MEDICAL TREATMENT OF CONGENITAL PHIMOSIS OF THE ADOLESCENT

MEDICAL TREATMENT OF CONGENITAL PHIMOSIS OF THE ADOLESCENT

by Dr Michel Beaugé

(translated by Michel Hervé Bertaux-Navoiseau)

TREATMENT

THERAPEUTIC APPROACH

MASTURBATION

CIRCUMCISION

CONCLUSION

Having been in charge for more than 10 years of systematic medical prevention examination of 1^st-year students, I am led to diagnosing a large number of phimosis with old adolescents and young adults.

In this 18-22 years old masculine population, we see that almost 10% have a to-varying-degree tight foreskin, ranging from complete inability to uncover the glans, to a simple ring that gets blocked in the balanic fissure. The term phimosis is used here in the sense of a preputial ring diameter smaller than the diameter of the erected penis.

On questioning, it appears that the vast majority of these subjects are virgins and that among those who are sexually experienced, many have experienced a failure with difficult intromission, pain and loss of erection, except perhaps the case of the tightest phimosis that succeeds in making the penis penetrate with the glans covered. Others expose themselves to the risk of paraphimosis through persevering in coital sex.

This occurrence and the difficulties to complete intercourse, make the medical treatment of phimosis necessary.

TREATMENT

The conventional treatment of phimosis is circumcision or, in the best case, a simple plasty of the foreskin that keeps the skin fold but opens the ring.

For a number of reasons, I was led to refute this therapeutic approach. The surgery is traumatic:

- brutal, irreversible,

- need for anaesthesia,

bleeding,

these last two elements can cause complications of surgery in general,

- reduces the mobility of the sheath in case of circumcision: This item is of importance and will come back to it,

- mentally stressful by the cutting of a highly symbolical element in a subject on the eve of his sexual life,

- creates an anatomical change: the amputation determining a sex different from his peers, synonymous of abnormality at an age when the certainty of normality is not achieved in general,

- brutal putting into the air of the mucosa due to the suppression of the glans protection,

- infringement of masturbatory habits, which can be a serious trauma,

- possible failure of plasties by scar reconstruction of the necking,

- cost of intervention and hospitalization.

Rehabilitation of the foreskin could be considered because it is:

- logical: in medicine, surgeons are only offered failures of rehabilitation, may it be of muscles, tendons or skin,

- lazy,

- progressive,

- discrete,

- free,

- non-traumatic or disturbing for the subject,

- keeps the foreskin that has a crucial role,

- enables to keep the masturbatory habits,

- avoids the pain of the bare glans in these subjects.

The cases encountered reveal that teens or young adult subjects with phimosis have masturbatory practices that are different from others.

Typically, the research of solitary pleasure is made with the dominant hand closing upon the penis, and performing alternative back and forth movements along the shaft, the hand going down to the pubis, uncovering the glans that the index or the thumb may sometimes skim over, replicating the mechanics of coitus.

This gymnastics amounts to performing the mobilizing of the skin of the penis as it will be requested in vaginal intercourse, and the matter is therefore exactly a training to adult sex. We shall see later that this practice is not purely mechanical, but participates in the psychic development of the individual.

I have established a classification of other masturbatory practices often encountered among patients with phimosis.

1 Some boys never masturbate. Their assertions may be doubted, but their tight phimosis almost constantly makes credible their claims. The ejaculations happen during sleep (nocturnal emissions), and more rarely spontaneously during the day, on occasionally stimulating events with these patients who feel guilty about sexual touching.

2 Other caress the glans through the foreskin in a rather conventional way but try to pull the skin towards the end of the penis instead of towards the pubis. The persistence of a long foreskin in spae of trunk, as with many small children, can be found with these boys.

3 Sometimes the matter is to roll the penis between both palms or between one hand and another surface such as the abdomen, the thigh, the table, the edge of a seat (WC in particular). It is quite common then, that the lower face of the sex is not median but more or less in spiral, the orifice of the foreskin being also often moved.

4 The physical stimulation without manual involvement is most frequently found again (perhaps with less guilt). The boy, generally laying flat on his bed, works as for a coitus with her pelvic muscles and rubs his penis against the mattress or pillow, often through the pants in which he arranged a disposable towel to avoid all stain that, facing his mother, would betray his practices.

5 ° Inter-femoral coitus exists, facilitated by a curved down penis, unless the activity determines this anatomical peculiarity. This technique has the advantage of being able to be performed in society, just like some women provoke orgasms through clenching their legs, climbing a rope, or pedalling a bicycle.

6 Instrumental masturbation: it is likely, by a vibrator, the shower of the bath... It was never revealed to me in this generation and should, therefore, be unusual or occasional.

