Purpose: Claims of superior sexual sensitivity and satisfaction for uncircumcised males have never been substantiated in a prospective fashion in the medical literature. We performed such a study to investigate these assertions.

Materials and Methods: The Brief Male Sexual Function Inventory (BMSFI) was administered to sexually active males older than 18 years before undergoing circumcision. After a minimum interval of 12 weeks after the operation, the survey was again administered. The 5 domains of the BMSFI (sexual drive, erections, ejaculation, problem assessment overall satisfaction) were each given a summed composite score. These scores before and after circumcision were then analyzed by Wilcoxon signed-rank testing.

Results: All 15 men who participated in the study between September 1999 and October 2000 were available for followup. Mean patient age plus or minus standard deviation was 36.9 +/- 12.0 years. There was no statistically significant difference in the BMFSI composite scores of reported sexual drive (p>0.68), erection (p>0.96), ejaculation (p>0.48), problem assessment (p>0.53) or overall satisfaction (p>0.72).

Conclusions: Circumcision does not appear to have adverse, clinically important effects on male sexual function in sexually active adults who undergo the procedure.

Circumcision has been described since antiquity, yet few surgical procedures have generated its degree of controversy in the modern era. The indications and recommendations for elective circumcision in newborns have vacillated in recent decades[1,2] but the operation is still commonly performed in the United States (77% of American-born men are circumcised[3]. However, the operation is performed infrequently on adults in the contemporary setting except for indications such as religious grounds, phimosis, recurrent balanitis and aesthetic appeal.

As early as 1878 circumcision was recommended as a cure for impotence when performed for phimosis[4]. In contrast to this 19th century assertion, the modern lay literature is replete with anecdotal reports of superior sensitivity and sexual satisfaction in uncircumcised men. Because of such controversies associated with the operation, some males who need circumcision may be reluctant to undergo the procedure. There have never been prospectively conducted studies, to our knowledge, that either support or refute the notion that circumcision affects male sexual function. In an attempt to answer this question, we performed a prospective study on men comparing sexual satisfaction scores before and after circumcision using a validated questionnaire.

Methods and Materials

This study was performed with appropriate approval from the internal review boards from the participating institutions, with patient accrual occurring between 1999 and 2001. All patients were at least 18 years old, heterosexual and sexually active without the use of erection enhancing devices or medications. Sexual partners were not interviewed. Informed consent was required for participation.

Before administration of the questionnaire, all men underwent routine urological history and physical examination, after which the Brief Male Sexual Function Inventory (BMSFI) was administered[5]. Briefly, the BMSFI is comprised of 5 domains intended to inquire about sexual drive, erections, ejaculation, problem assessment and overall satisfaction. This survey has been validated in several languages and was chosen for this study because it was the simplest questionnaire for our patient population to answer. After a minimum postoperative interval of 12 weeks, the survey was again administered. This interval was believed to be sufficient for the patient to have resumed full sexual activity after the operation.

The 5 domains of the BMSFI were each given a summed composite score. These scores were then analyzed before and after circumcision by paired Wilcoxon signed-rank tests. Results were considered statistically significant at p < 0.05.

Results

All 15 men who participated in the study were available for followup. Circumcision was performed for phimotic foreskin in 10 patients, completion of a dorsal slit procedure secondary to paraphimosis in 1, recurrent balanitis in 3 and cosmetic reasons in 1. Mean patient age was 36.9 ± 12.0 years. Mean interval plus or minus standard deviation between surveys was 24 ± 13.6 weeks. All circumcisions were performed by either a sleeve or dorsal slit technique, depending on surgeon preference. Except for postoperative pain, no patient reported complications or penile hypoesthesia related to the surgery. Patients were instructed to refrain from sexual intercourse for at least 4 weeks after the operation. Scores before and after treatment, BMFSI scores and p values for Wilcoxon signed-rank analysis are given for all 15 patients in the table. There were no statistically significant differences observed in any of the scores for any of the questionnaire domains.

