The foreskin (also called the prepuce) is the layer of skin that covers the glans or head of the penis. The exact function of the foreskin is a topic of much debate. Some medical authorities see it as a protective layer for the glans that prevents infection while others see it as an artefact like an appendix and increases the risk of infection. There are also views that the foreskin and its anchoring point at the underside of the glans called the frenulum serves to provide a bulking effect during sexual intercourse.
The 2 most common procedures done to the foreskin at our Men’s Health clinic are:
- Circumcision – complete removal of the foreskin
- Frenulectomy – removing the frenulum.
Why do a Circumcision?
First let’s talk about circumcisions.
Most circumcisions done in the world are for religious reasons. We will not be talking about this.
There are in fact many medical reasons to undergo a circumcision. I like to consider these reasons as either medically indicated or for aesthetic reasons (personal or partner preference). So we do encourage patients to consider their partner’s preference before proceeding with a circumcision.
Medical reasons for circumcision
- Paraphimosis – This is a medical emergency where the foreskin becomes stuck behind the head of the penis and cannot be pulled back up to cover the head. This situation will stop blood flow to the glans and will lead to death of the tissue. You need to see a Doctor urgently. We can use various techniques to replace the foreskin back up to cover the head. Then to prevent this from occurring again, the patient is advised to undergo a surgical circumcision.
- Recurrent infections – Balanitis or infection of the glans is most often caused by poor hygiene resulting in a fungal infection. Uncontrolled Diabetes and certain medicines to treat Diabetes can cause an increased amount of sugar in the urine increasing the risk of developing balanitis. Unfortunately, once you have had 1 balanitis episode, the chance of recurrence is up quite high – up to 30%. Balanitis makes the foreskin swollen, cracked and painful. Recurrent balanitis can cause the skin to thicken leading to phimosis. A surgical circumcision is a permanent cure for balanitis.
- Phimosis – A situation where the opening of the foreskin is not big or lax enough to allow the foreskin to be pulled over the glans. This is most commonly a physiological phenomenon meaning people are usually born with a “tighter” foreskin. Some patients develop Phimosis later on in life due to various medical issues like Diabetes, recurrent balanitis or skin issues like Lichen Planus. Phimosis also prevents patients from cleaning the glans and thus predisposes them to balanitis. And recurrent balanitis can also cause phimosis. Severe phimosis is also called “pinhole phimosis”. This is because the opening is as small as a pinhole. In such situations, during urination, the foreskin fills with urine and expands then contracts again as the urine slowly dribbles out of the small opening. In partial phimosis, the foreskin can be retracted to completely expose the head when the penis is flaccid. But becomes an extremely tight band when the penis is erect. Such a situation increases the risk of para-phimosis. Surgical circumcision is a permanent cure for phimosis.
- Viral Warts – Warts are caused by infection with the Human Papilloma Virus (HPV). Aside from being very unsightly, they are extremely contagious and can easily spread to your sexual partner. Aside from causing warts, HPV also increases the risk of developing cervical and anal cancer. There are many ways to treat warts. However when there are multiple warts on the foreskin, the simplest method to treat it is to undergo a surgical circumcision. Patients with warts are also encouraged to take the HPV vaccine to reduce the risk of wart recurrence. We talk more about the effect of HPV infections in our other blog post.
Personal reasons for circumcision
- Religious reasons
- Aesthetics – some patients (or their partners) prefer the “look” of a circumcised penis. There are situations in which patients look for a certain “tightness” for their circumcision. How tight a circumcision is defined by how far back you want your doctor to cut the foreskin.
- Reducing the risk of infections – We already discussed the fact that a surgical circumcision reduces the risk of developing balanitis. There is also a lot of data to show that circumcised men are at a significantly lower risk of getting infected with HIV. You can find the detailed data by following this link to my article on HIV risks.
The process of Surgical Circumcision – What to expect
First and foremost – all circumcisions are done at the minimum under Local Anesthesia meaning you will not feel anything during the procedure. That said, some patients still opt for General Anesthesia. This is also possible. The wound usually takes about 2-4 weeks to heal completely. The amount of discomfort varies from patient to patient. Most patients are able to go about their normal activities even the day after the procedure. We do advise patients to refrain from sexual intercourse and overtly strenuous physical during the healing period. Some patients opt to take painkillers regularly during the healing period to remain absolutely comfortable. While some choose to take painkillers only when they need it.
