THE CIRCUMCISION REFERENCE LIBRARY

Conservative Treatment of Primary Phimosis in Adolescents (Traitement médical du phimosis congénital de l'adolescent) By Michel Beaugé, MD

Quimper, France. Thesis for the University Diploma of Andrology. Director of Studies Professor G. Arvis. Faculty of Medicine, Saint-Antoine University, Paris VI

University Year 1990-1991 Translated by Dr J. P. Warren

I thank:

Professor G. ARVIS for the quality of his teaching, his availability and valuable advice in the editing of this work.

The lecturers of the diploma of Andrology of the Faculty of Medicine of Saint-Antoine (Paris).

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Introduction

Being in charge for over ten years of the routine examination of college freshmen as part of the preventive medicine programme of the university, I diagnose a significant number of phimoses among older children and young adults.

Among this male population aged 18 to 22, we have observed that nearly 10% have various degrees of tightness of the foreskin, ranging from total inability to expose the glans to a simple ring which gets stuck in the sulcus. In this report the word phimosis is used to mean the diameter of the inferior preputial ring is smaller than the diameter of the erect glans.

From the interviews it appears that the great majority of these subjects are virgin, and that among those who have had sexual experience, many have failed, with difficulty in penetration, pain and loss of erection; except perhaps in cases of the tightest phimoses who were successful in penile penetration with the glans covered. The remainder expose themselves to considerable risks of paraphimosis by persevering in intercourse. This possibility and the difficulties in carrying out successful intercourse make it necessary to intervene medically.

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Treatment

The conventional treatment of phimosis is surgical:

Circumcision which removes the foreskin, or simple plastic surgery which preserves the fold of skin but opens the ring.

For a number of reasons I have come to reject this therapeutic procedure:

* Surgical intervention:

- is traumatic, brutal, and irreversible

- necessitates anaesthesia

- is bloody.

These two latter features give rise to the possible complications of any other form of surgery.

- in the case of circumcision reduces the mobility of the penile skin; this factor is important and we shall return to it at length on page 12.

- is psychologically stressful by cutting an organ which is highly symbolic for a male at the dawn of his sexual life.

- creates a mutilation: the amputation causes the penis to differ from that of his friends at an age where he has scarcely acquired knowledge of normality.

- causes brutal exposure of the mucous membrane by the excision of the protection of the glans.

- interferes with the pattern of masturbation which may be seriously traumatic.

- in the case of plastic surgery may fail due to scar formation.

- is expensive and requires hospitalisation.

* Remodelling of the foreskin should be considered. It is:

- logical: in medicine we only refer for surgery failures of remodelling whether it be muscular, tendinous or cutaneous.

- painless

- gradual

- unobtrusive

- free

- not traumatic or troublesome to the patient

- preserves the foreskin which has definite functions, described on page 13.

- allows the preservation of patterns of masturbation.

- avoids the pain of the exposed glans.

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Reflections

The study of observed cases reveals that adolescent or young adult subjects suffering from phimosis have habits of masturbation different from others.

Conventionally the pursuit of solitary pleasure is done with the dominant hand closed over the penis making alternate back and forth movement over the shaft, the hand going down towards the pubis, uncovering the glans which the index finger or thumb may now and then stroke lightly, reproducing the sensation of intercourse.

This exercise results in moving the penile skin in the same way as will occur in vaginal intercourse, and therefore it is a preparation for adult sexual relations. We shall see later that this training is not only mechanical, but also participates in the psychological development of the individual.



I have established a classification of the other methods of masturbation and have often seen them among patients with phimosis.

Some boys never masturbate! We may doubt their assertions, but the tightness of their phimosis suggests their statements are correct. Ejaculation takes place during sleep (nocturnal emissions), and more rarely spontaneously while awake prompted by stimulating events, among those subjects who attach guilt to contact with the penis. Others stroke the glans through the foreskin in the usual way, but attempt to pull the skin towards the tip of the penis instead of pulling it back toward the pubis. We find among these boys the persistence of a long tubular foreskin such as is seen in infants. In some cases the boy rolls the penis between two palms or between one hand and another surface such as the abdomen, the thigh, a table, the edge of a chair (in particular the toilet). It is usual in these cases for the raphe on the underside of the penis not to be in the midline but more or less displaced to one side or even spiral; the preputial orifice is often displaced: figure 1. Mechanical stimulation without use of the hands is perhaps found most frequently (perhaps causing less guilt). In general, the boy, flat on his face on his bed, labours as if for intercourse with the help of his pelvic musculature, and rubs his penis against the mattress, the bolster or a pillow, often through a cover in which -- sign of the times -- he has placed a disposable paper tissue to avoid stains which would betray his activities to his mother. Interfemoral stimulation is found, facilitated by a penis curved downward (figure 2), unless it is this activity which determines this anatomical anomaly. This technique has the advantage that it can be carried out in company, much as some females have orgasms by squeezing their thighs, while climbing a rope, or while riding a bicycle. Instrumental masturbation: this can be achieved by vibro-masseur or by showering, but it has never been demonstrated in this population studied and therefore must be rare or of occasional practice. For the record: auto-fellation when mobility allows it.