7 ° For memory autofellatio when suppleness allows it.

THERAPEUTIC APPROACH

Facing a young man suffering from phimosis I propose:

after having analyzed the masturbatory practices of the subject, it is necessary to explain him the role of masturbation in adolescence as described in the 5 previous points. This conversation has the advantage of ridding of is guilt, if necessary, genital life.

He should then be taught the best technique in order to roll back his foreskin releasing the tip of the glans. In fact, triggering orgasmic pleasure and immediately supplanting it by another is rarely possible for a boy who had organized an appropriate stimulation. In general, this new practice is unable to lead him to the same pleasure and would tend to impair the quality of erection. This might explain why these boys willingly fail in their first sexual intercourses; the one accustomed to rotational movements on his penis for several years, will be quite unable to find these mechanics in a vagina. I also often advise alternating some felt and known movements as stimulants with rehabilitation gestures. It is, of course, important that the preputial ring is tensioned on the volume of the fully erected glans. This technique joins the basis of physiotherapy of soft tissues upon which mobilization enables progressive elongation and limbering up. In some cases, I happened to propose instrumental dilatation using a spacer to subjects accessible to this concept or suggest them the introduction of two fingers into the foreskin through the opening in order to force it.

Perhaps is it logical to draw a parallel between the preputial ring of the boy and the hymen of the girl. In both cases, the matter is a mucocutaneous narrowing opposing coitus, although allowing the flow of urination or menstruation. The hymen can be released by traumatic rupture during a brutal penetration, or by smooth and progressive expansion when the lover is sensitive or shy.

Either for the foreskin or the hymen, the turgid balanial punch will be able to expand the opening.

So, the boy can gradually bring the foreskin to a diameter equivalent to the glans, which will secondarily allow him to access sexual intercourse without risk of paraphimosis.

During this rehabilitation, however, there will come a time when the foreskin, sufficiently dilated to clear part of the glans, will be too tight to pass the biggest inferior part; due to the conical shape of the glans it is then possible to imagine that a strong pulling might succeed to drag the ring down into the balanial fissure, but that the reverse movement should be impossible, constituting the masturbatory paraphimosis. This seems highly unlikely to me for several reasons:

- handling is done under the control of sight by a subject perfectly able to perceive the degree of tension of the foreskin, which is not the case during sexual intercourse, especially if it is one of the first;

- if, however, paraphimosis were to occur under these conditions it could only be moderately tight and would immediately be reduced with the subject free to "readjust" himself easily. Furthermore, this case excludes the notion of orgasm (masturbation would immediately be interrupted) and thus the increase of volume and hardness of the glans. In coital paraphimosis, the passage of the foreskin in the balanial fissure takes place during intercourse, orgasm secondarily causes this increase and hardness of the glans, complicating recapping. And finally, the discomfort of the boy in handling himself in front of his partner in order to pull his foreskin back explains the time given for the oedema to settle and lock up the sad situation.

I was led to make these pieces of advice to forty boys every year and therefore, this relates to several hundred cases. Monitoring preventive medicine is not the rule and many are not seen again; however, about half of them turned out again to have a satisfactory result reported. And even, some particularly pleased to have benefited such a gentle and discreet method, granted me their confidence for other diseases and thus came to account for the success of their approach in the longer term.

Concerning my city customers, several dozens of teenagers received the same pieces of advice and I find that in 15 years of experience, I've never sent any of my patients to the surgeon.

For a small number of boys who accepted a photographic snapshot of their foreskin tense upon the erected glans day zero and a second shot 4 weeks later, it appears that the free passage of the foreskin is obtained by rule within this period.

MASTURBATION

If the therapeutic approach of the medical treatment of phimosis by adolescent masturbatory practice must be criticized, two questions arise:

Is it permissible to talk about masturbation with these boys?

Should circumcision be refused?

Masturbation is essential in humans:

It relates to all little children and usually forms the sexual life of the Western adolescent.

Note that in our society, adolescence extends sometime during the third decade, and that masturbation concerns these young singles.

Some married men often compensate for the difference of libidinal appetite they have concerning their wives or even their mistress!

Let us also include temporarily or permanently lonely men, voluntarily or involuntarily, according to the vagaries or even dramas of life.

We know that masturbation is also a type of relationship in the couple and that more and more often the woman will masturbate her partner to avoid for-several-reasons unwanted intercourse:

- menstruation

- vulvovaginal irritation

- risk of pregnancy

or finally, through a mere appeal for the phallus that, so, she can "tame".

Masturbation is also well known to obtain or renew an erection when the psychic stimulation is insufficient.

Masturbation is also the practice of "safer sex" (safe sex) as described in the prevention of AIDS and even advised by some governments such as Canada.