The Doctor’s Experience is important – the Dorsal Slit method
There are many methods to remove the foreskin and the most fundamental of which is the Dorsal Slit or conventional method. This is a method that the majority of Doctors who are competent in circumcisions start learning and training with.
It is important that your doctor doing your procedure is well versed with the conventional method. That is because if a circumcision device fails, the Doctor has to be able to complete the procedure using the conventional method. I have been called upon several times to help out a colleague and fix a circumcision mid procedure. Because the Doctor who was attempting the procedure with a device did not know how to do it manually. And could not complete the procedure when the device failed. Fortunately I could fix it and saved patient from an unpleasant trip to the Accident and Emergency.
So don’t be shy and ask your doctor how many conventional circumcisions he has done before he suggests using a device on your foreskin!
The dorsal slit method involves a slit down the top portion and stitches around the wound after the foreskin is removed. This method allows the doctor to adjust the “tightness” of the circumcision, which is not only useful for the aesthetic reasons but is also sometimes a requirement for religious circumcisions. Stitches are non-dissolvable and are removed after 2 weeks.
Circumcision Devices
There are also many devices in the market for circumcisions, the 2 most common are:
- Staplers – A guard is placed between the glans and the foreskin, the stapler clamp device is then placed over the guard. Upon clamping, the blades within the stapler cut the foreskin and leave behind a ring of silicon.
- Shang Ring – An inner ring much like the guard in the stapler is placed between the glans and the foreskin. An outer circular clamp is placed over the inner ring and the foreskin is removed. The clamp remains on for up to 2 weeks.
Key Points to remember about Circumcision
- There are many medical and personal reasons to get a circumcision
- The process is painless and simple. There is minimal discomfort during the healing period.
- Make sure your Doctor is familiar and experienced with the conventional circumcision technique.
Penile Frenulectomy
The Penile Frenulum is the strip of skin connecting the bottom of the head of the penis to the foreskin. (As opposed to the Lingual Frenulum which is the strip that connect the bottom of the tongue to the floor of the mouth.)
Frenulectomy is regarded by some as a “half circumcision”. However, this term is a misnomer as the procedure does not involve the foreskin at all but instead involves the removal of the frenulum which holds the foreskin down (much like an anchor).
When is a Frenulectomy required?
There are several reasons to undergo a frenulectomy:
- Frenulum Breve – The main indication or reason for a Frenulectomy is a condition called Frenulum Breve (Short frenulum). Patients with a Frenulum Breve will notice that the head of the penis is pulled forward when the penis is erected. A short frenulum becomes a source of pain during intercourse because like an anchor holding down a ship, the frenulum weights down the foreskin to ensure it stays around the glans. However if this anchor is too short it will pull the foreskin down too hard especially during intercourse. Such pain has been described by some patients as burning your finger on a stove repeatedly.
- Premature Ejaculation – The frenulum carries a lot of nerve fibers that supply the glans penis. Some men find that their glans are much too sensitive leading to premature ejaculation. A Frenulectomy removes some of these nerve fibers and reduces the sensitivity of the glans. This gives the patient much more control over his ejaculation. This can be done for normal length Frenulums but is especially useful when the Frenulum is also short.
- Recurrent Frenulum Tears – The Frenulum frequently tears during sex. This is obviously painful and bleeds profusely. One the Frenulum has torn once, it tends to tear again. A Frenuletomy permanently solves this issue
- Aesthetics – Some patients (or their partners) prefer the look of a smooth cylindrical penis without the Frenulum.
How is a Frenulectomy done? What to Expect.
A Frenulectomy is done under Local Anesthesia like circumcision. The foreskin has to be fully retracted for this procedure so if you are unable to do so, a circumcision may be more appropriate. After retracting, the foreskin, the frenulum is cut down the middle and the wound stitches with absorbable sutures. The sutures will dissolve over 2 weeks but sometimes small pieces of the suture are left over and your doctor can remove it for you during the follow up consultation. There is no downtime for a Frenulectomy, some men come in during their lunch break and head back to work after.
In Conclusion
There are many reasons for you to either get a Circumcision and Frenulectomy. Understanding how the procedure is done and the resulting outcome not just for you but also for your partner are important considerations to note before you proceed.
Our Men’s Health Center is accredited for you to use your Medisave and your personal hospitalisation insurance plans for both Circumcision and Frenulectomy procedures.
Have a question on Circumcision or Frenulectomy? Please put it in the comments section below.