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Prepuce

The prepuce is the retractable double-layered fold of skin and mucosal tissue that covers the glans penis in males and the glans clitoris in females, serving as a protective covering during development and non-erect states.^[1]^[2]^[3] In males, it originates embryologically from the genital fold and tubercle, forming a specialized mucocutaneous junction with an inner mucosal layer rich in Meissner's corpuscles for fine-touch sensation and an outer keratinized layer.^[4]^[5] The female prepuce, or clitoral hood, arises from analogous structures in the labia minora, providing similar coverage and retractability over the clitoral glans.^[6]^[7] Anatomically, the prepuce maintains a moist environment for the glans, potentially aiding in immunological defense through resident Langerhans cells and secretory functions, though empirical quantification of these roles remains limited by variability in observational studies.^[4] Its dense innervation supports erogenous sensitivity, with nerve densities highest in the ridged band near the mucocutaneous junction, contributing to sexual mechanoreception.^[8]^[9] In males, the prepuce's removal via circumcision—prevalent in certain religious and cultural contexts—alters penile mechanics, reducing gliding action during intercourse and exposing the glans to chronic keratinization, with meta-analyses indicating mixed effects on sexual function, including reports of diminished sensitivity in some cohorts alongside purported benefits like lower urinary tract infection rates in infancy.^[10]^[11] Complications from such procedures include hemorrhage, infection, and adhesions, occurring in up to 10% of cases, underscoring trade-offs absent in intact anatomy.^[12]^[13] Debates persist due to methodological challenges in blinding and long-term follow-up, with institutional sources often emphasizing preventive benefits while underreporting sensory losses.^[10]

Anatomy

Gross Anatomy

The prepuce, commonly referred to as the foreskin, constitutes a double-layered cutaneous fold that encircles and covers the glans penis in uncircumcised males, serving as a retractable sheath.^[5] Its outer surface forms a continuation of the penile shaft skin, featuring glabrous stratified squamous keratinized epithelium, while the inner surface transitions to a mucosal epithelium contiguous with that of the glans, delineating the preputial space.^[14]^[5] This structure exhibits high vascularity, with prominent blood vessels integrated into its lamina, contributing to its turgor and mobility.^[14] On the ventral aspect, the prepuce attaches to the glans via the frenulum preputii, a midline fold of skin bridging the inner mucosal layer to the inferior surface of the glans, which limits retraction and maintains alignment.^[14]^[5] In the flaccid state, the prepuce typically envelops the glans entirely, with its proximal attachment near the coronal sulcus and distal edge forming a puckered orifice that permits passage of the glans during erection or manual retraction.^[5] The overall length and laxity of the prepuce vary among individuals, influenced by genetic and developmental factors, but it generally allows full coverage without constriction in healthy adults.^[14] The prepuce integrates seamlessly with the penile integument, lacking hair follicles on its inner and distal portions, and its elasticity derives from underlying dartos fascia shared with the penile skin, facilitating smooth gliding over the glans.^[5] Gross examination reveals no skeletal support, relying instead on its fibroelastic composition for protection and mobility, with the inner layer often appearing smoother and more delicate than the tougher outer epidermis.^[14]

Microscopic Structure and Innervation

The human prepuce exhibits a pentalaminar histological organization, comprising an outer layer of glabrous stratified squamous keratinized epithelium continuous with penile shaft skin, underlying dermis rich in collagen bundles, elastic fibers, blood vessels, and lymphatics, a central dartos fascia of longitudinally oriented smooth muscle fibers providing elasticity and thermoregulation, lamina propria (corium) with loose connective tissue and immune elements such as plasma cells and lymphocytes, and an inner mucosal epithelium of stratified squamous type with minimal or absent keratinization, resembling mucocutaneous tissue.^[15]^[16] This inner epithelium features a thin stratum corneum and prominent vascular papillae extending into the lamina propria, facilitating lubrication and sensory functions.^[17] The dermis and lamina propria contain a dense network of fine nerve fibers of varying diameters, including myelinated and unmyelinated types, forming a subepithelial plexus that ramifies toward the epidermal-dermal junction.^[18] Specialized mechanoreceptors, such as Meissner's corpuscles, are concentrated in the papillary dermis of the inner preputial surface, enabling high-resolution tactile sensitivity, while free nerve endings predominate for pain and temperature detection.^[18]^[14] Sensory innervation derives primarily from the dorsal nerve of the penis, a terminal branch of the pudendal nerve (S2-S4), supplemented by branches of the perineal nerve, conveying somatosensory afferents via Aδ and C fibers to the spinal cord and brain for erotic and protective reflexes.^[19]^[4] Autonomic components include sympathetic postganglionic fibers from the hypogastric plexus for vasoconstriction and parasympathetic fibers via cavernous nerves for vasodilation, though sensory density far exceeds autonomic elements, with estimates of up to 20,000 nerve endings per square centimeter in the ridged band region.^[14]^[9] This innervation pattern supports the prepuce's role in mechanosensory feedback during sexual arousal, with age-related declines in corpuscular density observed post-puberty.^[9]

Embryological Development

Formation in Utero

The prepuce begins forming during the early fetal period, with initial epidermal thickening on the glans observed by 9-10 weeks gestation, distinguishing it from the penile shaft epidermis.^[14] At approximately 12 weeks, a dorsal preputial placode emerges from the glans ectoderm, marking the onset of preputial fold development, which initiates proximally and extends distally.^[20] This placode arises through localized epidermal proliferation rather than simple invagination, contrasting earlier hypotheses, and corresponds to a crown-rump length of about 40-70 mm.^[21] Morphological progression involves epidermal splitting mediated by mesenchymal intrusion, forming the preputial lamina—a transient structure with basophilic inner cells facing the glans and squamous outer cells.^[14] This process starts dorsally and laterally at 10-11 weeks, spreading ventrally by 13-14 weeks, with the folds gradually enclosing the glans; partial coverage occurs by 13 weeks, near-complete by 16-17 weeks, and full enclosure by 18 weeks.^[20]^[21] Ventrally, incomplete fusion leaves mesenchymal remnants that develop into the frenulum, while desquamating cells accumulate between the prepuce and glans, later degenerating to establish the preputial space.^[14] Histologically, the prepuce's formation is androgen-influenced, with receptors in the mesenchyme supporting ectodermal-mesodermal interactions, though not strictly dependent on circulating androgens at this stage.^[14] Innervation parallels morphogenesis, with dorsal penile nerve branches reaching the prepuce by 14-16 weeks via S100-positive fibers in the mesenchyme.^[14] These developments occur amid urethral canalization, where preputial growth coordinates with glans remodeling to ensure coverage without adhesions until postnatal separation.^[20]

Postnatal Changes

In human males, the prepuce remains adherent to the glans penis at birth, forming physiological adhesions that prevent retraction, a normal state present in nearly all newborns.^[22]^[23] This separation initiates gradually postnatally, driven by desquamation of epithelial cells producing smegma, which lubricates the interface, and augmented by spontaneous penile erections that exert mechanical force.^[22]^[24] The process typically progresses unevenly, with partial retractability emerging first, and complete separation achieved in over 99% of cases by adolescence without medical intervention.^[23]^[25] Longitudinal observations document age-related retractability rates: in a Danish cohort, full retraction occurred in approximately 12% of boys by age 1, 28% by age 3, 50% by ages 6–7, 62% by ages 10–11, 84% by ages 13–14, and 92% by ages 16–17.^[26] A Japanese cross-sectional study of 603 prepubertal boys confirmed similar progression, with non-retractability decreasing from 96% in infancy to under 10% by age 13–14, attributing delays to incomplete separation rather than scarring.^[27]^[28] Post-separation, residual synechiae may persist but usually resolve spontaneously by age 5–10.^[26]^[24] Accompanying histological changes include transition of the inner preputial mucosa toward stratified squamous epithelium with increasing keratinization, alongside proportional growth matching penile elongation during childhood and puberty.^[29] Innervation matures postnatally, with mechanosensory nerve endings in the prepuce reaching peak density around age 20 before stabilizing.^[9] Pathological non-separation beyond puberty, termed true phimosis, arises from fibrotic scarring and affects fewer than 1% of uncircumcised males, often linked to recurrent inflammation rather than developmental arrest.^[22]^[23] In human females, the clitoral prepuce exhibits limited distinct postnatal alterations beyond resolution of transient neonatal edema, which can mimic clitoromegaly but self-resolves within weeks to months. Pubertal hormonal surges induce vulvar enlargement, including modest preputial hood expansion to accommodate clitoral growth, though quantitative data on these changes remain sparse compared to male counterparts.^[30]