Masturbation is currently proposed twice a week as an adjuvant treatment of chronic prostatitis of the bachelor.

The symbolic of masturbation is ubiquitous in daily activities and humorous stories. Let us be content with illustrating this idea by the image of the arrival of a car race with the triumphant agitation of a Champagne Magnum rewarded by an abundant ejaculation.

Sexual pleasure obtained by masturbation is it legitimate?

Vision, hearing, smell are senses that have been determined to ensure the survival of the individual through hearing, seeing, smelling predators in order to defend from them, but also to capture them and be fed by them. Today, in our society, these senses are extensively exploited for obtaining voluptuous sensations through music, visual or pictorial arts, perfumes. Similarly, the necessary taste to recognize the suitability of food is operated in the direction of gastronomy, and even smoking and oenology.

We acknowledge that civilization allows us this drift in the use of our sense organs, we outscored sensual and sexual pleasure from the imperative of reproduction and survival of the species (which would be satisfied with 3 or 4 coitus in one's life?), therefore, we can free the expression of sexuality as each one wants (within the limits of the freedom of others of course) and get rid of the biblical guilt of erotic function. Masturbation perfectly stands into this erotic function and morality has no rational arguments to repress it.

To quote Freud, "The birth of psychoanalysis": "I have come to believe that masturbation was the only major habit, the primitive need and that the other appetites, such as the need for alcohol, morphine, tobacco, are only substitutes, alternative products. "

Current Western sexology emphasizes the quality of love and psychic relationship in the success of sexuality. This is very commendable and noble, and also often checked, but it is in fact neither sufficient nor necessary. The technique of sexuality and the characteristics of the genitalia also have their part in sexual success. Analyzing the factors of sexual nomadism and possibly of prostitution is enough to be convinced.

Whereas masturbation is involved in the acquisition of sexual technique and contributes to morphological development, it seems to be justified again.

Reducing masturbation to sole organic pleasure through mechanical stimulation is often tempting. This is untrue, despite the tale of the sad animal afterwards...

It is certain that masturbation has anxiolytic and antidepressant action if it is not felt guilty. Moreover, behind all masturbation, on the psychic level, conscious and unconscious fantasy activity exists. And so, the teen dreams and repeats (in the sense of theatrical rehearsal) the still inaccessible sexual intercourse. In fact, on the day of the first intercourse, he is not completely a virgin, not quite innocent, not quite inexperienced.

So, we must get rid of the socio-cultural guilt and then, advising the teenager to turn to a technique related to coital mechanics appears legitimate.

CIRCUMCISION

Circumcision is experienced by the subject who endures it as a partial castration; it removes some of the genitals, at the end, which symbolically is particularly striking. The patient ignores, like most doctors, the part and usefulness of the foreskin, which makes that the degree of loss, of damage – dare we say - is not quantified, and in this way can have no limit.

Circumcision is akin to excision that inspires us so much disgust since it is often proposed with the ulterior motive of preventing auto-eroticism while maintaining reproductive capacity. This assault of genitality is still very present in the minds and let us note that in France, if excision does not exist in its bloody and sharp form, it has been expressed, however, till little time, under a mental and insidious form with the peddling of notions such as "an honest woman should not have fun", and that sexual relationship within the couple was a conjugal duty like other works. Every practitioner with experience of sexology knows that the damage that these ideas go on provoking in the sexual life of many patients.

Man in general and adolescents, in particular, is facing a fear of genital abnormality, both in its biometrics, as in its morphology, as well as for sexual performance abilities. This fear is fueled by common boasting in the schoolyard ... On this sensitive field, an amputation makes this concept of abnormality mature, especially as we are in a country where men are usually not circumcised.

More objectively, the procedure determines an aesthetic change and the risk of considering the sex disfigured; circumcised men, in our latitudes, may impose disgust at himself and at his troubled-by-this-continually-uncovered-glans partners. We are used to a skin cover of the entire body, and a break or change of this envelope creates, by the cruel vision of the husked penis, a feeling of uneasiness like the sight of blood, or of a tegument anomaly (labial slit, eczema ...). When we know the fragility of the sensitive erotic function to psychic disturbance, we measure the impact that may result from this change.

Conversely, it should be recognized that in the USA, it is observed that the sisters of circumcised boys may feel this very trouble facing a partner with a glans naturally covered.

The foreskin is the lid of the glans. Its folding exposes the balanic mucosa and causes more or less temporarily a sharp pain that the subject really would have done without. The glans is a valuable part of the male and it is in our minds that the things of value have a sheath. The circumcision is the removal of the sheath.

