) the coronal ridge; (12) the frenulum
OUTER AT URETHRAL at the urethral slit; (13) the frenulum near the
PREPUCE SLIT ridged band; (14) the frenulum at the muco-
3. 13. cutaneous junction; (15) the rim of the
ORIFICE FRENULUM preputial orifice; (16) the outer prepuce; (17)
RIM NEAR the shaft proximal to the coronal ridge; and
4. RIDGED BAND locations pertaining to circumcised men only
MUCO- 14. (18) the circumcision scar on the dorsal
CUTANEOUS FRENULUM AT
surface and (19) the circumcision scar on the
JUNCTION MUCO-CUTANEOUS
JUNCTION ventral surface. Locations 2–5 and 13–16
5.
RIDGED 15.
were measured only in uncircumcised men
BAND ORIFICE because these locations are ablated by
6. RIM circumcision.
PREPUTIAL 16.
MUCOSA OUTER Because of the method of data collection, it
7. PREPUCE was impossible for the physician measuring
SULCUS 17. the fine-touch thresholds to be unaware of
8. SHAFT PROXIMAL the circumcision status of the subject.
CORONAL TO CORONAL Likewise, because of the number of locations
RIDGE RIDGE
sampled, it was also impossible for the
9. 18.
statistician to be unaware of the circumcision
MIDDLE SCAR /
DORSAL status of the subject.
OF GLANS
10. SURFACE
GLANS 19. Based on unpublished pilot data, it was
AT MEATUS SCAR / determined that sampling 50 uncircumcised
VENTRAL and 150 circumcised men would have 80%
SURFACE power to show a difference of 0.046 g with a
penis and quantify the differences in penile type I error of 5%. Demographic information
sensitivity between men with and without genitals, e.g. hypospadias; a history of by circumcision status were compared using
foreskins. diseases or conditions known to affect sexual Mantel-Haenszel, Fisher’s exact, chi-square
sensitivity and function, e.g. diabetes mellitus; and t-tests. Fine-touch pressure thresholds by
SUBJECTS AND METHODS a history of genital, prostate, or urinary tract location were compared using t-tests and
disease of any kind, including but not limited linear regression. Mixed models for repeated
Subjects were recruited by posting ‘fliers’ at to sexually transmitted diseases, open sores, data on single subjects stratified by location
the San Francisco Bay Area medical school. or lesions at the time of screening; prostatitis; of measurement, which control for within-
Also, announcements were made on a medical prostate cancer; BPH; spinal cord injury; subject variability, were developed using
radio programme, and advertisements were peripheral nerve injury; peripheral locations present in both the circumcised and
placed in local Bay Area general circulation neuropathy; sciatica; any penile piercing; the complete penis. Models were assessed
newspapers. penile enlargement surgery; any form of using forward, backwards and stepwise
psychiatric condition; or a history of alcohol selection. Similar models were developed
Subjects were men aged >18 years in good or substance abuse. Informed consent was using only locations on the glans penis. This
health, with no genital alterations, except for obtained before testing. study protocol was approved by the Western
circumcision, as determined by health- Institutional Review Board.
screening questions. A short questionnaire The fine-touch sensitivity of 19 locations on
was completed to determine ethnicity, place the penis was measured using Semmes-
of birth, highest education degree obtained, Weinstein monofilament touch-test sensory
type of underwear worn, timing of last evaluators (North Coast Medical Supply, RESULTS
ejaculation, referral source, and health status. Morgan Hill, CA, USA) [15–17] to create a
Circumcision status was determined by a penile sensitivity map (Figs 1 and 2) In all, 163 subjects were enrolled; one
physical examination. uncircumcised man was excluded for
On the dorsum of the penis, these locations diabetes, two uncircumcised men and one
Exclusion criteria were: transsexuals; intersex were: (1) the shaft proximal to coronal ridge; circumcised man were excluded for
individuals; males born with abnormal (2) the outer prepuce; (3) the rim of the hypospadias. All of the men completed the
© 2 0 07 T H E A U T H O R S
JOURNAL COMPILATION © 2 0 07 B J U I N T E R N AT I O N A L 865
S O R R E L L S ET AL.
