Foreskin
Foreskin | |
---|---|
urogenital folds | |
System | Male reproductive system |
Artery | Dorsal artery of the penis |
Vein | Dorsal veins of the penis |
Nerve | Dorsal nerve of the penis |
Identifiers | |
Latin | praeputium, preputium penis[1] |
MeSH | D052816 |
TA98 | A09.4.01.011 |
TA2 | 3675 |
FMA | 19639 |
Anatomical terminology] |
In
In humans, foreskin length varies widely and coverage of the glans in a flaccid and erect state can also vary.[7] The foreskin is fused to the glans at birth and is generally not retractable in infancy and early childhood.[8] Inability to retract the foreskin in childhood should not be considered a problem unless there are other symptoms.[9] Retraction of the foreskin is not recommended until it loosens from the glans before or during puberty.[9] In adults, it is typically retractable over the glans, given normal development.[9] The male prepuce is anatomically homologous to the clitoral hood in females.[10][11] In some cases, the foreskin may become subject to a pathological condition.[a][12]
Structure
External
The outside of the foreskin is a continuation of the
Subcutaneous
The human foreskin is a laminar structure made up of outer skin, mucosal epithelium, lamina propia, dartos fascia and dermis.[14][17] The superficial dartos fascia, formerly called the peripenic muscle, is one of the two sheaths of smooth muscle tissue found below the penile skin, along with the underlying Buck's fascia or deep fascia of the penis.[18] The dartos fascia extents within the skin of the prepuce and contains an abuncance of elastic fibers.[19] These fibers form a whorl at the tip of the foreskin, known as the preputial orifice, which is narrow during infancy and childhood.[20][17] The dartos fascia is sensitive to temperature and reacts to temperature changes by expanding and contracting.[21] The fascia is only loosely connected with the underlying tissue, so that it provides the mobility and elasticity of the penile skin.[19] Langerhans cells are immature dendritic cells that are found in all areas of the penile epithelium, but are most superficial in the inner surface of the foreskin.[22]
As a continuation of the human shaft skin, the prepuce receives somatosensory innervation from the bilateral dorsal nerve of the penis and branches of the perineal nerve, and autonomic innervation from the pelvic plexus.[23][24] The somatosensory receptors that are found in the prepuce are both nociceptors and mechanoreceptors, with a predominace of Meissner's corpuscles.[23][25] Blood supply to the prepuce is provided by the preputial artery, a division of the axial and dorsal artery of the penis.[18] The axial and dorsal arteries that run within the penile skin unite through perforating branches and give off the preputial arteries before they reach the corona of the glans.[26][27] The preputial vein, an extension of the superficial dorsal vein, receives blood from the prepuce and connects to the larger dorsal veins of the penis that drain the rest of the penile shaft.[28][29]
Development
Gestation
The penis develops from a
Historically, the theories regarding the stages of preputial development during gestation fall into two main ideas.[37] The earliest report by Schweigger-Seidel (1866)[38] and later Hunter (1935)[39] suggested the formation of the prepuce out of dorsal skin and its progressive distal extension to completelly cover and eventually fuse with the epithelium of the glans.[37] Glenister (1956)[40] expanded the theory suggesting that the preputial fold results as an ingrowth of the cellular lamina, which rolls outwards over the glans, but with the resultant preputial lamina also expanding backwards to form an ingrowing fold at the coronal sulcus.[37]
By eleven and twelve weeks of gestation, the process of preputial formation is evident as a thickening of the
Retraction
During the first years of life, the inner foreskin is fused to the glans making them hard to manually separate.[8][53] At that time, forced retraction can cause pain or microtearing and is thus not recommended.[54][55][56] The two surfaces may begin to separate from early childhood, but complete separation and retraction is a process that normally occurs over time.[57][58] The phenomenon of non retractile or tight foreskin in childhood, sometimes referred to as physiologic phimosis,[51] may completely resolve before, during or even after puberty.[9][59][55] When the foreskin starts to become retractile, a pediatrician can recommend careful retraction at home and rinsing with water during bath.[54] Mild soap may be used, but can be avoided, if it causes irritation.[56] If full retraction is hard to achieve, the child may only wash the exposed area of the glans.[60] Since there is no specific age when non-retractile foreskin begins to resolve, the time of foreskin retraction can vary considerably among children.[52]