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Roles of Masturbation

Following this analysis, we may consider the purposes of masturbation.

It serves of course to evacuate the semen secreted by a pubescent boy. The tension felt by men after a certain time following the last ejaculation is well known. It is enjoyable; a boy who has discovered that he can bring on pleasure by the mechanical stimulation of his penis recreates the conditions of this pleasure, and this effort is gratified by orgasm. For the future masturbation allows the subject to learn to obtain orgasmic sensations and also to recognise the erogenous stimuli which create them, to perceive the beginning of ejaculation, and therefore to find ways to prevent it. No doubt the regular practice of this activity forms the basis for the avoidance of premature ejaculation. Variations are possible on the theme of sexual pleasure and give the opportunity to explore the field of eroticism. To be sure masturbation has a role in preparing the penis for its future purpose. It seems to me that we could draw a parallel between athletic training which affects the development of the athlete who is preparing himself for competition, and the technique of masturbation which, during adolescence, serves to overcome organic obstacles to penetration.

The basis of the therapeutic procedure I propose to describe is based on this understanding of the effects of the handling of the penis on the development of the foreskin and the elimination of phimosis.

Indeed it is apparent that the number of phimoses observed in a population of boys decreases with age. Inability to retract the foreskin is normal in infants, common among young boys, but only persists in about 10% of the subjects at the end of adolescence. Finally masturbation contributes to fantasy life and helps the subject to structure himself mentally in his future life.

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Therapeutic Procedure

Faced with a man suffering from phimosis, I propose:

After analysis of the patient's method of masturbation, it is necessary to explain to him the roles of masturbation during adolescence, such as are described in the five preceding points. The discussion has the advantage of removing feelings of guilt, if necessary.

Next it is advisable to instruct him on the technique that seems to be most useful, attempting thus to pull back the foreskin by exposing the tip of the glans. In fact it is only rarely possible for a boy who has developed for himself a method that leads to orgasm to replace it initially by another. Generally the new method fails to give pleasure and may even tend to impair the quality of the erection. This could explain why boys fail in their first attempts at sexual intercourse; a man who has become accustomed to rotational movements on his penis for several years will be quite unable to use this technique in the vagina. Therefore I advise "prescribe" alternating a few pleasurable manipulations known to be stimulative with the remodelling manipulations. It is of course essential that the preputial opening be stretched round the circumference of the fully erect glans. This technique meets the requirements of the kinesitherapy of soft tissues, gradual stretching. In some cases I have recommended instrumental dilatation with the use of a dilator in patients who agree to this procedure, or I have advised the introduction of two fingers into the opening of the foreskin to stretch it. Figure 18.

Perhaps it is logical to draw a parallel between the preputial ring of the boy and the hymen of the girl. In both cases there is a mucocutaneous stricture obstructing intercourse, but allowing the passage of urine and in the case of the hymen the flow of menses. The opening of the hymen may occur through traumatic rupture during brutal penetration, or by gradual and gentle dilatation when the lover is careful or shy.

Prepuce or hymen, it is the erect glans acting as a mould (or mandrel) which dilates (and models) the orifice.

Thus the boy can progressively expand his foreskin until the diameter is equal to that of the erect glans, allowing him subsequently to proceed to sexual intercourse without risk of paraphimosis.

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During the course of this remodelling there will come a time when the foreskin is sufficiently dilated to uncover the distal part of the glans but is still too tight to go over the proximal and larger part; due to the conical shape of the glans we can then imagine that a strong enough pull might succeed in sliding the ring into the sulcus, but that the reverse movement might be impossible, causing paraphimosis during masturbation. This appears to me unlikely for several reasons:

- the manipulation is done under visual control of the subject who is well able to detect the degree of tension in the foreskin, unlike the situation during sexual intercourse, particularly when it occurs for the first time;

- if paraphimosis nevertheless did occur in these conditions it could only be moderately tight and would be reduced immediately by the subject who is free to readjust himself at his convenience. Furthermore in this situation orgasm would not occur (masturbation would be stopped at once) and so the secondary increase in volume and firmness of the glans would not take place; whereas in coital paraphimosis the foreskin enters the sulcus during intercourse and then orgasm causes further increase in volume and firmness of the glans making reduction more difficult. And finally the boy's embarrassment at manipulating himself in the presence of his partner to reduce the foreskin, explains the delay during which oedema collects and the condition becomes established.

