Data regarding the relation between premature ejaculation (PE) and post-circumcision mucosal cuff length are controversial. The aim of this study is to analyze the relation between post-circumcision mucosal cuff length/penile length ratio (MCR) and PE. After exclusion of patients with erectile dysfunction, penile deformity, history of penile surgery and severe lower urinary tract symptoms, 49 circumcised men with PE were included. The control group is constituted of 50 healthy volunteers with normal ejaculatory function. Self-estimated intravaginal ejaculation latency time (IELT) and premature ejaculation profile (PEP) measures of all subjects were recorded, and the MCRs of patients and controls were compared. The mean age of PE patients and controls was 35.82±7.73 (range 23–54) and 38.78±13.42 (range 19–71) years, respectively (P=0.183). Although mucosal cuff length was not associated with either self-estimated IELT (r=−0.185, P=0.067) or PEP (r=−0.098, P=0.336), there was a negative correlation between MCR and self-estimated IELT (r=−0.205, P=0.0001) and PEP measures (r=−0.308, P=0.002). The length of the mucosal cuff after circumcision may have an impact on ejaculatory function. Surgeons should avoid leaving excessive amount of mucosa during circumcision.
Premature ejaculation (PE) is a common male sexual dysfunction that has been recognized for more than a century.1 Lack of clear, practical and evidence-based recommendations for the diagnosis of PE has resulted in conflicting prevalence rates.2, 3, 4 Recently, International Society of Sexual Medicine (ISSM) developed a unified definition for acquired and life-long PE.5 PE has a complex pathophysiology where biological causes including penile hypersensitivity, hyper-excitable ejaculatory reflex, increased sexual arousability, a genetic predisposition and central 5-hydroxytryptamine receptor dysfunction are all attributed, and none of them seems to explain the whole picture alone.6, 7, 8
Male circumcision is being performed since the ancient times, either because of religious needs, personal preferences and/or medical reasons.9, 10 Today, it is accepted to be the most commonly performed operation in the world.11 However, the effect of circumcision on sexual function, sexual satisfaction and ejaculation duration remains controversial.12, 13, 14, 15 This controversy may arise from the non-standardized manner of PE diagnosis and differences in measurement methods of both mucosal cuff and penile length.
This study aims to assess the relationship between post-circumcision mucosal cuff length to penile length ratio (MCR) and PE.
Materials and methods
A total of 50 circumcised patients with PE who referred to our andrology clinic between January 2014 and June 2014 were included into the study. The patients were diagnosed in accordance with the recent ISSM Guidelines4 and fulfilled the recent ISSM definition for PE.5 Patients under 18 and over 60 years of age were excluded, along with patients who had penile deformity, erectile dysfunction confirmed with IIEF score, lower urinary tract symptoms and previous penile/pelvic surgery. Patients with documented diabetes, hypertension, hyperlipidemia and cerebrovascular disease together with patients who use selective serotonin reuptake inhibitors were also excluded. However, patients with minor depression diagnosed using the DSM-IV criteria who are not under anti-depression therapy were included. Patients who were treated for PE in the last 6 months were not included either. During the same time period, 50 circumcised volunteers without any sexual dysfunction who fulfill the same exclusion criteria were selected as a control group. An institutional review board approval was obtained, and all patients gave their written informed consent.
The same physician (AC) measured penile and mucosal cuff length of all subjects during the flaccid state of the penis. Dorsal penile length was measured with the ruler pushed into the pubic bone in order to eliminate the effects of the pubic fat pad, from the pubo-penile angle to the tip of glans penis in an upright position on the fully stretched penis. Mucosal cuff length was measured dorsally from the mucosa–skin line until the base of the glans. MCR was calculated by dividing mucosal cuff length to penile length.
The self-estimated intravaginal ejaculatory latency times (IELT) of all participants were recorded; and the Turkish validation of the PEP questionnaire was administered.16 PEP contained four measures: perceived control over ejaculation, personal distress related to ejaculation, satisfaction with sexual intercourse and interpersonal difficulty related to ejaculation, each assessed on five-point response scales. PEP score was accepted as the sum of all four measures.17 Moreover, all patients completed the International Index of Erectile Function (IIEF) questionnaire.
Statistical analyses were performed by Number Cruncher Statistical System (NCSS) 2007 software package program (NCSS, LLC, Kaysville, UT, USA). In addition to the descriptive statistics (mean, s.d., median and interquartile range), independent t-test and paired t-test were used for the comparison of the groups. The correlation of the variables was evaluated with Pearson's correlation test. Statistical significance was set as P<0.05.
After exclusion of one patient from the PE group due to the discrepancy in his sexual history, self-estimated IELT and PEP score; 49 patients with PE and 50 sexually healthy volunteers were enrolled into the study. The demographic characteristics of the patients are presented in Table 1. Mean patient age (P=0.183) and mean mucosal cuff lengths (P=0.104) of patients with and without PE were similar, whereas the penile length of PE patients was significantly shorter (P=0.001).
Although mucosal cuff length was positively correlated with penile length (r=0.372, P=0.0001), no statistically significant correlation was observed between the mucosal cuff length and either self-estimated IELT (r=−0.185, P=0.067) or PEP score (r=−0.098, P=0.336).