TABLE 2 Mean fine-touch pressure threshold value (g) by position and circumcision status, and differences in fine-touch pressure threshold between the ventral
scar (Position 19) and the position found only on the uncircumcised penis
© 2 0 07 T H E A U T H O R S
866 JOURNAL COMPILATION © 2 0 07 B J U I N T E R N AT I O N A L
FINE-TOUCH PRESSURE THRESHOLDS IN THE ADULT PENIS
FIG. 3. Fine-touch pressure thresholds (g) by location on the adult penis, comparing uncircumcised men (red testing locations that provide the most
bars) and circumcised men (green bars), with a range of one SD shown with the error bars. differentiation.
over time.
© 2 0 07 T H E A U T H O R S
JOURNAL COMPILATION © 2 0 07 B J U I N T E R N AT I O N A L 867
S O R R E L L S ET AL.
In a study designed to measure the impact of men, there were no significant differences that take longer to develop. Likewise, the
anterior urethroplasty on erectile function, between the measurements taken at the glans acute changes from surgery and scar
Coursey et al. [4] included a control group of with the foreskin retracted and those taken at remodelling are known to take up to
men who were circumcised for ‘phimosis or the level of the glans with the foreskin in its 12 months to resolve [18]. Finally, except for
other benign indication’. Of the 48 men normal position. The positions used in that the Turkish study, the men in these studies
circumcised, only 22 (46%) completed the study correlate to positions 9, 10 and 16 in the had penile pathology. Consequently,
survey. Using an internally validated survey, present study. In our mixed model, controlling improvements in this population would be
27% reported worsening satisfaction with for location of the measurement, age, wearing expected regardless of the intervention, due
their erectile function after a procedure. briefs, being Hispanic, and circumcision to what is commonly referred to as the ‘floor
status, position 10 had a lower threshold than effect’ (more room for improvement than
In a Turkish population of 42 men in their position 9 (−0.243 g, SEM 0.079, P < 0.002). deterioration). Consequently, the worsening
third decade undergoing circumcision, 39 of The present data indicated that the location in so many subjects is remarkable. It could be
whom sought circumcision for religious on the uncircumcised penis measured by concluded that circumcision might be an
reasons, the Brief Male Sexual Function Bleustein et al. had one of the highest invalid intervention for these medical
Inventory, measured before and at least thresholds of the locations found only conditions.
12 weeks after the procedure, showed no on the uncircumcised penis. We found
difference in any of the five areas assessed by that the age-adjusted thresholds were The present subjects, while drawn from the
the instrument. However, the mean IELT was significantly lower in location 16 than either general population, were men who showed
significantly longer after circumcision 9 or 10 (location 9, −0.75 g, SEM 0.184, the initiative to participate. This might
(P = 0.02) [5]. As noted earlier, Turkish men P < 0.001; location 10, −0.56 g, 0.17, introduce a population and selection bias, but
had the shortest mean IELT of the countries P < 0.002). the objective nature of the measure should
assessed [9]. not have been affected. In the USA,
The studies detailed above share several uncircumcised men are demographically
In a study of 95 men undergoing circumcision important flaws: (i) a low response rate to different from circumcised men. They tend
in China, erectile function was measured opportunities to complete surveys (it is to be younger and from certain ethnic
before and after surgery. Eighteen patients speculative as to how the half who did not backgrounds. They might also be from
reported mild erectile dysfunction before complete these surveys would have families with either higher or lower parental
circumcision, while 28 reported from mild responded); (ii) the lack of agreed upon, education levels, depending on the decade of
to moderate erectile dysfunction after externally validated instruments to measure their birth [19,20]. Younger men might have
circumcision (P = 0.001). Also reported were erectile function; (iii) small population sizes been less willing to participate in the study
increased problems with weakened erectile that limit the study power; (iv) the subjective due to their increased modesty. As there are
confidence (P = 0.04), difficult insertion nature of instruments used; (v) short follow- many more circumcised than uncircumcised
during coitus (P = 0.03), prolonged up times; and (vi) the patients in the studies men in the USA, recruiting equal numbers of
intercourse in 31 cases (P = 0.04), and were not genitally healthy. subjects from each group was challenging.