Table 1. Domain scores of BMSFI before and after circumcision

Pt. No.	Pre-Drive	Post-Drive	Pre-Erection	Post- Erection	Pre- Ejaculation	Post- Ejaculation	Pre- Assessment	Post- Assessment	Pre- Overall	Post- Overall
1	4	4	6	5	8	6	12	7	2	2
2	7	3	12	10	8	0	12	12	2	4
3	8	7	12	12	4	4	12	4	4	0
4	4	6	8	6	5	5	4	12	3	3
5	7	8	12	12	4	4	12	12	2	3
6	8	8	12	12	4	4	12	12	4	3
7	6	7	6	10	7	4	7	6	4	4
8	5	4	10	8	5	5	9	10	3	3
9	8	6	12	11	3	2	11	11	4	3
10	4	7	5	10	4	4	4	6	2	2
11	6	5	9	9	8	8	5	7	2	3
12	4	5	6	9	5	8	10	10	2	3
13	8	8	12	12	8	8	12	12	4	4
14	8	8	12	11	8	8	4	12	4	4
15	8	6	12	10	4	7	4	4	4	2
Mean ± S.D. (±)	6.3 ± 1.7	6.1 ± 1.6	9.7 ± 2.8	9.8 ± 2.1	5.7 ± 1.9	5.4 ± 2.0	8.7 ± 3.6	9.1 ± 3.1	3.1 ± 0.96	2.9 ± 1.1
p Value	> 0.68		> 0.96		> 0.48		> 0.53		> 0.72

Discussion

To our knowledge we report the first prospective comparison of male sexual function parameters before and after circumcision. We demonstrated no statistically significant changes in any BMFSI parameter of male sexual function in this cohort of sexually active males.

The glans penis epidermis gradually undergoes some degree of cornification after circumcision. It has been hypothesized that these changes may result in decreased sensitivity to tactile and erogenous stimuli. Masters and Johnson observed no differences, however, in glanular tactile sensation with circumcision[6]. More recently, Laumann et al reported that uncircumcised men were actually more prone to have sexual difficulties than uncircumcised peers[3]. Contrary to such reports in the conventional medical literature, there is a growing interest in surgically restoring the foreskin in males circumcised at birth in the hopes of increasing erogenous sensation[7]. It was this disparity between the mythology and medical reality of circumcision regarding male sexuality that prompted our study.

The methodology used in this study admittedly has limitations. The BMSFI has been criticized as an instrument because it does not specifically address the problem of premature ejaculation and its sensitivity to detect changes resulting from treatments is unknown[5,8]. Furthermore, since the majority of our patients underwent circumcision for medical conditions related to the foreskin, the prepuce may actually have preoperatively inhibited normal sexual function to some degree. A more ideal mode of inquiry would entail studying only men who undergo the procedure for nondiseased foreskins, for example for religious or cosmetic reasons only. Our study may also lack the statistical power required to detect changes in male sexual functioning after circumcision using the BMSFI instrument. This lack of power is due in large part to the relative rarity with which this procedure is performed in sexually active adults at most institutions, making patient accrual difficult. Similarly, we did not address the outcomes of neonatal circumcision and adult male sexuality, for which a prospective study would be difficult to design. Nonetheless, we believe that our observations will provide a rational medical basis for further inquiries regarding the issue of circumcision and male sexuality. It is possible that subtle, measurable changes in tactile sensation after circumcision may occur but our data suggest that such changes may not be clinically important. This study may also give men who undergo circumcision later in life some reassurance that a properly performed procedure should not significantly alter sexual functioning.

References

1. Committee on Fetus and Newborn. Report of the ad hoc task force on circumcision. Pediatrics 1975; 56: 610
2. Herzog L. Urinary tract infections and circumcision: a case control study. Am J Dis Child 1987; 143: 348
3. Laumann EO, Masi CM, Zuckerman MA. Circumcision in the United States: prevalence, prophylactic effects and sexual practice. JAMA 1997; 277: 1052
4. Dunsmuir WD, Gordon EM. The history of circumcision. BJU Intl 1999; 83: 1
5. O'Leary MP, Fowler FJ, Lenderking WR, et al. A brief male sexual function inventory for urology. Urology 1995; 46: 697
6. Masters WH, Johnson VE. Human Sexual Response. Boston: Little Brown, 1966
7. Goodwin W. Uncircumcision: a technique for plastic reconstruction of a prepuce after circumcision. J Urol 1990; 144: 1203
8. Rosen R: Sexual function assessment in the male: physiological and self-report measures. Int J Imp Res 1998; 10: 59