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Acquisition of Erectile Dysfunction from Circumcision

Dan Bollinger Our new study published in the International Journal of Mens Health showed that circumcised men have a 4.5 times greater chance of suffering from erectile dysfunction (ED) than intact men, revealing what appears to be a significant acquisition factor.1 Robert S. Van Howe, M.D., M.S., FAAP and I found a surprisingly strong secondary finding between circumcision and ED in our survey of 300 participants (OR = 4.53, p=.0058). It was outside the scope of our article to delve deeper into this topic, but our finding does raise some questions: Are there other studies showing a similar connection? What could be the underlying cause? Eighteen percent of adult American menthree-fourths of whom are circumcisedhave ED, affecting 18 million men.2 Circumcisions role as a risk factor may be reflected in ED drug sales; while the United States represents 5% of the worlds population, it also accounts for 46% of Viagra sales.3 Other studies have previously observed that circumcisions damage results in worsened erectile functioning,4 inability to maintain an erection,5 and reducing overall penis sensitivity by a whopping 75%.6 Premature ejaculation, ED, and circumcision are inextricably linked; a recent study revealed that premature ejaculation is five times more likely when adjusted for ED and circumcision.7 A new Danish study8 found that circumcised men are three times more likely to have sexual dysfunction.9 Case studies of men circumcised as adults are revealing since they compare sexual function and satisfaction before and after the surgery. They are also alarming. Circumcision was supposed to correct a problem ostensibly resulting in entirely favorable outcomes, but this is not the case, as these failure rates illustrate. In one study, circumcision worsened erectile function and decreased penile sensitivity, and 38% reported sexual harm.10 Another survey found that 27% of recently circumcised adult men reported dissatisfaction with erectile functioning.11 In a third study, the number of men reporting erectile dysfunction almost doubled after circumcision, and ED severity increased, too.6 A fourth study found that 35% of participants and 46% of partners 1

Adding Insult to Injury:

had a worsened sex life after circumcision.12 The study implicated loss of nerve endings as a reasonaddressed below. The true dissatisfaction rate is probably higher since all of the men elected circumcision, and would naturally be biased toward the outcome being beneficial. An exhaustive case study of five impotent men circumcised as adults involved a complete workup, including a thorough examination of genitalia, neurological examination, complete blood counts, oral glucose tolerance tests, and protein bound iodine and T-4 uptake, serum electrolytes, VDRL, sperm counts, and 24-hour urinary steroid tests. None of these tests were significant, and in the end, circumcision was the only common factor.13 Circumcision is a risk factor for both physiological and psychosomatic aspects for ED since it is a sexual trauma and damages the penis.14 The traumatization from the procedures pain is thought to be particularly damaging to an infant, whose brain is still developing.15 One obvious cause for ED from circumcisiontruncating the perineal nervemust be considered since injuries to this nerve are known to cause permanent sexual dysfunction.16 The perineal nerve is critically important to sex, lovemaking, and orgasms in both males and females. Dubbed the sex nerve, it serves some of the most sensitive erogenous zones in the human body. It is responsible for initiating and maintaining an erection in males17 and females (yes, females get erections, too).18 Without the perineal nerves input, intercourse and sexual satisfaction will be limited. In males, it contributes not only to obtaining an erection, but for ejaculation and feelings of orgasm, too. In females it contributes to clitoral erection, feelings of orgasm, and closes the vagina after orgasm. The perineal nerve runs the length of the penis on the underside and terminates in the frenulum.19 This little bridle, which attaches the underside of penis shaft to the inner foreskin, is one of the most sensitive portions of the penis6 and is solely innervated by the perineal nerve.20 During intercourse the foreskin inverts and the frenulum is exposed, presenting a great number of perineal nerve endings to repeated stimulation every time the penis enters and withdraws from the vagina. Circumcision partially or completely excises the frenulum, always severing the nerve at this point. This variable frenular aspect, and because there are other risk factors, might explain why not all circumcised men suffer from ED. This news that circumcision, once considered as beneficial to a mans sexual health, is now connected to sexual dysfunction is disheartening. Every man has the right to good sexual health and to feel sexual pleasure for full psychophysical wellbeing. Erectile dysfunction is devastating to the lives of so many men and their partners, which calls elective and infant circumcision into question. November 17, 2011

1 Bollinger D, Van Howe, RS. Alexithymia and circumcision trauma: A preliminary investigation. Int J Mens Health, 2011;10:18495. 2 Selvin E, Burnett AL, Platz EA. Prevalence and risk factors for erectile dysfunction in the U.S. Am J Med, 2007;120(2):1517. 3 Pfizer. Pfizer, Inc. 2008 Annual Report, 2008; p. 17. 4 Bailey RC, Egesah O, Rosenberg S. Male circumcision for HIV prevention: A prospective study of complications in clinical and traditional settings in Bungoma, Kenya. Bull World Health Organ, 2008; 86: 66977. 5 Shen Z, Chen S, Zhu C, Wan Q, Chen Z. Erectile function evaluation after adult circumcision. Zhonghua Nan Ke Xue, 2004;10:189. 6 Sorrells ML, Snyder ML, Reiss MD, et al. Fine-touch pressure thresholds in the adult penis. BJU Int, 2007;99:8649. 7 Tang WS, Khoo EM. Prevalence and correlates of premature ejaculation in a primary care setting: A preliminary crosssectional study. J Sex Med,2011;8:20718. 8 Christensen BS, Grnbk M, Frisch M, et al. Sexual dysfunctions and difficulties in Denmark: Prevalence and associated sociodemographic factors. Arch Sex Behav, 2011;40:12132. 9 M. Frisch speaking about his study at a press conference. Available online at: 10 Fink KS, Carson CC, DeVillis RF. Adult circumcision outcomes study: Effect on erectile function, penile sensitivity, sexual activity and satisfaction. J Urol, 2002;167:21136. 11 Coursey JW, Morey AF, McAninch JW, et al. Erectile function after anterior urethroplasty. J Urol, 2001;166:22736. 12 Solinis I, Yiannaki A. Does circumcision improve couple's sex life? J Men's Health and Gender, 2007;4:361. 13 Stinson JM. Impotence and adult circumcision. J Natl Med Assoc, 1973;65:161,179. 14 Cold CH, Taylor JR. The prepuce. BJU Int, 1993;83(Suppl. 1):344. 15 Taddio A, Katz J, Ilersich AL, et al. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet, 1997;349(9052):599603. 16 Yucel S, Baskin LS. Neuroanatomy of the male urethra and perineum. BJU Int, 2003;92:62430. 17 Shafik A. Perineal nerve stimulation: role in penile erection. Int J Impot Res, 1997;9(1):116. 18 Martin-Alguacil N, Pfaff DW, Shelley DN, et al. Clitoral sexual arousal: An immunocytochemical and innervation study of the clitoris. BJU Intl, 2008;101:140 713. 19 Uchio EM, Yang CC, Kromm BG, Bradley WE. Cortical evoked responses from the perineal nerve. J Urol, 1999;162:19836. 20 Yang CC, Bradley WE. Innervation of the human glans penis. J Urol, 1999;161:97102.

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