Physiological Functions

Protective and Lubricative Roles

The prepuce serves as a retractable sheath that physically shields the glans penis from external friction caused by clothing or environmental factors, as well as from desiccation and potential contaminants, thereby preserving the underlying mucosal integrity.^[31]^[32] This coverage maintains a moist, non-keratinized environment for the glans, preventing the thickening and coarsening of its epithelial layer that develops in response to chronic exposure post-circumcision.^[33] In newborns and young children, the prepuce additionally protects the developing glans during periods of non-retractability, reducing vulnerability to irritation or infection.^[33] Regarding lubrication, glandular secretions within the prepuce and glans contribute to the formation of smegma, a mixture of sebum, desquamated epithelial cells, and moisture that coats the inner mucosal surfaces, facilitating smooth gliding motion and preventing dryness or chafing.^[34]^[35] Smegma's lipid content specifically aids in reducing inter-tissue friction, supporting hygienic mobility of the prepuce over the glans during erection or manual retraction.^[34] During sexual intercourse, the prepuce's elasticity and mobility enable it to roll distally, allowing the penile shaft to thrust within the foreskin sheath; this mechanism distributes natural lubricants, diminishes direct glans-vaginal friction, and protects both partners' tissues from abrasion.^[33]^[32] Studies of adult males report that this gliding action correlates with reduced mechanical stress on the glans compared to circumcised penises, where the exposed surface relies more on external lubrication.^[33]

Sensory and Sexual Functions

The prepuce of the penis is densely innervated with sensory nerve endings, including a high concentration of Meissner's corpuscles in its glabrous inner mucosa, which function as rapidly adapting, low-threshold mechanoreceptors specialized for detecting fine tactile stimuli such as light touch, low-frequency vibration, and skin stretch.^[18] These corpuscles predominate over other sensory structures like Pacinian corpuscles or free nerve endings in the preputial skin, enabling heightened sensitivity to mechanical deformation during contact or movement.^[36] Additional innervation arises from branches of the penile dorsal and ventral nerves, which transmit afferent signals essential for tactile discrimination and reflexive responses in the genital region.^[9] In sexual function, the prepuce contributes to pleasure through its mobility, which allows it to glide over the glans penis during erection and penile-vaginal intercourse, thereby stimulating embedded mechanoreceptors via rhythmic shear and stretch forces without direct glans friction.^[37] This gliding mechanism reduces mechanical stress on the mucosal surfaces of both the penis and vagina, potentially enhancing mutual sensory feedback by distributing contact across the prepuce's innervated epithelium rather than concentrating it on the less protected glans.^[33] Empirical mapping of erogenous zones indicates that preputial tissues, particularly the ridged band near the mucocutaneous junction, elicit strong hedonic responses to tangential stimulation, correlating with activation in brain regions associated with genital pleasure processing.^[38] Physiological studies further confirm that intact preputial innervation supports fine-grained sensory input during arousal, distinct from coarser touch detection elsewhere on the penile shaft.^[39]

Immunological Contributions

The prepuce features a mucosal inner epithelium rich in immune sentinel cells, including Langerhans cells (dendritic cells) that serve as antigen-presenting cells for pathogen detection and T lymphocyte activation, alongside CD4+ and CD8+ effector memory T cells that mediate adaptive responses through cytokine secretion and targeted cytotoxicity.^[40]^[41] Natural killer (NK) cells, predominantly CD56^dim and expressing activation markers like NKp44 and CD16, contribute innate defenses via antibody-dependent cellular cytotoxicity and production of proinflammatory cytokines such as IL-17 and IL-22.^[41] Plasma cells (CD138+) and memory B cells predominate in foreskin-associated regions, facilitating local antibody production integral to mucosal barrier function.^[41] Secretory immunoglobulin A (IgA), produced by foreskin-resident plasma cells, neutralizes enveloped viruses including HIV at the mucosal surface, with detectable IgA+CD138+ cells confirming site-specific synthesis.^[42] Innate antimicrobial mechanisms involve peptides like α-defensins (HNP1–3) and secretory leukocyte protease inhibitor (SLPI), secreted by epithelial and inflammatory cells, alongside lysozyme and lipids from ectopic sebaceous glands (Tyson's glands).^[42]^[40] Smegma, comprising desquamated keratinocytes, sebum, and moisture, harbors antibacterial lipids and proteins that may suppress pathogenic overgrowth, supporting a balanced penile microbiome.^[40] These elements collectively enable the prepuce to mount localized responses against bacterial, viral, and fungal challengers in the genital environment, though empirical correlations in cohort studies link elevated antimicrobial peptide levels to heightened HIV acquisition risk, suggesting context-dependent efficacy influenced by inflammation or microbial dysbiosis.^[42]^[40]

Evolutionary and Comparative Biology

Evolutionary Origins in Primates

The prepuce in male primates, homologous to the clitoral hood in females, represents a conserved feature across the order Primates, indicating its origin in the last common ancestor of extant primates approximately 55 to 65 million years ago during the late Paleocene to early Eocene epochs.^[43]^[44] This structure, a double-layered fold of skin and mucosa enveloping the glans penis, is documented in all major primate clades, including basal strepsirrhines such as lemurs and galagos, which diverged early in primate phylogeny.^[45]^[46] Its uniform presence predates the split between strepsirrhines and haplorhines (tarsiers, monkeys, and apes), underscoring a plesiomorphic trait retained through millions of years of diversification.^[43] Comparative anatomical studies reveal that the prepuce provides mechanical protection for the glans, facilitates lubrication via preputial glands, and contributes to sensory innervation, with variations in receptor density across species reflecting adaptive modifications.^[46] For instance, while rhesus macaques exhibit denser glans innervation relative to the prepuce, humans display heightened preputial sensitivity with specialized corpuscular receptors, suggesting evolutionary refinement in simian lineages.^[43] The structure's endurance implies selective pressures favoring genital protection and enhanced copulatory function, as evidenced by its role in maintaining mucosal integrity against environmental and mechanical stresses in arboreal and terrestrial primate ancestors.^[46] In the hominin branch, post-chimpanzee divergence around 7 million years ago, the prepuce co-evolved with penile elongation and behavioral shifts, including pair-bonding and reduced sexual dimorphism, potentially amplifying its sensory contributions amid changing mating strategies.^[43] Phylogenetic reconstructions attribute these developments to sexual selection, where preputial morphology influenced reproductive success without evidence of regression in non-human primates.^[46] Fossil and genetic data lack direct preputial preservation, but extant distributions affirm its deep-rooted integration into primate reproductive anatomy.^[44]

Prepuce in Non-Human Mammals

The prepuce, also known as the penile sheath, is a tubular fold of skin that envelops the distal free portion of the non-erect penis in the vast majority of non-human mammalian species, providing protection against environmental damage and facilitating penile protrusion during erection.^[47] ^[48] It generally comprises an outer layer of haired integument and an inner mucosal lamina lined with squamous epithelium, sebaceous and sweat glands, and sometimes lymphoid follicles, with smegma accumulation in the preputial cavity.^[48] Blood supply derives primarily from the external pudendal artery, while innervation involves pudendal and ilioinguinal nerves.^[47] Species-specific variations in preputial anatomy reflect adaptations to locomotion, mating behaviors, and hygiene. In equines such as horses, the prepuce is double-folded, forming distinct external and internal cavities separated by the plica preputialis, with a pendulous sheath featuring a preputial ring that forms a raised ridge during erection and an extra preputial fold when retracted; urination occurs extra-preputially.^[49] ^[48] In ruminants like bulls and rams, it is sigmoid-curved and elongated (35-40 cm in bulls), with a narrow cavity, orifice diameter of about 2.5 cm located 5 cm caudal to the umbilicus, and muscular support from protractor and retractor preputial muscles; urination is intra-preputial.^[47] ^[49] In swine, the prepuce includes a distinctive diverticulum (collecting debris and secretions) dividing the cavity into narrow caudal and wider cranial portions, with less extensiveness overall than in horses.^[47] ^[49] In carnivores and rodents, the prepuce often integrates sensory and glandular elements. Dogs exhibit a complete sheath with a caudally directed orifice, enclosing the penis fully when flaccid.^[48] Cats have a similar structure but with the orifice positioned ventral to the scrotum.^[48] Rodents, such as mice, possess both external (perineal appendage forming a mucosal sleeve) and internal prepuces integral to the glans, housing erectile tissue and preputial glands that secrete pheromones for sexual signaling; these glands are paired sebaceous structures adjacent to the prepuce, prominent in species like rats and hamsters.^[50] ^[51] Urination in dogs and cats is extra-preputial, contrasting with intra-preputial modes in some herbivores.^[47] Female non-human mammals frequently retain a homologous clitoral prepuce, underscoring its conserved role across sexes.^[48]