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Results

I had to recommend this treatment for 30 to 40 boys annually and therefore have observed several hundred cases. Follow-up in preventive medicine is not usual and many were not seen again. However about half did return to report a satisfactory outcome. Some of them grateful to have benefited from such a gentle and discreet treatment method entrusted me with other problems and therefore have provided accounts of the success of the treatment over a longer period.

With regard to patients from the town a number were given the same advice and I reckon that in 15 years of practice I never had to refer a single one for surgery.

In a few cases patients agreed to be photographed with the foreskin stretched on the erect glans at the start, with a second photograph taken four weeks later. These demonstrate that retraction of the foreskin was achieved as a rule within this time.

The illustrations that follow (Figures 7 to 16) show the outcomes occurring in the same time as that of the scar formation after surgery. These results encourage therefore the use of this technique.

I did not come across any failures, but this does not mean that they did not occur since such cases may have failed to reattend. It should be pointed out that an attempt at conservative treatment does not prevent subsequent recourse to surgery should this prove to be necessary.

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Discussion

If we must criticise this method of treatment of adolescent phimosis by the masturbation technique, we must ask ourselves two questions:

- Is it permissible to discuss masturbation with these boys?

- Should circumcision be rejected?

About masturbation

* Masturbation is universal in humans.

- It occurs in all young children and is the usual form of sexual expression among Western adolescents. Georges Mendel in "Anthropologie Differentielle" points out that "If we recall the universality of infantile masturbation during the first years and the near- universality in adolescent boys, we realise then what a role it must take."

In our society adolescence tends to be prolonged voluntarily into the third decade and masturbation continues in these young single men.- Some married men often make up for the difference in libido compared with their partner by taking a mistress as well.- Mention should also be made of men temporarily or permanently alone whether willingly or unwillingly as a result of life's vicissitudes.

* We know that masturbation also forms part of the sexual relationship of couples and often the woman will masturbate her partner to avoid intercourse which may be undesirable for various reasons:

- A young girl who wants to defer her first real relationship,

- menstruation,

- vulvo-vaginal irritation

- fear of pregnancy or finally just because of a plain and simple attraction for the penis which she can own or tame.

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Masturbation is also a well known means of obtaining or reviving an erection when mental stimulation is insufficient.

Masturbation is still the main method of "Safe Sex" as described for the avoidance of HIV infection and even recommended by certain governments e.g. Canada.

* Masturbation is in fact advised twice weekly as adjuvant treatment of chronic prostatis in single men.

* The symbolism of masturbation is found everywhere in daily life and humour: for example the shaken champagne bottle ejaculating foam in the hands of the winner of a motor race.



Is sexual pleasure obtained by masturbation legitimate?

Our senses of sight, hearing and smell have been developed to ensure survival by detecting predators so that we can defend ourselves against them, as well as to capture prey and obtain food. Today in our society these senses are extensively exploited to obtain pleasure from pictures, music, sculpture and perfumes. Likewise the sense of taste necessary to recognise wholesome food is exploited in cooking and even in tobacco smoking and the enjoyment of wine.

We admit that civilisation allows us this leeway in the use of our sense organs. We have freed sexual and sensual pleasure from the confines of reproduction and survival of the species (who would be satisfied with intercourse three or four time in their life?); we can therefore allow sexuality to be expressed freely by individual choice (within the limits of the liberty of others of course) and free ourselves from the biblical guilt of sex.

Masturbation has its place within the range of sexual expression and morality has no rational arguments to displace it.

To quote Sigmund Freud's Birth of Psychoanalysis: "I have come to believe that masturbation was the only great habit, the primitive need and that other appetites, such as the need for alcohol, morphine, tobacco, are only substitutes, the products of replacement."



Contemporary Western sexology emphasises the quality of loving and spiritual relationships in the success of sexuality. This is very laudable and noble, and also frequently true, but is in fact neither sufficient nor indispensable. Sexual technique and the characteristics of the genital organs also play a part in successful sex. One need only analyse the factors of sexual nomadism and even prostitution to convince oneself of this.

The fact that masturbation has a role in the acquisition of sexual technique and contributes to morphological development is sufficient to justify it, we think.