During puberty, as the male begins to sexually mature, foreskin retractability gradually increases allowing more comfortable exposure of the glans when needed. Gentle washing under the foreskin during shower and maintaining good genital hygiene is sufficient to prevent smegma buildup.[61][57] Smegma is an oily secretion in the genitals of both sexes that maintains the moist texture of the mucosal surfaces and prevents friction.[62][63] In boys, it helps resolve the natural adhension of the glans and inner prepuce.[64][53] By the end of puberty, most boys have a fully retractable foreskin.[59]
Variability
In children, the foreskin usually covers the glans completely but in adults it may not. During erection, the degree of automatic foreskin retraction varies considerably; in some adults, when the foreskin is longer than the erect penis, it will not spontaneously retract upon erection. In this case, the foreskin remains covering all or some of the glans until retracted manually or by sexual activity. The foreskin can be classified as long, when the preputial orifice extents beyond the glans, medium, when the preputial orifice is located around the meatus, and short, when most of the glans is exposed.[65] The variation of long foreskin was regarded by Chengzu (2011) as 'prepuce redundant'. Frequent retraction and washing under the foreskin is suggested for all adults, particularly for those with a long or 'redundant' foreskin.[66] Some males, according to Xianze (2012), may be reluctant for their glans to be exposed because of discomfort when it chafes against clothing, although the discomfort on the glans was reported to diminish within one week of continuous exposure.[67] Guochang (2010) states that for those whose foreskins are too tight to retract or have some adhesions, forcible retraction should be avoided since it may cause injury.[68]
Evolution and function
The foreskin is part of the human
The World Health Organization (WHO) stated in 2007 that there was "debate about the role of the foreskin, with possible functions including keeping the glans moist, protecting the developing penis in utero, or enhancing sexual pleasure due to the presence of nerve receptors".[16] In 2009, the World Health Organization called it a "myth" that circumcision has an effect on sexual pleasure. The view is echoed by other major medical organizations.[70] The foreskin contains Meissner's corpuscles, which are one of a group of nerve endings involved in fine-touch sensitivity. Compared to other hairless skin areas on the body, the Meissner's index was highest in the finger tip (0.96) and lowest in the foreskin (0.28) which suggested that the foreskin has the least sensitive hairless tissue of the body.[71] The foreskin helps to provide sufficient skin during an erection.[72] In infants, it protects the glans from ammonia and feces in diapers, which reduces the incidence of meatal stenosis. And the foreskin helps prevent the glans from getting abrasions and trauma throughout life.[72]
In modern times, there is controversy regarding whether the foreskin is a vital or vestigial structure.[73] In 1949, British physician Douglas Gairdner noted that the foreskin plays an important protective role in newborns. He wrote, "It is often stated that the prepuce is a vestigial structure devoid of function... However, it seems to be no accident that during the years when the child is incontinent the glans is completely clothed by the prepuce, for, deprived of this protection, the glans becomes susceptible to injury from contact with sodden clothes or napkin".[73] During the physical act of sex, the foreskin reduces friction, which can reduce the need for additional sources of lubrication.[73] The College of Physicians and Surgeons of British Columbia has written that the foreskin is "composed of an outer skin and an inner mucosa that is rich in specialized sensory nerve endings and erogenous tissue".[74] In the March 2017 publication of the Global Health Journal: Science and Practice, Morris and Krieger wrote, "The variability in foreskin size is consistent with the foreskin being a vestigial structure".[75]
Clinical significance
The foreskin can be involved in balanitis, phimosis, sexually transmitted infection and penile cancer.[76] The American Academy of Pediatricians' now expired 2012 technical report on circumcision found that the foreskin can harbor micro-organisms that may increase the risk of urinary tract infections in some infants and contribute to the transmission of some sexually transmitted infections in adults.[77] In some cases of recurrent pathologies, excessive soap washing may irritate the mucosa, therefore washing of the area should be done gently.[78]
Phimosis is a condition where the foreskin of an adult cannot be retracted properly. Phimosis can be treated by using topical steroid ointments and using lubricants during sex; for severe cases circumcision may be necessary.[79] Posthitis is an inflammation of the foreskin.