The foreskin is also an erogenous zone of importance; it is perhaps the first one known to the child, then, it is an erogenous "starter" place, especially effective for triggering an erection, as the glans, at that time, has only a poor sensitivity. It also seems that the caress of the foreskin particularly well maintains the erection, without risk of switching to orgasm. An informed partner perceives these features and will know, thanks to the foreskin, to communicate lasting and high-quality sensations. Circumcision removing the nerve endings of this skin surface will deprive the subject of this pleasure.

Beyond the specific sensitivity of the foreskin, the suppression by the circumcision of the possibility of friction of the glans must be taken into account, and the obligation to search for a more or less difficult new masturbatory technique.

Fragility, the fineness of the balanic mucosa explains that the stimuli through direct digital friction be quickly unpleasant. At variance, they are tolerable and even voluptuous when friction, instead of being direct, occurs through the sheets of the foreskin. There is no longer friction-rubbing at the level of the mucosa but variations of pressure inside the glans. Nerve endings are not sensitive to touch but to pressure. Let us note that some masturbations are done through massaging the spongy body, pushing blood into the penis, and each wave increasing the pressure.

Dr Gérard Zwang, in "Circumcision, what for?", expresses the same ideas with rich and crisp semantics: "the child acquires the experience of conscious sexual pleasure. Through practicing these pleasant gropes of the penis, the foreskin is the intermediary. The only contact that the glans appreciates, tastes, and tolerates is that, wet and padded, of the vaginal (or oral) mucosa. The rough and dry friction of the hand, fingers, would soon become unbearable if good nature had not precisely put the preputial screen between manual prompting and the very touchy erogenous epithelium."

Circumcision appears to promote rapid tensioning of the fraenulum during penetration and could contribute to rapid ejaculation.

But overall, the removal of the integumentary reserve that the foreskin is affects the physiology of coitus. The main mission of the foreskin is not to allow masturbation, although we welcome it, but to make that vaginal intercourse occurs in optimal conditions without confrontation of the teguments of both partners.

A little experiment: through two-finger pinching of the tip of the erect penis of an uncircumcised boy, it is possible to lower these fingers down to the base of the penis without making the slightest slip on the skin. The foreskin unfolds, this skin slides on the penis, the length and elasticity of the tegument enabling to browse the entire organ. There is no other body part where subcutaneous tissue allows such mobility.

This explains why intercourse can continue without causing friction and thus irritation of the tegument in contact, namely the skin of the penis and vaginal mucosa. The slide is not between these surfaces, but between the dartos of the penis and subcutaneous tissue particularly suited to this function.

At the contrary, the amputation of the foreskin considerably, and even totally reduces, this mobility by removing 4-6 cm of the reserve of the skin.

The consequences of this reduction may be small if the subject suffers premature ejaculation since the very brief intercourse cannot be irritating, as if the penis is very short or animated motion of small amplitude. Conversely, a prolonged and vigorous intercourse risks determining, despite the natural and possibly artificial lubrication, severe irritation with man and woman.

I was led to examine a young circumcised man in the military service: his erection was rendered painful by the sole tensioning of the sheath, became shorter than the turgid corpora cavernosa. His sexual ability was, at least for a time, completely destroyed, and certainly impaired for the rest of his life.

One can also wonder whether circumcision, so common in the United States, is not an element that, promoting erosions of the ano-rectal mucosa during sodomy, would participate in the transmission of HIV when we know that tegumentary breakings are the privileged gateway of the virus.

CONCLUSION

Therefore, it appears that phimosis, constant in young children, sees its frequency decrease with age due to the handling of the penis. Therefore, masturbatory practice allows a consistent morphological evolution towards future adult sexuality.

In cases where the handling of sex does not lead to a tensioning of the preputial ring, this part keeps a diameter insufficient to expose the glans and constitutes the congenital phimosis of adolescents.

Physiotherapy is effective to expand this ring and directs the subject to conventional masturbation. The reduction of the phimosis can be obtained in a few weeks.

Speaking of masturbation helps to take away the guilt of the subject and can break a taboo.

Medical treatment of phimosis of the adolescent allows, when it is effective (and in the absence of integumentary anomaly, this seems constant), to avoid multiple disadvantages of the preputial amputation that circumcision is. Skin mobility of the sheath of the penis, no longer able to benefit from the reserve of tissues, is thereby limited and dynamics of coitus may be disrupted. In North America where circumcision is widespread, techniques of reconstruction of a balanial cap develop through surgical plasty or "stretching". The latter practice, by tensioning the remaining skin, seeks to restore the mobility of the sheath as it existed before resection.

We can smile finding that the handling of tissues avoids surgery and, in the contrary case, to limit the outcomes when such a gesture has unfortunately been practiced.