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We may often be tempted to reduce masturbation to a solitary pleasure derived from mechanical stimulation of the genitals. It is not so. Despite the fable of "The Animal Sad After---", there is no doubt that masturbation is antidepressant and anxiolytic if it is freed from guilt. This sexual activity distances the individual from the worries and constraints of daily life lulling him to sleep. whereas the pre-existing depressed state of mind would have prevented sleep. By ejaculating the adolescent sends himself to sleep just as infants and some older children do by sucking their thumb for comfort.

Furthermore underlying all masturbation there is at the psychological level both conscious and subconscious fantasising. Thus the adolescent dreams and rehearses (in the same way as repeated theatrical performances) sexual relationships as yet unattainable. In this sense when he comes to his first sexual relationship he is not entirely virgin, innocent and inexperienced.

Autoeroticism and fantasising are described by Gerard Mendel as "productions of the same nature, that is memories, secondary and associative." and furthermore: "masturbation is in the last resort only the means to recall, of renewing intensely the memory of the pleasure arising from the penis, as well as the whole range of sensory memories which, when stimulated, constitute fantasy."

Therefore we must get rid of excessive guilt of socio-cultural origin, and then it seems permissible to advise an adolescent to direct himself towards a technique that relates to sexual intercourse.

About circumcision

Circumcision is seen by the patient subjected to it as a partial castration; it removes part of the genitals, at their tip, which is particularly significant at the symbolic level. The patient is ignorant of, as are most doctors, the functions of the foreskin, which means that the amount of loss, of damage one may even dare to call it, is unquantified and therefore unlimited.

Circumcision is akin to amputation, which disgusts us so much since it is often proposed with the ulterior motive of preventing masturbation while preserving the ability to procreate. This attack on sexuality remains still present in people's minds, and it should be noted that even if the operation does not occur in France in its bloody and cutting form it has nevertheless been expressed until very recently in an insidious way of thinking with tales about ideas such as "that an honest woman must not enjoy any pleasure" and that the sexual relationship between the couple was a "conjugal duty" like other chores. All practitioners in the field of sexology are familiar with the damage which such ideas continue to produce in the sexual lives of a great many patients.

Mankind in general, and especially adolescents, face a fear of genital abnormality, more as regards size than form or concerning the ability for sexual function. This fear is fuelled by the usual boasting of the school playground. On this

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sensitive ground an amputation increases this notion of abnormality, the more so since we live in a country where men are not generally circumcised.

More objectively the operation causes an aesthetic modification, and there is a risk of regarding the penis as disfigured; a circumcised man in our part of the world may himself be disgusted and his partners disturbed by the glans permanently exposed, just as we feel uncomfortable faced with an ectropion or a prolapse. We are used to a cutaneous covering of the entire body, and a break or alteration of this envelope creates by this raw appearance of the decorticated penis, a feeling of discomfort like the sight of blood or of a defect in the skin (the labial slit or eczema) well beyond what reason would lead one to expect; and when one considers how fragile and sensitive to emotional disturbances sexual function is, one gets an idea of the consequences that may result from this mutilation.

Conversely it is important to recognise that in USA the sisters of a circumcised boy feel this same discomfort when faced with a partner whose glans is naturally covered.

The foreskin is the eyelid of the glans. Its ablation denudes the mucosa of the glans and causes more or less temporarily a dreadful causalgia which the patient could well do without. The glans is a precious part of the male and in our minds we know that objects of value are kept in a case. Circumcision is the ablation of this case.

The foreskin is also an important erogenous zone: it is perhaps the first such zone discovered by the infant, then it is the site of the erogenous trigger, particularly effective at producing an erection since the glans at that time has only a moderate sensitivity. It seems also that stroking the foreskin is particularly good for maintaining the erect state without precipitating orgasm. An informed partner discovers these properties and knows very well how to communicate lasting sensations of high quality through the foreskin. Circumcision removes the nerve endings of this skin surface depriving the subject of this delightful sensation.

Apart from the foreskin's own sensitivity, the loss through circumcision of indirect stimulation of the glans must be taken into account, and the need to discover with more or less difficulty a new technique of masturbation.

The fragility and delicacy of the mucosa of the glans explain why stimulation by direct digital massage becomes painful at once. On the other hand it is bearable and even delightful when the stimulation instead of being direct is carried out indirectly through the folds of the foreskin. In these conditions it is the pressure receptors that are stimulated. There are variations of pressure within the glans rather than friction or rubbing on its mucosa. The nerve endings are not tactile but sensitive to pressure. Note that some of the masturbation massages the corpus spongiosum, propelling blood towards the glans, and each wave increases the pressure there.

Dr. Gerard Zwang, in "Circumcision -- whatever for?" expresses the same ideas in rich and well-chosen words: "The child acquires .... the experience of conscious sexual pleasure. By practising this delicious handling of the penis indirectly through the foreskin.