improved satisfaction in only 34 patients
(P = 0.04) [6]. The last three items deserve special comment. The measurement of fine touch using
Self-reporting is notoriously unreliable, and pressure thresholds might be limited. Fine
In a study of 125 men drawn from a urology all but one of the reported studies relied on touch transmitted through Meissner’s
clinic, Bleustein et al. [7] found that patient testimony rather than objective corpuscles might be dynamic, using a network
uncircumcised men, both with and with no measurements. Patients are highly susceptible of nerve endings. For example, the fingertips,
erectile dysfunction, had lower thresholds for to suggestions or inferences that surgery or which have a high density of Meissner’s
pressure using the same device as used in the treatments used to correct a problem will, in corpuscles, are able to interpret Braille when
present study. The differences they found fact, correct that problem. Also, otherwise moving over raised dots, not merely by
were no longer statistically significant when healthy men who seek circumcision for other pressing on them. Consequently, a static
adjusted for age, diabetes, and hypertension. than medical reasons are predisposed to measurement of pressure threshold can miss
Their age difference (7 years) was greater reporting a favourable outcome. Furthermore, much of what the Meissner’s corpuscles are
than in the present population. Their surveys with subjective measures are capable of transmitting. An instrument that
population consisted of patients referred to a dependent on the respondent’s state of measures the sensitivity to light brushing or
urologist; the present subjects were drawn health. When asked to rate quality of life of that can discriminate surface texture when
from the general population, and diabetics various impaired health states, healthy rubbing might be needed to measure this
were excluded. We did not enquire about individuals will rate the quality lower than will dynamic sensation.
hypertension nor measure blood pressure. a person in that particular health state. In
Bleustein et al. only sampled two locations, these studies, it would be expected that the The differences in age, based on circumcision
the meatus and the dorsal glans halfway men rate their genital performance higher status, were expected. In their study, Bleustein
between the meatus and the corona, in when in the genitally impaired condition than et al. [7] found that uncircumcised men were
circumcised men, with an additional sample if they were not genitally impaired. a mean of 7 years older. Based on the
in uncircumcised men at the ‘dorsal midline fluctuations of circumcision rates over the
foreskin’ with the prepuce in its natural The short follow-up might have precluded past century, we expected genital integrity to
position over the glans. In uncircumcised changes in genital response and sensitivity be more prominent among older men and
© 2 0 07 T H E A U T H O R S
868 JOURNAL COMPILATION © 2 0 07 B J U I N T E R N AT I O N A L
FINE-TOUCH PRESSURE THRESHOLDS IN THE ADULT PENIS
among men in their twenties. Because the manuscript, and approved the final version. A multinational population survey of
confidence, sufficient to volunteer for Norma Wilcox, RN contributed to the intravaginal ejaculation latency time.
mapping of genitalia, might not come until conception and design of the study, revision J Sex Med 2005; 2: 492–7
the later twenties, this population might have of the manuscript, and approved the final 10 Richardson D, Goldmeier D. Premature
been under-represented in our study. version. Robert S. Van Howe, MD, MS ejaculation – does country of origin tell us
contributed to the design of the study and the anything about etiology? J Sex Med 2005;
Additional study with vibratory, hot and cold analysis and interpretation of the data, 2: 508–12
thresholds on a wider variety of positions drafted the article and revised it critically, and 11 Halata Z, Munger BL. The
on the penis is needed. Furthermore, approved the final version. neuroanatomical basis for the
development of a reliable method of protopathic sensibility of the human
measuring dynamic sensation is needed to glans penis. Brain Res 1986; 371:
identify, elucidate and quantify the sensory CONFLICT OF INTEREST 205–30
capacity of the various nerve endings in all 12 Winkelmann RK. The cutaneous
parts of the penis, and to provide a greater None declared. Source of funding: National innervation of human newborn prepuce.