On the other hand, mean MCR of PE group was significantly higher compared with the control group (0.11±0.03 vs 0.09±0.03, P=0.0001) (Table 1), and it was negatively correlated with both self-estimated IELT (r=−0.406, P=0.0001) and PEP score (r=−0.308, P=0.002).
Similar to the previously published literature,12, 13, 14, 15 our results also did not demonstrate a correlation between the length of mucosal cuff left after circumcision and self-estimated IELT and PEP score. However, when compared with penile length, MCR may be correlated with self-estimated IELT and PEP score.
Circumcision is believed to have originated in Egypt more than six millennia ago and seems to be the oldest and most common surgical procedure worldwide.18 It is undertaken for many reasons including religious, cultural, social and medical conditions. Although the rates significantly differ in different cultures and religions, approximately 30% of the males aged 15 years or older are circumcised.19
The rationale for considering circumcision as an etiological factor for PE depends on the association of PE with penile hypersensitivity. The tissue extracted by circumcision has intensive free nerve endings,20 which may result in increased sensitivity. However, debate continues on the exact role of circumcision on the penile sensitivity and consequent sexual problems.14, 21, 22, 23 Fink et al.21 examined the sexual function in men who have experienced sexual intercourse in both the uncircumcised and circumcised states. The authors showed that 50% of the responders reported benefits, whereas 38% reported harm. Overall, 62% of men were satisfied with having been circumcised.21 In another study, Senkul et al.14 evaluated the effects of adult circumcision on sexual function in 42 male patients with a median age of 22.3 years (range 19–28) who were circumcised for religious or cosmetic reasons. The sexual performance of the patients was evaluated with both Brief Male Sexual Function Inventory and IELT. They demonstrated that adult circumcision does not significantly change the Brief Male Sexual Function Inventory scores; however, it was found to be associated with increased IELT (2.9±0.4 vs 4.6±0.7 min, P=0.02).14 In a similar study conducted by Collins et al.,22 Brief Male Sexual Function Inventory values were not found to be significantly different before and after the circumcision procedure. Masood et al.23 also assessed the effects of circumcision on sexually active men and the possible impact of these effects on informed consent. In addition to administration of the IIEF-5, they asked questions about libido, penile sensitivity, PE, pain during intercourse and appearance, both before and after circumcision. The authors reported that mean IIEF-5 score did not change significantly (P=0.4), whereas penile sensation improved after circumcision in 38% of patients (P=0.01). However, 18% of the patients reported worse penile sensation. The overall satisfaction rate of 61% suggested that penile sensitivity has variable outcomes after circumcision and these data should be discussed during the informed consent process.23
Various studies analyzed the effects of post-circumcision mucosal cuff length on PE status.15, 24, 25 Tarhan et al.15 compared the circumcision scar thickness and post-circumcision mucosal cuff length in patients with and without PE and did not observe any relation. Hosseini et al.24 also demonstrated that there was not any statistically significant difference in the length of the penis, mucosal cuff or penile skin between subjects with and without PE. Finally, Bodakci et al25 investigated the association between IELT and each of penile and mucosal cuff length in 288 circumcised volunteers. They demonstrated that there was no association between the mucosal cuff length and PE, in terms of IELT (P=0.167) or PEDT score (P=0.764).
Different from the aforementioned studies that could not find an association between the PE status and mucosal cuff length, we hypothesized that the effect of similar mucosal cuff lengths would be different among patients with different penile sizes; thus, the actual impact of mucosal cuff length can be elucidated by using the MCR.15, 25 Confirming the findings of the previous studies, mucosal cuff length was not associated with either self-estimated IELT or PEP score. However, MCR was negatively correlated with both self-estimated IELT (P=0.0001, r=−0.406) and PEP score (P=0.002, r=−0.308).
The current study has several limitations. First of all, we did not have any data regarding the PE status of the before the circumcision procedure as most of these procedures were performed during childhood period. Furthermore, the overall number of patients included in this study is limited, and larger population-based studies are required to confirm our findings. Another limitation of the study is that we did not provide data about the marital status of the subjects. However, all of the subjects had regular sexual partners for at least 6 months. Moreover, the measurements were performed during the flaccid stretched state of the penis. Although respective measurements may vary from subject to subject between flaccid and rigid states, Veale et al.26 showed that there is a significant correlation between flaccid stretched and erect lengths of the penis. Finally, self-estimated IELT had to be used instead of stopwatch measured IELT. However, it must be noted that self-estimated and stopwatch measured IELT are found to be interchangeable and self-estimated IELT can correctly assign PE status with 80% sensitivity and 80% specificity.27
Our results demonstrate that the length of the mucosal cuff after circumcision may have an impact on ejaculatory function. The surgeons should avoid leaving excessive mucosa during circumcision in order to reduce the risk of PE. Further, population-based studies are necessary to support our findings.
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The authors declare no conflict of interest.
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Yuruk, E., Temiz, M., Colakerol, A. et al. Mucosal cuff length to penile length ratio may affect the risk of premature ejaculation in circumcised males. Int J Impot Res 28, 54–56 (2016). https://doi.org/10.1038/ijir.2015.34