Clinical Significance

Common Disorders

Phimosis, the inability to retract the prepuce over the glans penis, affects approximately 1% of boys by seventh grade in its pathologic form, though physiologic phimosis is normal in infancy and resolves naturally in most cases by adolescence.^[52] Pathologic phimosis arises from scarring due to recurrent inflammation, such as balanitis xerotica obliterans (BXO), or forceful retraction attempts, with an incidence of 0.6% by age 15.^[53] It can lead to urinary obstruction, recurrent infections, or penile carcinoma in untreated adults.^[54] Paraphimosis occurs when the retracted prepuce becomes constricted behind the glans, causing venous congestion, edema, and potential ischemia if not promptly reduced; it is a urologic emergency most common in uncircumcised males after iatrogenic retraction or sexual activity.^[55] Prevalence data are limited, but it disproportionately affects uncircumcised individuals due to preputial adhesions or poor hygiene.^[56] Balanoposthitis, inflammation involving both the glans and prepuce, has a prevalence of 12-20% across males, peaking in children aged 2-5 years from poor hygiene, candidal or bacterial infections, or irritants like soaps.^[57] Uncircumcised males face higher risk, with lifetime balanitis incidence up to 68% versus negligible in circumcised cohorts, often linked to smegma accumulation fostering anaerobic bacteria.^[58] Symptoms include erythema, discharge, and pain, complicating to phimosis if chronic.^[59] Other notable disorders include posthitis, isolated preputial inflammation from similar infectious or irritative causes, and lichen sclerosus (BXO), a fibrotic condition causing white plaques and phimotic scarring, with onset often in childhood but progression in adulthood.^[24] These conditions underscore the prepuce's vulnerability to microbial overgrowth in uncircumcised states, though many resolve with hygiene or topical steroids without surgery.^[60]

Diagnostic and Therapeutic Approaches

Diagnosis of prepuce-related disorders primarily relies on clinical history and physical examination. For phimosis, characterized by the inability to retract the foreskin over the glans, assessment involves evaluating retraction during a gentle physical exam, distinguishing physiological (normal in young children) from pathological forms often due to scarring or inflammation; additional tests like urinalysis may rule out associated urinary tract infections.^[61] Paraphimosis is diagnosed by observing a constricted, retracted foreskin forming a tight band proximal to a swollen glans, with symptoms including pain and edema; urgent evaluation prevents vascular compromise, and no imaging is typically required unless complications like necrosis are suspected.^[62] Balanoposthitis, inflammation of the glans and prepuce, is identified through inspection for erythema, discharge, or ulceration, supplemented by swabs for microbiology to detect candidal or bacterial causes, and blood tests for hyperglycemia in recurrent cases linked to diabetes.^[57] Therapeutic approaches prioritize conservative management to preserve the prepuce when possible. For phimosis, topical corticosteroids such as 0.05% betamethasone applied twice daily for 4-8 weeks, combined with manual stretching, achieve retraction in approximately 80-90% of non-scarred cases in children, with success rates supported by randomized trials showing reduced need for surgery.^[63] In adults, similar steroid regimens or devices like PhimoStop for graded stretching offer non-invasive alternatives for mild to moderate phimosis (Kikiros grade ≤2), yielding durable outcomes in over 70% of patients at 12-month follow-up.^[64] Refractory cases may require preputioplasty, a foreskin-preserving surgery involving transverse incisions (e.g., Heineke-Mikulicz or Y-V plasty) at stenotic sites closed longitudinally to widen the preputial ring, with low complication rates (under 5%) and full retraction achieved in most patients.^[65] Circumcision remains definitive for severe pathological phimosis but is reserved after conservative failure.^[61] Paraphimosis management begins with immediate manual reduction after analgesia and edema control via compression wraps, ice, or osmotic agents like hypertonic saline; success exceeds 90% in early presentations, averting necrosis.^[66] Persistent cases necessitate urgent dorsal slit under local anesthesia or emergent circumcision to restore blood flow.^[67] For balanoposthitis, treatment targets etiology: antifungal creams (e.g., clotrimazole) for candidal infections predominant in uncircumcised males, antibiotics for bacterial overgrowth, and hygiene education to prevent recurrence; underlying conditions like diabetes must be managed, reducing relapse by addressing causal factors such as poor glycemic control.^[68] Prophylactic low-potency steroids may aid chronic non-infectious forms, though evidence emphasizes identifying infectious contributors via culture to guide precise therapy.^[57]

Circumcision

Historical Context

Circumcision, the surgical removal of the prepuce, represents one of the oldest documented human surgical practices, with archaeological evidence tracing its origins to ancient Egypt around 2400 BCE. A bas-relief from the Sixth Dynasty tomb of Ankhmahor at Saqqara depicts the procedure being performed on adolescents using a flint knife, indicating it was a ritualistic rite likely associated with initiation into manhood or priestly status, performed on boys aged 6 to 14. Mummified remains and hieroglyphic inscriptions from the Old Kingdom period (c. 2686–2181 BCE) further corroborate its prevalence among elites, possibly for hygienic or symbolic purity reasons in a hot climate conducive to balanitis and infections.^[69]^[70] The practice spread to Semitic peoples, including early Israelites, predating its biblical codification. While Genesis 17:10–14, dated to circa 1800–1600 BCE, mandates circumcision as a covenantal sign established with Abraham on the eighth day of life for male descendants, extrabiblical evidence suggests it was already customary among neighboring groups in the Levant and Arabia for tribal identification or fertility rites. In Judaism, it evolved into the brit milah ceremony, enduring Hellenistic persecutions—such as Antiochus IV's 167 BCE ban, which sparked the Maccabean Revolt—and Roman-era prohibitions under Hadrian in 135 CE, where Jews faced forced epispasm (foreskin restoration) to assimilate. Medieval Jewish texts, like the Talmud (c. 500 CE), standardized techniques to prevent reversal, reinforcing its role as an indelible marker of identity amid diaspora expulsions and conversions.^[69]^[71] In the 19th century, circumcision transitioned from primarily religious observance to medical procedure in Europe and the United States, driven by emerging germ theory and moral hygiene campaigns. British physician Jonathan Hutchinson advocated it in 1855 to curb venereal diseases like syphilis, while American advocates, including John Harvey Kellogg, promoted neonatal circumcision from the 1870s onward to prevent masturbation, which they pathologized as causing epilepsy, paralysis, and moral decay—claims rooted in unverified Victorian pseudoscience rather than controlled trials. By 1900, U.S. rates rose to 25–50% among urban elites for purported benefits against phimosis and infections, though European adoption lagged due to less emphasis on routine intervention. This medicalization decoupled it from ritual, framing it as preventive health amid industrialization's sanitation challenges, despite lacking empirical validation until later epidemiological data.^[72]^[73]

Surgical Techniques

Circumcision involves the surgical removal of the prepuce, with techniques differing based on patient age, anatomical considerations, and clinical setting. Neonatal procedures commonly employ device-based methods to facilitate rapid execution and reduce bleeding, while adult or older child circumcisions favor freehand excision approaches for precision in tissue handling.^[74]^[75] Standard techniques are designed to excise the prepuce while preserving the glans and underlying structures, typically under local anesthesia.^[76] Gomco clamp method, widely used in neonatal circumcision since its development in 1935, positions a metal bell over the glans to protect it, followed by application of a clamp to compress the prepuce against the bell, allowing excision of the foreskin distal to the clamped line. This technique provides hemostasis through compression and enables adjustable removal of preputial tissue, though it requires careful sizing of the bell to avoid excessive skin removal.^[77]^[74] Mogen clamp method, another neonatal staple originating from traditional Jewish practices and refined in the mid-20th century, involves retracting the prepuce over the glans, inserting a rectangular shield to delineate the excision line, and applying the clamp to crush the tissue before cutting. It is noted for its speed and minimal equipment needs but demands precise alignment to prevent glans injury.^[75]^[78] Plastibell device method, introduced in the 1950s, entails placing a plastic ring between the prepuce and glans, tying a suture around the foreskin to secure it, and trimming excess tissue above the ring, which remains in place as a tourniquet until it sloughs off naturally after 5-8 days. This approach minimizes intraoperative bleeding and operative time but carries a risk of incomplete ring expulsion if not monitored.^[79]^[78] In adults, the sleeve resection technique predominates, involving circumferential incisions on the inner and outer preputial surfaces to mark the excision boundaries, followed by longitudinal approximation and removal of the intervening skin sleeve, with suturing to achieve hemostasis and cosmesis. It allows for controlled tension and customization to penile anatomy, particularly useful in cases of phimosis.^[76]^[75] The dorsal slit technique, often a preparatory or standalone method for adults with tight prepuce, creates a midline incision along the dorsal prepuce to facilitate retraction and exposure before completing excision, reducing risks associated with forcible retraction. This approach is especially indicated when adhesions or stenosis complicate access.^[76]^[74] Emerging variations, such as laser-assisted or thermocautery methods, employ CO2 lasers or thermal devices for incision and coagulation, reportedly reducing operative time and blood loss compared to scalpel techniques in select studies, though long-term outcomes require further validation.^[80]^[81]