understanding of the dynamic sensory Organization of Circumcision Information J Invest Dermatol 1956; 26: 53–67
interplay between the various parts of the Resource Centers. The director of National 13 Taylor JR, Lockwood AP, Taylor AJ. The
uncircumcised penis during sexual activity. Organization of Circumcision Information prepuce: specialized mucosa of the penis
Finally, prospective real-time stopwatch Resources Centers (MFM) was involved in the and its loss to circumcision. Br J Urol
assessments of the IELT at coitus in men, design and conduct of the study; collection 1996; 77: 291–5
investigated in the laboratory by the Semmes- and interpretation of the data; and review, or 14 Cold CJ, Taylor JR. The prepuce. BJU Int
Weinstein touch test, would provide approval of the manuscript. 1999; 83 (Suppl. 1): 34–44
additional objective information of their 15 Bell-Krotoski J, Tomancik E. The
sexual and particularly ejaculatory repeatability of testing with Semmes-
performance. Long-term monitoring of REFERENCES Weinstein monofilaments. J Hand Surg
numerous factors of sexual pattern, including [Am] 1987; 12: 155–61
sexual pattern films, would provide additional 1 Masters W, Johnson V. Human Sexual 16 Vileikyte L, Hutchings G, Hollis S,
information. Ideally, such investigations could Response. Boston, MA: Little Brown & Co, Boulton AJ. The tactile circumferential
be undertaken on adult subjects before and 1966 discriminator. A new, simple screening
after elective circumcision, and in whom there 2 Fink KS, Carson CC, DeVellis RF. Adult device to identify diabetic patients at risk
is no preoperative pathology. circumcision outcomes study: effect on of foot ulceration. Diabetes Care 1997;
erectile function, penile sensitivity, sexual 20: 623–6
In conclusion, circumcision removes the most activity and satisfaction. J Urol 2002; 167: 17 Romanzi LJ, Groutz A, Feroz F, Blaivais
sensitive parts of the penis and decreases 2113–6 JG. Evaluation of female external
the fine-touch pressure sensitivity of glans 3 Collins S, Upshaw J, Rutchik S, genitalia sensitivity to pressure/touch: a
penis. The most sensitive regions in the Ohannessian C, Ortenberg J, Albertsen preliminary prospective study using
uncircumcised penis are those parts ablated P. Effects of circumcision on male sexual Semmes-Weinstein monofilaments.
by circumcision. When compared to the most function: debunking a myth? J Urol 2002; Urology 2001; 57: 1145–50
sensitive area of the circumcised penis, 167: 2111–2 18 McNamara RN, Loiselle J. Laceration
several locations on the uncircumcised penis 4 Coursey JW, Morey AF, McAninch JW repair. In Henretig F, King C eds, Textbook
(the rim of the preputial orifice, dorsal and et al. Erectile function after anterior of Pediatric Emergency Procedures.
ventral, the frenulum near the ridged band, urethroplasty. J Urol 2001; 166: 2273–6 Baltimore, MD: Williams and Wilkins,
and the frenulum at the muco-cutaneous 5 Senkul T, Iseri C, Sen B, KarademIr K, 1997: 1141
junction) that are missing from the Saracoglu F, Erden D. Circumcision in 19 Laumann EO, Masi CM, Zuckerman EW.
circumcised penis were significantly more adults: effect on sexual function. Urology Circumcision in the United States:
sensitive. 2004; 63: 155–8 prevalence, prophylactic effects, and
6 Shen Z, Chen S, Zhu C, Wan Q, Chen Z. sexual practice. JAMA 1997; 277: 1052–7
[Erectile function evaluation after adult 20 Walton RE, Ostbye T, Campbell MK.
ACKNOWLEDGEMENTS circumcision]. Zhonghua Nan Ke Xue Neonatal male circumcision after
2004; 10: 18–9 delisting in Ontario. Survey of new
Author contributions: Morris L. Sorrells, MD, 7 Bleustein CB, Fogarty JD, Eckholdt H, parents. Can Fam Physician 1997; 43:
James L. Snyder, MD, Mark D. Reiss, MD, and Arezzo JC, Melman A. Effect of neonatal 1241–7
Christopher Eden, MD contributed to the circumcision on penile neurologic
conception and design of the study, the sensation. Urology 2005; 65: 773–7 Correspondence: Robert S. Van Howe,
acquisition of data, revision of the 8 O’Hara K, O’Hara J. The effect of male 1414 W. Fair Avenue, Suite 226, Marquette, MI
manuscript, and approved the final version. circumcision on the sexual enjoyment of 49855, USA.
Marilyn F. Milos, RN contributed to the the female partner. BJU Int 1999; 83 e-mail: rsvanhowe@mgh.org
conception and design of the study, the (Suppl. 1): 79–84
acquisition of data, the interpretation of the 9 Waldinger MD, Quinn P, Dilleen M, Abbreviations: IELT, intravaginal ejaculation
data, obtained funding, revision of the Mundayat R, Schweitzer DH, Boolell M. latency time.
© 2 0 07 T H E A U T H O R S
JOURNAL COMPILATION © 2 0 07 B J U I N T E R N AT I O N A L 869