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The only frictional contact that the glans appreciates, savours and tolerates is that of the moist and padded vaginal (or oral) mucosa. The rough, dry friction of the hand or of the fingers would soon become unbearable if Mother Nature in her wisdom had not interposed the foreskin as a screen between the stimulating hand and the very delicate primary erogenous epithelium. The to and fro movement of the foreskin on the glans, nicely eased by the lubricating sebaceous coating, gives rise to this alternating stimulation which is an effective method of producing orgasm."

Circumcision seems to cause a rapid tensing of the frenum during penetration and could contribute to premature ejaculation.

But above all it is the loss of the reserve of skin provided by the foreskin that damages the physiology of coitus. The primary function of the foreskin is not to permit masturbation, even though we may congratulate ourselves for it, but to allow vaginal intercourse to take place under optimal conditions without friction between the mucosal surfaces of the two participants.

Try an experiment: holding the tip of the erect penis of an uncircumcised boy you can as a rule move your fingers to the base of the penis without causing the slightest slippage on the skin. The foreskin unrolls; this skin slides on the penis; its length and elasticity allow it to travel the entire length of the organ. There is no other part of the body where the subcutaneous tissues allow such mobility. (Photos 19 et seq.)

This explains why sexual intercourse can be prolonged without causing friction and therefore irritation of the surfaces in contact, i.e. the penile skin and the vaginal mucosa. The movement does not occur between these surfaces but between the penile dartos muscle and its subcutaneous tissues specially adapted for this function.

Amputation of the foreskin reduces considerably or even totally this mobility, by removing 4-6 cms of the reserve of skin and eliminates this amazing function.

The effects of this loss may be slight if the man is a premature ejaculator, since the very brief intercourse will not cause irritation, the same if the penis is very short or moved by thrusts of small amplitude. On the other hand prolonged and vigorous intercourse risks causing irritation in spite of natural or even artificial lubrication, explaining certain cases of female and even male dyspareunia. I have examined a young man circumcised during military service; his erection was painful due to the sheer stretching of the sheath cut too short over the erect corpora cavernosa. His sexual capacity was as a result at least for a while totally destroyed, and certainly altered for the rest of his life.

We may also question whether circumcision, so popular in the USA, may not be a factor encouraging erosions of the ano-rectal mucosa in the course of anal intercourse, and may thus encourage the spread of HIV, since we know that breaks in the skin or mucosa are the usual portals of entry of the virus.

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Conclusion

It would appear then that phimosis which is normal in infancy diminishes in frequency with age due to the fact of the manipulation of the penis. It depends therefore on the practice of masturbation which permits an organised morphological development in the direction of future adult sexual behaviour.

In those cases where the manipulation of the penis does not lead to stretching of the ring of the foreskin, this part remains of insufficient diameter to expose the glans and constitutes congenital (primary) phimosis of the adolescent.

Prescription of kinesitherapy is effective at dilating this ring, and results in redirecting the patient towards conventional masturbation. Reduction of the phimosis can be achieved in a few weeks.

Tackling the subject of masturbation contributes to removing guilt from a very widespread genital activity, but one which is often very poorly accepted due to the taboo which continues without reason to weigh upon it.

Medical treatment of adolescent phimosis, allows when it is effective (and in the absence of a cutaneous abnormality it seems to be always effective) the avoidance of the many problems caused by amputation of the foreskin that is circumcision. The cutaneous mobility of the penile sheath being no longer able to benefit from the reserve of tissue is restricted as a result and the dynamics of coitus are altered. In North America where circumcision is very widespread techniques to re-cover the glans by plastic surgery or stretching have been developed. This latter method by stretching the remaining skin sets out to restore the mobility of the sheath just as it would have been prior to the ablation.

We can be happy that manipulation of the tissues allows the avoidance of surgical intervention, and in other circumstances the limitation of the problems when surgery has unfortunately occurred.

References

AME (Association contre la mutilation des enfants): La circoncision pourquoi faire.

Report of the International Symposium on Circumcision San Francisco 1991.

Delaroche: Les idees recues en medicine.

Emme: Manuel de la Masturbation.

Freud: Birth of Psychoanalysis.

Guillerm: Le Sexe Epanoui.

Kahn L'Adas: Le Point G.

Mendel: Anthropologie Differentielle.

Rossaut: Votre Enfant.

Winberg: The Prepuce: A mistake of Nature? (Lancet 18 March 1989.)

Zwang: Contraception Fertilite Sexualité 1989 vol 17 No. 12.