Empirical Evidence of Benefits

Randomized controlled trials conducted in Africa, including studies in South Africa, Kenya, and Uganda published between 2005 and 2008, demonstrated that voluntary medical male circumcision reduces the risk of HIV acquisition by heterosexual men by approximately 50-60% over 24-30 months of follow-up.^[82]^[83]^[84] These findings, based on over 10,000 participants, prompted World Health Organization recommendations for circumcision as an HIV prevention strategy in high-prevalence regions, with modeling estimating millions of averted infections since 2007.^[85] A 2024 trial in men who have sex with men further indicated reduced HIV risk, though evidence remains preliminary compared to heterosexual contexts.^[86] Circumcision in infancy lowers the incidence of urinary tract infections (UTIs) by about 90%, with a number needed to treat (NNT) of 111 to prevent one UTI in otherwise healthy boys, where baseline risk is approximately 1%.^[87] A cohort study of over 200,000 boys found a 9.1-fold reduction in UTI rates during the first year of life among circumcised newborns, alongside substantial decreases in associated medical costs.^[88] Meta-analyses confirm this protective effect persists in subgroups with anatomical abnormalities like anterior urethral narrowing, though absolute benefits diminish with low baseline UTI prevalence.^[89]^[90] The procedure substantially mitigates penile cancer risk, with systematic reviews of case-control studies showing circumcised men, particularly those operated on in childhood or adolescence, face up to a 3-22 times lower incidence of invasive disease compared to uncircumcised peers.^[91] This association holds after adjusting for confounders like human papillomavirus (HPV) exposure, with meta-analyses linking circumcision to reduced penile HPV prevalence, a key carcinogen.^[92]^[93] Penile cancer remains rare overall (1-2 per 100,000 annually in Western populations), but the relative risk reduction underscores prevention of hygiene-related cofactors.^[94] Circumcision prevents inflammatory conditions such as balanoposthitis and pathological phimosis, with adult studies reporting incidence reductions exceeding 60-90% post-procedure.^[74]^[95] Longitudinal data indicate these benefits arise from eliminating preputial accumulation of smegma and pathogens, though conservative treatments like steroid creams can resolve many non-pathologic cases without surgery.^[96] Systematic overviews affirm net preventive value against such disorders, independent of infectious outcomes.^[59]

Risks and Complications

Acute complications of circumcision, primarily occurring during or shortly after the procedure, include hemorrhage, infection, and penile injury, with reported rates varying by setting and patient age. In neonatal circumcisions performed in medical settings, minor adverse events such as bleeding or infection occur in approximately 0.2% to 2% of cases, while severe complications like significant hemorrhage or glans injury are rarer, affecting fewer than 0.1%. ^[97] ^[98] ^[99] Systematic reviews indicate overall complication rates for non-therapeutic neonatal procedures around 3.34%, rising to 7.47% for therapeutic circumcisions addressing underlying conditions. ^[100] Surgical errors represent another category of immediate risks, encompassing excessive or insufficient skin removal, adhesions, and damage to the glans or urethra. Meatal stenosis, a narrowing of the urethral opening, has been associated with circumcision in some studies, though causality remains debated and rates are estimated at 0.9% to 8% in circumcised males, potentially influenced by technique. ^[101] ^[102] Incomplete circumcision or skin bridges may necessitate revision surgery in 1-2% of cases, particularly when performed without general anesthesia or in non-sterile conditions. ^[103] Risks escalate significantly with age; adverse events are 10- to 20-fold higher in males circumcised after infancy compared to newborns. ^[104] Long-term complications, though infrequent, include scarring, phimosis recurrence in partial cases, and potential impacts on sexual function such as reduced sensitivity or dissatisfaction, reported anecdotally but with limited high-quality longitudinal data quantifying prevalence below 1%. ^[105] ^[106] Anesthesia-related risks, including reactions to local agents like lidocaine, are minimal in neonates but can include methemoglobinemia in rare instances when inappropriate formulations are used. ^[107] Overall, death from circumcision is exceedingly rare, with estimates under 1 in 500,000 procedures in developed settings, often linked to undiagnosed coagulopathies rather than the procedure itself. ^[108] Complication rates are lower for neonatal procedures than for those in older children or adults, emphasizing the influence of physiological factors like tissue vascularity and healing capacity. ^[99]

Controversies and Ethical Debates

The primary ethical controversy surrounding the removal of the prepuce in infant males centers on the principle of bodily autonomy and the absence of informed consent from the individual undergoing the procedure. Critics argue that non-therapeutic circumcision constitutes a violation of the infant's right to physical integrity, as it involves the irreversible excision of healthy, functional tissue without immediate medical necessity or the child's ability to consent.^[109] ^[110] This perspective aligns with broader bioethical consensus emphasizing that proxy consent by parents should not extend to elective alterations of a child's genitals, particularly when alternatives like hygiene education exist for later life.^[111] Proponents counter that parental authority includes decisions on minor, low-risk interventions with potential long-term health advantages, framing deferral to adulthood as impractical due to increased procedural risks and reduced compliance.^[112] Human rights frameworks have intensified the debate, with some scholars classifying routine infant circumcision as a form of iatrogenic injury akin to other non-consensual body modifications. In 2013, J. Steven Svoboda contended that such procedures infringe on universal rights to bodily inviolability, applicable even to religious or cultural practices, unless overridden by urgent therapeutic needs.^[110] The intactivist movement, advocating genital autonomy, amplifies these claims by likening circumcision to female genital cutting, though opponents dismiss this analogy as hyperbolic and note that intactivist assertions often rely on anecdotal or low-quality evidence rather than randomized trials.^[113] Ethicists on both sides invoke autonomy but diverge on its application: anti-circumcision views prioritize the child's future self-determination, while supporters emphasize communal and familial precedents in decision-making.^[114] Legally, challenges have yielded mixed outcomes, highlighting tensions between child protection and parental freedoms. A 2012 German regional court ruling deemed non-therapeutic circumcision bodily harm, prompting national legislation in 2013 to permit it under regulated conditions for religious reasons, yet sparking ongoing European scrutiny.^[115] In the United States, proposed bans in states like California (2011) failed amid religious liberty defenses, though some Medicaid restrictions since 2006 have curbed routine access, indirectly questioning public funding for non-essential procedures.^[97] Critics of bodies like the American Academy of Pediatrics (AAP) argue its 2012 policy—stating benefits outweigh risks but stopping short of routine endorsement—exhibits cultural bias, overstates evidence quality, and inadequately addresses ethical conflicts with contemporary standards on informed consent.^[116] ^[117] These debates underscore a divide: while empirical benefits are acknowledged, the ethical calculus for healthy infants remains contested, with calls for deferral until maturity to respect individual agency.^[118]

Cultural and Religious Contexts

Prevalence and Practices

Approximately 38% of males worldwide undergo circumcision, with the vast majority performed for religious or cultural reasons rather than medical ones. Religious practices account for roughly two-thirds of global cases, predominantly among Muslims and Jews, where prevalence nears universality at over 99% in adherent populations.^[119]^[120] In Judaism, circumcision, termed brit milah, occurs on the eighth day of life as a biblical covenantal obligation outlined in Genesis 17:10-14, executed by a mohel using a sharp blade in a ritual ceremony that includes blessings and a festive meal. This neonatal timing minimizes complications and aligns with halakhic requirements, prohibiting delay except for health risks, even on Sabbaths or holidays. Observance remains near-complete among Orthodox and Conservative Jews, though some Reform communities permit alternatives or opt out on ethical grounds.^[121]^[122] Islamic tradition mandates khitan as a sunnah practice emulating the Prophet Muhammad, though unspecified in the Quran, with no fixed age but common performance between infancy and puberty—often around age 7 in regions like Turkey or Indonesia—to promote hygiene and maturity. Methods vary culturally, from surgical excision by physicians in urban settings to traditional barbers in rural areas, achieving 90-100% prevalence across Muslim-majority nations and communities.^[123]^[124]^[125] Beyond Abrahamic faiths, traditional circumcision prevails in sub-Saharan African societies as a puberty rite of passage, with prevalence reaching 62% regionally but varying by ethnicity—such as 32% traditional among South African blacks via group initiations using non-sterile tools like spears among Xhosa males aged 12-18. These ceremonies emphasize manhood and tribal identity but carry elevated infection risks due to unsterilized practices, prompting WHO-supported medical alternatives in high-HIV areas. In North Africa, Islamic influence drives near-93% rates, blending religious and customary norms.^[126]^[127]^[128]

Symbolic Interpretations

In Judaism, the prepuce is symbolically interpreted as the removable excess that signifies the covenant (brit) between God and the Jewish people, as established in Genesis 17:10-11, where its excision marks eternal dedication and identity.^[129] This act transforms the physical body into a vessel for spiritual commitment, with rabbinic sources viewing the foreskin as an impediment to full procreative and moral maturity, its removal enabling readiness for reproduction and ethical living.^[130] Anthropological analyses note that this symbolism reinforces communal belonging, where retaining the prepuce equates to exclusion from the sacred pact.^[131] In Islamic tradition, the prepuce's removal through khitan embodies fitrah (natural disposition) and purification (tahara), perfecting the body's innate form as a marker of submission to divine order and affiliation with the ummah (Muslim community).^[132] Drawing from Abrahamic precedent, it signifies fidelity to prophetic practice rather than alteration of God's creation, with jurists emphasizing its role in enhancing cleanliness and ritual eligibility, such as for leading prayer.^[123] Though absent from the Quran, hadith and scholarly consensus frame it as a sunnah obligation, symbolizing holistic piety over mere hygiene.^[133] Christian symbolic views historically tied the prepuce to relics like the Holy Foreskin, purportedly from Jesus' circumcision, representing incarnate divinity and the transition from Old Covenant law to spiritual circumcision of the heart (Romans 2:29).^[134] Early Church Fathers interpreted its excision as purging carnal corruption, aligning bodily sacrifice with redemption, though post-Reformation skepticism diminished relic veneration.^[135] Anthropologically, across African and Polynesian rites, the prepuce often symbolizes immature or profane vitality, its ritual severance initiating males into warrior or elder status via bloodletting as communal atonement or fertility enhancement.^[136] In ancient Greco-Roman contexts, conversely, an intact, elongated prepuce denoted civilized restraint and apotropaic protection against excess lust, contrasting with barbaric exposure; Jews defended their practice against such ideals by framing removal as mastery over appetites.^[137] These interpretations underscore the prepuce's cross-cultural role as a mutable signifier of transition, purity, or restraint, varying by societal emphasis on collective identity over individual anatomy.^[138]

Recent Developments and Research

Advances in Preservation Techniques

Recent developments in prepuce preservation have emphasized conservative and minimally invasive surgical alternatives to circumcision, particularly for managing phimosis, driven by evidence of comparable efficacy with reduced risks of complications such as altered penile sensitivity and cosmetic dissatisfaction.^[139] A 2025 narrative review highlights a paradigm shift toward these methods, noting their ability to maintain prepuce functionality while achieving high patient satisfaction rates exceeding 80% in multiple studies.^[139] Conservative therapies represent the first-line advances, with topical corticosteroids like 0.05% betamethasone demonstrating an 82.2% success rate in resolving phimosis through daily application combined with gentle retraction, though recurrence occurs in 17.8% of cases.^[139] Emerging adjuncts include platelet-rich plasma (PRP) injections, which reduced mean phimosis severity from 75.5% to 6.7% in treated patients, and mechanical devices such as Novoglan, achieving 90% improvement in retraction with 95% sustained outcomes at two-year follow-up.^[139] Similarly, Phimostop devices yielded significant retraction gains, enabling 52% of users to avoid surgery altogether.^[139] Surgical preservation techniques, notably preputioplasty, have advanced through refined incisions like the Heineke-Mikulicz principle, which widens the preputial ring via dorsal slitting and transverse closure, preserving innervation and aesthetics with low complication rates under 5% and high retractability post-procedure.^[139] Variants such as Y-V plasty offer alternatives for adult phimosis, demonstrating good functional and cosmetic results in series of 89 cases, with patients retaining foreskin mobility.^[140] These approaches are particularly relevant for refractory cases, outperforming historical circumcision in preserving natural anatomy without evidence of increased recurrence when executed precisely.^[141] In tissue engineering contexts, decellularization protocols have progressed to preserve prepuce extracellular matrix (ECM) for potential regenerative scaffolds, using enzymatic (trypsin-EDTA followed by DNase) or detergent (Triton X-100 and SDS) methods that reduce DNA content below 50 ng/mg while maintaining collagen, elastin, and fibronectin integrity, as validated in 2023 studies on pediatric samples.^[142] These techniques enable non-immunogenic grafts for skin reconstruction, though clinical translation remains investigational.^[142]

Ongoing Studies on Function and Outcomes

Ongoing investigations into the prepuce's sensory functions utilize immunohistochemical analysis to map nerve innervation, particularly mechanosensitive fibers, revealing age-related declines that may affect tactile sensitivity in sexual contexts.^[9] These findings contribute to understanding the prepuce's role in fine-touch discrimination, with denser innervation observed in younger tissues compared to older samples.^[9] High-quality systematic reviews of circumcision outcomes, synthesizing data from randomized trials and longitudinal cohorts, consistently report no adverse impacts on penile sensitivity, sexual function, or satisfaction post-procedure.^[143] Conversely, studies on intact prepuces identify associations between redundant foreskin and elevated risks of premature ejaculation or other dysfunctions, informing preservation strategies in non-pathological cases.^[144] Immunological research highlights the prepuce's mucosal environment as a site of T-cell subsets vulnerable to pathogens like HIV, with recent randomized trials testing pre-circumcision antimicrobials—such as topical metronidazole—to mitigate infection susceptibility and evaluate post-intervention tissue outcomes.^[145] In phimosis management, prepuce-preserving techniques are assessed for functional retention, showing comparable efficacy to excision in resolving inflammation while minimizing sensory loss, as evidenced by histopathological correlations.^[139]^[146] Device-assisted circumcision studies report sustained improvements in sexual quality of life metrics, including reduced complications and enhanced satisfaction scores at 6-12 months follow-up, though long-term sensory data remain under collection in prospective cohorts.^[147] These efforts underscore persistent scrutiny of trade-offs between infection prevention benefits and potential subtle functional alterations, with ongoing histopathological and microbiological analyses in preserved versus removed tissues.^[148]

References

[1]
https://www.dictionary.com/browse/prepuce
[2]
Foreskin (Prepuce): Appearance, Function, Retraction & Care
Foreskin is a moveable layer of skin covers the head of the penis (glans). It's important to take care of it to prevent certain conditions.
[3]
Prepuce - an overview | ScienceDirect Topics
The prepuce is a specialized junctional mucocutaneous tissue that provides adequate skin and mucosa to cover the entire penis during erection.
[4]
The Prepuce: Anatomy, Physiology, Innervation, Immunology, and ...
The prepuce is an integral, normal part of the external genitalia that forms the anatomical covering of the glans penis and clitoris.
[5]
Penis Anatomy: Gross Anatomy, Vasculature, Lymphatics and Nerve ...
Mar 18, 2025 · At the corona, it is folded on itself to form the prepuce (foreskin), which overlies the glans.Gross Anatomy · Vasculature · Pathophysiologic Variants
[6]
Prepuce of Clitoris | Complete Anatomy - Elsevier
The prepuce is a thin hairless portion of skin covering the body and glans of clitoris and contains folds that produce mucous.
[7]
Prepuce of clitoris - e-Anatomy - IMAIOS
The upper division passes above the clitoris to meet its fellow of the opposite side, forming a fold which overhangs the glans clitoridis, and is named the ...
[8]
Single-cell analysis of human prepuce reveals dynamic changes in ...
Sep 1, 2023 · The cellular and molecular dynamics of human prepuce are crucial for understanding its biological and physiological functions, ...Missing: evidence | Show results with:evidence
[9]
Sexual Mechanosensitivity: Age-Related Changes in the Innervation ...
The prepuce is richly innervated by sensory nerve fibers from the penile dorsal and ventral nerves [4] which are required for sexual function since they are the ...Missing: empirical | Show results with:empirical
[10]
Do the Benefits of Male Circumcision Outweigh the Risks? A ... - NIH
The conclusion they draw – that circumcision has no impact on sexual functioning, sensitivity, or sexual satisfaction – does not necessarily line up with the ...
[11]
The Contrasting Evidence Concerning the Effect of Male ...
Those studies found MC has no or minimal adverse effect on sexual function, sensation, or pleasure, with some finding improvements. A consensus from ...
[12]
Circumcision: Pros and cons - PMC - NIH
Common complications of circumcision include hemorrhage (35%), wound infection (10%), meatitis (8-20%), and UTI (2%) respectively. Opening of the wound, ...
[13]
Complications of Circumcision - Stanford Medicine
Bleeding · Infection · Insufficient Foreskin Removed · Excessive Foreskin Removed · Adhesions / Skin Bridges · Inclusion Cysts · Abnormal Healing · Meatitis.
[14]
Development of the human prepuce and its innervation - PMC
The adult human prepuce is a circumferential flap of highly vascular skin largely covering the glans penis. Its outer surface is continuous with skin of the ...
[15]
(PDF) Histology of the Prepuce - ResearchGate
The prepuce is a pentalaminar structure composed of a squamous mucosal epithelium, lamina propria (corion), dartos muscle, dermis, and outer glabrous skin.
[16]
Histological and morphological development of the prepuce ... - NIH
The epithelium of the prepuce consists of stratified squamous cells that are keratinized, and the dermis of the prepuce has connective tissue, blood vessels, ...
[17]
Histologic characteristics of the human prepuce pertaining ... - PubMed
The aim of this study was to investigate the unique histologic structure of the normal human prepuce, paying particular attention to the resemblance and ...
[18]
Sensory innervation of the human male prepuce: Meissner's ...
Jun 12, 2021 · Human male prepuce is richly innervated by nerve fibers of various diameters that form a dense network in the reticular dermis. These fibers ...
[19]
The Penis - Structure - Muscles - Innervation - TeachMeAnatomy
The prepuce (foreskin) is a double layer of skin and fascia, located at the neck of the glans. It covers the glans to a variable extent. The prepuce is ...
[20]
[PDF] Human glans and preputial development - eScholarship
Sep 1, 2018 · Development of the prepuce. Development of the prepuce is initiated by ~12 weeks with the appearance of a novel structure, the preputial ...
[21]
https://embryology.med.unsw.edu.au/embryology/index.php/Paper_-_Notes_on_the_development_of_the_prepuce_(1935)
[22]
EAU Guidelines on Paediatric Urology - THE GUIDELINE
Progressive separation of the inner prepuce from the glans is associated with build-up of epithelial debris (smegma) and aided by penile erections. During ...
[23]
Phimosis and Paraphimosis - DynaMedex
Oct 16, 2024 · Adhesions between the prepuce and the glans naturally and usually resolve, resulting in their gradual and complete separation. Almost 99% of ...Missing: neonate | Show results with:neonate
[24]
Clinical Practice Guidelines : The penis and foreskin
Sometimes the normal process of separation is uneven, and the foreskin becomes partially retractable but with residual attachments to the glans. This may lead ...
[25]
Penile adhesions and skin bridges - Cleveland Clinic
Typically, over the first several years of your child's life, the foreskin will separate from the glans. After this occurs, you can pull the foreskin away ( ...Missing: puberty | Show results with:puberty
[26]
Normal Development of the Prepuce
The genital organs are in a very immature stage of development at birth. The growth and development continues through puberty and into adulthood.Missing: fetus | Show results with:fetus
[27]
Analysis of Shape and Retractability of the Prepuce in 603 ...
Incomplete separation of the prepuce is common and normal in neonates and infants, and preputial separation progresses until adolescence. Awareness of these ...Missing: puberty | Show results with:puberty<|separator|>
[28]
Age-specific foreskin development before adolescence in boys.
Preputial separation from the glans is a developmental process and begins by 24 weeks of gestation. The degree of preputial retractability varies considerably ...
[29]
A Proteomics Signature of Mild Hypospadias: A Pilot Study - Frontiers
Although it has been noted that histological and morphological changes occur in foreskin tissue during postnatal development (88), such as changes in ...
[30]
Let's talk about the vulva and how it changes in puberty
Aug 28, 2023 · The glans or tip of the clitoris can vary in size and is protected by the clitoral hood or prepuce. ... Vulval changes pre to post puberty.
[31]
The development of a decellularized extracellular matrix–based ...
Dec 22, 2018 · The glans and inner mucosa are physically protected against external irritation and contaminants while maintaining a healthy, moist surface.
[32]
A Novel Procedure of Prepuce Reconstruction Customized to ... - NIH
The prepuce acts as a roller bearing during sexual intercourse, unfolding, and gliding, thus protecting the glans penis from abrasive and biomechanical stress, ...
[33]
Vital or vestigial? The foreskin has its fans and foes - PMC - NIH
“It is often stated that the prepuce is a vestigial structure devoid of function,” he wrote. “However, it seems to be no accident that during the years when ...Missing: empirical | Show results with:empirical
[34]
A comprehensive review of current knowledge on penile squamous ...
May 22, 2024 · The function of smegma is associated with lubrication of the thin mucosal lining of the inner prepuce and glans, allowing for smooth skin ...
[35]
Phimosis in Children - PMC - NIH
Phimosis is nonretraction of prepuce. It is normally seen in younger children due to adhesions between prepuce and glans penis.
[36]
Sensory innervation of the human male prepuce - PubMed
Jun 12, 2021 · Meissner's corpuscles are the most abundant sensory corpuscles in the glabrous skin of the male prepuce. They are type I, rapidly adapting, low-threshold ...
[37]
Foreskin motion generates Meissner corpuscle stimulation - The BMJ
Sep 10, 1994 · The gliding action of the foreskin allows it to move during coitus. It everts and un-everts in rapid succession during coitus. It appears ...
[38]
PD30-12 MAPPED EROGENOUS SENSATION & PLEASURE IN ...
Sep 1, 2021 · PD30-12 MAPPED EROGENOUS SENSATION & PLEASURE IN THE PENIS ... Most research has focused on changes in sensitivity primarily to the glans and ...
[39]
A psychophysical and neuroimaging analysis of genital hedonic ...
Jun 17, 2022 · The skin areas for stimulation (except the penile glans) were marked in black with a washable skin pencil, and the penis was stabilized on the ...
[40]
Immunological functions of the human prepuce - PMC
Immunological functions of the human prepuce. P M Fleiss. P M Fleiss. Find ... The fate of the foreskin, a study of circumcision. Br Med J. 1949 Dec 24;2 ...Missing: peer- reviewed
[41]
The Human Penis Is a Genuine Immunological Effector Site - Frontiers
The human penis is a main portal of entry for numerous pathogens, and vaccines able to control resulting infections locally are highly desirable.Penile Cd4 And Cd8 T Cells... · Cytokines Produced By Penile... · Penile Nk Cells Have An...
[42]
HIV Acquisition Is Associated with Increased Antimicrobial Peptides ...
Oct 2, 2014 · Three independent randomized clinical trials demonstrated that male circumcision reduces the risk of HIV acquisition by 50–60% [2]–[4], and ...
[43]
Anatomy and histology of the penile and clitoral prepuce in primates
Since primates have been on earth for at least 65 million years, it can be assumed that the prepuce has been present since the earliest primate ancestors. As ...
[44]
Early Primate Evolution: The First Primates
Primates are relative newcomers on our planet. The earliest ones are found in the fossil record dating to 50-55 million years ago. These first prosimians ...
[45]
Prosimian - an overview | ScienceDirect Topics
In general, prosimians, Old and New World monkeys, and apes externally have a fibrovascular penis with a glans and an os penis or baculum, a distinct preputial ...
[46]
ANATOMY AND HISTOLOGY OF THE PENILE AND CLITORAL ...
The male and female prepuce has persisted in all primates, which strongly supports the contention that the prepuce is valuable genital sensory tissue. 4.Missing: origins | Show results with:origins
[47]
Prepuce of Animals - Vetscraft
The prepuce of animals, also known as the sheath, is a tubular fold of skin that covers the cranial free portion of the penis in its non-erect state.
[48]
Prepuce - an overview | ScienceDirect Topics
The prepuce, or sheath, is a voluminous, folded sleeve of integument covering the mobile portion of the quiescent penis.
[49]
Reproductive Tracts and Genitalia – CVM Large Animal Anatomy
In all species there is a root, body, and free part of the penis. (Figs. 5.53, ) (The distinctive features of the penis in each species will be discussed ...
[50]
Anatomy of the mouse penis and internal prepuce - PMC - NIH
Sep 30, 2020 · The mouse internal prepuce is integral to the glans penis and clearly is involved in sexual function in so far as it contains a major erectile body innervated ...Missing: non- | Show results with:non-
[51]
Preputial Gland - an overview | ScienceDirect Topics
The preputial gland is defined as a paired modified sebaceous gland located in the subcutaneous adipose tissue adjacent to the penis in males and the ...<|separator|>
[52]
Phimosis - UCSF Department of Urology
Phimosis is divided into two forms: physiologic and pathologic. Current incidence of phimosis is about 1% in 7th grade boys. Physiologic phimosis: Children are ...
[53]
Phimosis and Paraphimosis - DynaMed
Oct 16, 2024 · The incidence of pathologic phimosis by age 15 years is reported to be 0.6% (ISRN Urol 2012;2012:707329). Paraphimosis - Incidence of ...Types Of Phimosis · Epidemiology · Etiology And Pathogenesis
[54]
Phimosis, Adult Circumcision, and Buried Penis
May 28, 2024 · Phimosis is defined as the inability of the prepuce (foreskin) to be retracted behind the glans penis in uncircumcised males.<|separator|>
[55]
Phimosis and Paraphimosis - Men's Health Issues - MSD Manuals
In paraphimosis, the retracted foreskin cannot be pulled forward to cover the glans penis. The condition most commonly develops when the foreskin is left ...
[56]
Disorders of the glans penis and foreskin - Phimosis - AMBOSS
Mar 28, 2025 · Common disorders of the glans penis and foreskin include balanitis, balanoposthitis, phimosis, and paraphimosis.
[57]
Balanoposthitis - StatPearls - NCBI Bookshelf
May 6, 2024 · Balanoposthitis, a condition affecting the glans penis and prepuce, is prevalent among both pediatric and adult uncircumcised males, with a ...
[58]
Balanitis, Phimosis, and Paraphimosis | 5-Minute Clinical Consult
Balanitis: occurs in all ages but most common in children <4 years old and uncircumcised elderly; lifetime incidence for uncircumcised males is 68% (1).
[59]
Penile Inflammatory Skin Disorders and the Preventive Role of ... - NIH
May 4, 2017 · Penile inflammatory skin conditions such as balanitis and posthitis are common, especially in uncircumcised males, and feature prominently ...
[60]
Penile Diseases & Disorders: Causes & Treatments - Cleveland Clinic
Penile diseases and disorders may include priapism, balanitis, penile fracture, penile cancer and erectile dysfunction.
[61]
Phimosis - StatPearls - NCBI Bookshelf
Circumcision is the preferred treatment for pathological phimosis and represents the only absolute indication for this procedure in children.Continuing Education Activity · Etiology · Epidemiology · Treatment / Management
[62]
Paraphimosis - StatPearls - NCBI Bookshelf - NIH
Diagnosis is made clinically by direct visualization, as well as the inability to easily reduce the retracted foreskin manually. Go to: Treatment / Management.
[63]
Phimosis: Learn More – What are the treatment options for ... - NCBI
May 12, 2023 · There are two treatment options: A steroid cream is usually tried first. Surgery is then recommended if the cream doesn't work.What does treatment with... · What benefits does treatment...
[64]
Can circumcision be avoided in adult male with phimosis? Results ...
Conclusions: PhimoStopTM device is effective for the treatment of adult male phimosis of Kikiros grade ≤2. The results seem to be durable in most patients at a ...Methodsother Section · Phimostop Device · Resultsother Section
[65]
Preputioplasty - PMC - NIH
This procedure involves two laterally placed vertical incisions over the stenotic preputial bands which are subsequently closed horizontally. It provides ...
[66]
Paraphimosis: Current Treatment Options - AAFP
Dec 15, 2000 · Treatment often begins with reduction of edema, followed by a variety of options, including mechanical compression, pharmacologic therapy, puncture technique ...
[67]
Paraphimosis Treatment & Management - Medscape Reference
Mar 25, 2024 · When diagnosed early, paraphimosis can be remedied easily with simple manual reduction in combination with other conservative measures.
[68]
Approach to balanitis/balanoposthitis: Current guidelines - PMC - NIH
Balanitis describes inflammation of the glans penis and posthitis means inflammation of the prepuce. In practice, both areas are often affected together.
[69]
Male Circumcision: Integrating Tradition and Medical Evidence - PMC
Jan 1, 2014 · Male circumcision is the oldest known human surgical procedure, with historical records and archeological evidence dating the practice back to ancient ...
[70]
Circumcision in the Ancient World - EARLY CHURCH HISTORY
The oldest depiction of circumcision comes from a bas-relief (above) in the necropolis at Saqqara in Egypt dating to c. 2400 BC. It was performed with a flint ...<|separator|>
[71]
Circumcision in the Old Testament | Religious Studies Center - BYU
Following its biblical beginnings with Abraham, the practice of religious circumcision in the Old Testament was passed down from generation to generation, ...
[72]
The History of Circumcision in the United States - SpringerLink
Medicalised circumcision did not appear until the latter part of the nineteenth century, when some members of the American medical establishment began to ...
[73]
From Ritual to Science: The Medical Transformation of Circumcision ...
Circumcision generally has remained either a religious ritual or an infrequent medical intervention to treat specific diseases.
[74]
Circumcision - StatPearls - NCBI Bookshelf
May 2, 2024 · Two basic versions of performing a standard surgical circumcision are recognized: the dorsal slit technique and the sleeve technique. These ...
[75]
Techniques of Male Circumcision - PMC - NIH
Circumcision methods can be classified into one of three types or combinations thereof: dorsal slit, shield and clamp, and excision.[12,14] Many of the methods ...
[76]
Adult Circumcision - AAFP
Mar 15, 1999 · The procedure is commonly performed using either the dorsal slit or the sleeve technique. The dorsal slit is especially useful in patients who ...Indications and... · Dorsal Slit Technique · Sleeve Technique · Complications
[77]
Gomco Clamp Technique | Newborn Nursery - Stanford Medicine
The Gomco clamp is the most commonly used circumcision device in our nursery. It has the advantages of a steel bell which protects the glans penis during the ...
[78]
Neonatal circumcision techniques - PubMed
Neonatal circumcision is most commonly performed using one of three techniques--the Mogen clamp, the Gomco clamp or the Plastibell device.<|separator|>
[79]
Circumcision | Newborn Nursery - Stanford Medicine
Circumcision · What is Circumcision · Benign Physical Findings · Contraindications · Complications · Gomco Clamp Technique · Mogen Clamp Technique · Plastibell ...
[80]
CO2 Laser Circumcision versus Conventional - Dove Medical Press
Jul 16, 2020 · Our results show that the use of a CO 2 laser was associated with a shorter operative time, less wound irritation and better cosmetic appearance
[81]
Thermocautery-assisted Circumcision - Grand Journal of Urology
Saracoğlu et al. reported that circumcisions performed with the thermocautery technique resulted in shorter operation times and less bleeding, contributing to ...
[82]
Randomized, Controlled Intervention Trial of Male Circumcision for ...
Oct 25, 2005 · Observational studies suggest that male circumcision may provide protection against HIV-1 infection. A randomized, controlled intervention trial was conducted.
[83]
Male circumcision for HIV prevention in young men in Kisumu, Kenya
Feb 24, 2007 · Our aim was to determine whether male circumcision had a protective effect against HIV infection, and to assess safety and changes in sexual behaviour related ...
[84]
Articles Male circumcision for HIV prevention in men in Rakai, Uganda
This large, randomised trial of adult male circumcision in a rural Ugandan population shows that such a surgical intervention reduces the risk of the ...
[85]
Voluntary medical male circumcision for HIV prevention
The recommendation was based on strong evidence from randomized controlled trials showing an approximately 60% lower risk. Since 2007, more than 27 million ...
[86]
Circumcision — A Surgical Strategy for HIV Prevention in Africa
Dec 4, 2008 · The data were clear: circumcision reduced the rate of HIV infection among heterosexual men by 60%. Since then, two other randomized, controlled ...
[87]
Circumcision for the prevention of urinary tract infection in boys
Conclusions: Circumcision reduces the risk of UTI. Given a risk in normal boys of about 1%, the number-needed-to-treat to prevent one UTI is 111. In boys ...
[88]
Newborn circumcision decreases incidence and costs of urinary ...
Newborn circumcision results in a 9. 1-fold decrease in incidence of UTI during the first year of life as well as markedly lower UTI-related medical costs ...
[89]
Review Article Circumcision reduces urinary tract infection in ...
Our meta-analysis revealed that circumcision was associated with a lower incidence of UTI in children with ANH.
[90]
Circumcision reduces rate of urinary tract infection especially for ...
Circumcision reduces the risk of UTI. Given a risk in normal boys of about 1%, the number needed to treat (NNT) to prevent one UTI is 111.<|separator|>
[91]
Male circumcision and penile cancer: a systematic review ... - PubMed
Conclusions: Men circumcised in childhood/adolescence are at substantially reduced risk of invasive penile cancer, and this effect could be mediated partly ...
[92]
Male Circumcision, Penile Human Papillomavirus Infection, and ...
Male circumcision is associated with a reduced risk of penile HPV infection and, in the case of men with a history of multiple sexual partners, a reduced risk ...
[93]
The Strong Protective Effect of Circumcision against Cancer of the ...
May 22, 2011 · A meta-analysis of 8 studies published in 2007 found an association of circumcision with a statistically significant reduced risk of penile HPV ...
[94]
Causes, Risk Factors, and Prevention of Penile Cancer
Feb 9, 2016 · This was based on studies that found much lower penile cancer rates among circumcised men than among uncircumcised men.
[95]
Circumcision - American Urological Association
Properly performed neonatal circumcision prevents phimosis, paraphimosis and balanoposthitis, and is associated with a markedly decreased incidence of cancer of ...
[96]
Review Pros and cons of circumcision: an evidence-based overview
The meta-analysis showed that circumcision may reduce HIV acquisition among MSM reporting an insertive anal role (seven studies), but might not have an effect ...
[97]
Neonatal Circumcision: New Recommendations & Implications ... - NIH
Significant acute complications of neonatal circumcision are rare (1/500); usually minor and most commonly involve bleeding, infection or an imperfect amount of ...
[98]
What Parents Should Understand About Infant Male Circumcision
The risk of bleeding or infection from circumcision in the newborn period is low, about 1 in every 500 patients, and typically easy to treat. Risks of bleeding ...
[99]
Circumcision Policy Statement | American Academy of Pediatrics
Complications are infrequent; most are minor, and severe complications are rare. Male circumcision performed during the newborn period has considerably lower ...
[100]
Male Circumcision Complications - A Systematic Review, Meta ...
Feb 2, 2021 · Our meta-analysis revealed that therapeutic circumcisions were associated with a 2-fold increase in complications as compared to nontherapeutic (7.47% and 3.34 ...
[101]
A comprehensive comparison of the early and late complications of ...
Nov 21, 2022 · The total complication rate of circumcision is 0%–16% (1.5%). The main early and late complications of circumcision are bleeding, glans injury, ...
[102]
Systematic review of complications arising from male circumcision
Complication of newborn circumcision: Meatal stenosis or meatal web. Does circumcision increase meatal stenosis risk?—A systematic review and meta‐analysis.
[103]
Complications of circumcision in male neonates, infants and children
Feb 16, 2010 · Nine studies reported no serious adverse events, but three studies reported that 1-2% of boys had a serious complication [10, 27, 29]. One, a ...
[104]
Rates of Adverse Events Associated With Male Circumcision in US ...
May 12, 2014 · Compared with boys circumcised at younger than 1 year, the incidences of probable AEs were approximately 20-fold and 10-fold greater for males ...
[105]
Male Circumcision Complications – A Systematic Review, Meta ...
Aug 6, 2025 · An analysis of medicalized circumcisions found a complication rate of 4% and that adult complications are not greater than infant complications ...
[106]
Retrospective analysis of clinical outcomes and early complications ...
Feb 28, 2025 · As with any surgical procedure, circumcision may involve potential complications. Literature reports complication rates ranging from 0.1–35%. In ...
[107]
Assessment of risk factors for surgical complications in neonatal ...
Conclusions. This investigation of neonatal circumcision revealed that patients weighing >5.1 kg may be at higher risk of bleeding and long-term complications, ...
[108]
Complications Associated With Circumcision in a Community-Based ...
Jun 6, 2025 · Acute complications include bleeding (0.08% to 0.18%), injury to the penis (0.04%), and infection (0.06%). Late complications are rare and ...
[109]
Non-therapeutic infant male circumcision: Evidence, ethics ... - NIH
The aim of this paper is to review the evidence of the benefits and harms of infant male circumcision, and the legal and ethical perspectives of infant male ...
[110]
[PDF] Circumcision of male infants as a human rights violation
May 22, 2013 · Indeed, as I will argue, human rights protect the bodily integrity of all infants against any unnecessary and non-medically indicated intrusion.
[111]
Evidence and Ethics on: Circumcision
In this article, we explore the research evidence as well as the ethical debate around routine circumcisions performed on healthy newborn males.
[112]
Critical evaluation of unscientific arguments disparaging affirmative ...
The article maintains that the foreskin serves as a valve to, “let urine out” while, “blocking the entry of dirt”, that it provides lubrication, that it ...
[113]
Critical evaluation of arguments opposing male circumcision: A ...
Sep 8, 2019 · Compelling data, such as randomized controlled trials (RCT), systematic reviews and meta-analyses, showing net benefits of male circumcision (MC) ...<|separator|>
[114]
Infant male circumcision and the autonomy of the child: two ethical ...
In this article, I suggest that much of the disagreement results from conflicting ideas about the autonomy of the child. I examine two questions about autonomy.
[115]
Nontherapeutic Circumcision of Minors as an Ethically Problematic ...
Nontherapeutic infant male circumcision is not medically or ethically justifiable and should be deferred until the person is able to decide for himself.
[116]
Cultural Bias in the AAP's 2012 Technical Report and Policy ...
Apr 1, 2013 · The AAP does not recommend routine circumcision of all infant boys as a public health measure but asserts that the benefits of the procedure are ...Criteria for Preventive Medicine · HIV AND AIDS · Complications · Conclusions
[117]
fatal flaws in the latest AAP policy report on neonatal circumcision
The policy statement and technical report suffer from several troubling deficiencies, ultimately undermining their credibility. These deficiencies include the ...
[118]
Recommendation by a law body to ban infant male circumcision has ...
Recent attempts in the USA and Europe to ban the circumcision of male children have been unsuccessful. Of current concern is a report by the Tasmanian Law ...
[119]
Estimation of country-specific and global prevalence of male ...
Approximately half of circumcisions were for religious and cultural reasons. For countries lacking data we assumed 99.9 % of Muslims and Jews were circumcised. ...
[120]
[PDF] Male circumcision - Global trends and determinants of prevalence ...
Of these, around two thirds (69%) are Muslim (living mainly in Asia, the Middle East and North Africa), 0.8% are Jewish, and 13% are non-Muslim and non-Jewish ...
[121]
Tradition … Tradition … - Oxford Academic - Oxford University Press
Ritual male circumcision (brit milah), performed on 8-day-old infants, has been an essential component of Jewish practice across the generations in every ...
[122]
Circumcision: a religious obligation or 'the cruellest of cuts'? - PMC
It is forbidden to postpone the Brit Milah for any reason other than the health of the child and it can even be conducted on the Jewish holy days of Shabbat and ...Missing: prevalence | Show results with:prevalence
[123]
Bodily Integrity and Male Circumcision: An Islamic Perspective - PMC
Uncircumcised Muslims are rare. The rate of circumcision in Muslim nations is between 90 and 100 percent. This includes the Christians who form a significant ...
[124]
https://bbc.co.uk/religion/religions/islam/islamethics/malecircumcision.shtml
[125]
Reported Male Circumcision Practices in a Muslim-Majority Setting
Unlike Jewish traditions where circumcision is clearly advised on the seventh day after birth, Islamic traditions do not provide specific recommendations on the ...
[126]
Circumcision and its effects in Africa - PMC - NIH
Neonatal circumcision, largely for religious and cultural purposes, is performed on more than 85% of boys in Nigeria, Western Africa, and majority of the ...
[127]
Estimates of the prevalence of male circumcision in sub-Saharan ...
Mar 13, 2024 · The prevalence of male circumcision increased from 40% during 2010–2015 to 56% during 2016–2023 in the priority countries. Further, the ...
[128]
A Case Study of Male Circumcision in South Africa - Sage Journals
Jul 26, 2020 · (2014: 127) reported “the prevalence of male circumcision to be 48.2%, of which 32.1% were traditionally circumcised and 13.4% were medically ...
[129]
The Power of Circumcision - Jewish Theological Seminary
The removal of the foreskin admits the young male into manhood by readying him symbolically for procreation. The symbol and substance are closely related ...
[130]
Circumcision: Is the Foreskin a Defect? - TheTorah.com
Nov 1, 2017 · You shall circumcise the flesh of your foreskin, and it shall be the sign of the covenant between Me and you. Beyond that, the biblical cupboard ...<|separator|>
[131]
Fruit Trees and Foreskins - Jewish Theological Seminary
May 6, 2022 · This connection between circumcision and fertility is related to a cultural perception that the foreskin symbolizes an excess of masculinity ...
[132]
Religions - Islam: Circumcision of boys - BBC
Aug 13, 2009 · The preferred age is often seven although some Muslims are circumcised as early as the seventh day after birth and as late as puberty. There is ...
[133]
Benefits of Circumcision in Islam - Islam Question & Answer
Apr 13, 2001 · So Allah has made circumcision a symbol of those who belong to Him and to His religion, and who attribute themselves to Him as being utterly ...
[134]
Topical Bible: Foreskin
The concept of the foreskin in the Bible is deeply intertwined with themes of covenant, identity, and spiritual transformation.
[135]
The concept of Foreskin in Christianity
Jun 21, 2025 · In Christianity, the foreskin symbolizes corruption and is removed during circumcision, representing a covenant.Missing: contexts | Show results with:contexts
[136]
More than just a cut: a qualitative study of penile practices and their ...
Jul 20, 2012 · The penis and its foreskin have long held the interest of historians, anthropologists and the medical fraternity. Foreskins are cultural facts ...<|control11|><|separator|>
[137]
The Ideal Prepuce in Ancient Greece and Rome: Male Genital ...
The association between the longer prepuce and respectability was so strongly felt that Greeks took steps to prevent unwanted exposure of the glans. In this ...<|separator|>
[138]
[PDF] Possible Psychoanalytic Meanings of the Foreskin in the Hebrew Bible
foreskin seems to be a sign of social and religious belonging. There seems to be some ambivalence towards the foreskin just as Karl Abraham (Jones. 1927, 295 ...
[139]
Prepuce‐Preserving Management of Phimosis: Therapeutic Options ...
Sep 19, 2025 · Eligible sources included peer-reviewed clinical trials, observational studies, systematic reviews, meta-analyses and clinical guidelines ...
[140]
Y-V Preputioplasty for Adult Phimosis: A Review of 89 Cases - Urology
YV preputioplasty would seem a good alternative to circumcision for men with phimosis who wish to preserve their foreskin.Missing: advances | Show results with:advances
[141]
Preputioplasty as a surgical alternative in treatment of phimosis
Dec 1, 2021 · This procedure starts with an inverted “V” with 1 cm “legs” at the narrowest part of the external foreskin, which are then extended to form a “Y ...
[142]
Decellularization techniques of human foreskin for tissue ... - NIH
Oct 31, 2023 · The present study confirms the feasibility of foreskin decellularization based on enzymatic or detergent methods.
[143]
https://academic.oup.com/jsm/article/10/11/2644/6939976
[144]
Association of redundant foreskin with sexual dysfunction:...
Our study revealed a positive correlation between the presence of redundant foreskin and the risk of sexual dysfunction, especially in PE patients.
[145]
Impact of antimicrobials on penile HIV susceptibility and ...
Sep 17, 2024 · This trial randomizes men to one of four antimicrobials prior to penile circumcision. Topical metronidazole and oral tinidazole reduce foreskin HIV ...
[146]
[PDF] Inflammatory changes in the prepuce and clinical findings according ...
Feb 18, 2025 · This study was designed to investigate the inflammatory processes in the prepuce according to the degree of phimosis in patients who underwent ...
[147]
Impact of device-assisted circumcision on sexual quality of life in ...
Aug 7, 2025 · The results of this systematic review suggest that adult males who underwent device-assisted circumcision generally improved or maintained their ...
[148]
Advances in the study of the correlation between balanoposthitis ...
These findings suggest that changes in the microbial flora may affect the microecological balance in the glans penis and prepuce area, thereby triggering BP.