A condition called paraphimosis may occur if a tight foreskin becomes trapped behind the glans and swells as a restrictive ring. This can cut off the blood supply, resulting in ischemia of the glans penis.[79]
Some birth defects of the foreskin can occur; all of them are rare. In aposthia there is no foreskin at birth,[81]: 37–39 in micropathia the foreskin does not cover the glans,[81]: 41–45 and in macroposthia, also called and congenital megaprepuce, the foreskin extends well past the end of the glans.[81]: 47–50
It has been found that larger foreskins place men who are not circumcised at an increased risk of HIV infection
Society and culture
Modifications
Circumcision is the removal of the foreskin, either partially or completely. It is most commonly performed as an elective procedure for
Foreskin-based products
Foreskins obtained from circumcision procedures are frequently used by biochemical and micro-anatomical researchers to study the structure and proteins of human skin. In particular, foreskins obtained from newborns have been found to be useful in the manufacturing of more human skin.[91]
Foreskins of babies are also used for
Foreskin-derived fibroblasts have been used in biomedical research,[96] and cosmetic applications.[97]
History
The foreskin was considered a sign of beauty, civility, and masculinity throughout the Greco-Roman world.[98] In ancient Greece, foreskins were valued, especially those that were longer.[99] The earliest known illustrative depiction of the foreskin dates back to Egyptian kingdoms.[100]
The foreskin has also been depicted in art from different historical ages:
-
David Marble sculpture, 1504 AD
-
"Orestes at Delphi". Painting of two naked males, ca. 330 BC.
-
The Marathon Youth, National Archaeological Museum, Athens, ca. 340–330 BC
Notes
References
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The prepuce is a specialized junctional mucocutaneous tissue that provides adequate skin and mucosa
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It is also a warm, moist environment that may allow viral particles to linger longer on the penis
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At birth, the inner foreskin is usually fused to the glans penis and should not be forcibly retracted
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Virtually all foreskins become retractable in puberty. Thus, phimosis is not a pathological condition in young children unless it is associated with balanitis, or, rarely, urinary retention.
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ts outer surface is continuous with skin of the penile shaft and is covered by a glabrous stratified squamous keratinized epithelium. Its inner mucosal surface is lined by variably-keratinized squamous epithelium
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physiologic phimosis consists of a pliant, unscarred preputial orifice
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branches of the dorsal nerve of the penis are already present within the preputial mesenchyme", "Parasympathetic and sympathetic input to the penis is via the pelvic plexus
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Certain preputial sensory corpuscles, such as Meissner's corpuscles, Pacinian corpuscles, and Merkel cell‐neurite complexes, function as mechanoreceptors in human glabrous skin
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Behind the corona, the axial arteries send perforating branches through Buck's fascia to anastomose with the terminal branches of the dorsal arteries before they end in the glans. The attenuated continuation of the arteries pass into the prepuce.
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The superficial dorsal vein drains blood from the foreskin into saphenous and external pudendal veins
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Human preputial development begins at ~11 weeks of gestation [...] when the epithelium thickens on the dorsal aspect of the glans penis and forms the preputial placode [...] from which bilateral preputial laminar processes extend ventrally into the glanular mesenchyme
- ^ PMID 22763876.
The complete foreskin was formed only in the fetuses at 18 and 19 WPC, in which the foreskin totally covered the glans.
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...the earliest stages (8 weeks) of human preputial development to advanced preputial development at 17 weeks of gestation.
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The first indication of the onset of the developmental processes of the prepuce involved the appearance of a raised fold (the preputial fold), just at the coronary sulcus.
- PMID 30245194.
Development of the prepuce is initiated by ~12 weeks with the appearance of a novel structure, the preputial placode, which is a dorsal thickening of the epidermis on the dorsal aspect of the developing glans penis.
- PMID 31654825.
The process of preputial lamina formation is initiated dorsally or dorsal-laterally in the proximal aspect of the glans at 11 to 12.5 weeks
- PMID 22763876.
The glans was partially covered by the foreskin in the fetus at 13 WPC
- PMID 30245194.
From the lateral aspect of the preputial placode the bilateral preputial laminae expand ventrally until the preputial folds (foreskin) cover all of the glans, fusing in the ventral midline at ~16 weeks gestation.
- PMID 30245194.
Formation of the prepuce occurs after formation of the urethra in the penile shaft. The penile raphe within the penile shaft is a manifestation of fusion of the urethral folds within the shaft
- PMID 31654825.
Examination of the ontogeny of innervation of the glans penis and prepuce reveals the presence of the dorsal nerve of the penis as early as 9 weeks of gestation. Nerve fibers enter the glans penis proximally and extend distally...to eventually reach the distal aspect of the glans and prepuce by 14 to 16 weeks of gestation.
- S2CID 216479793, retrieved 2022-11-15,
Prepuce completely covering and fusing with the glans structure at around twenty-fourth week of gestation.
- PMID 28292801.
The foreskin and glans are connected by the balanopreputial lamina, a membrane similar to the synechial membrane that connects the nail bed and the fingernail... This membrane and the small preputial opening prevent retraction in boys with normal physiologic phimosis.
- PMID 30245194.
At birth the solid preputial lamina is intact and thus "physiologically adherent" to the glans. Thereafter, the preputial lamina will canalize creating the preputial space that "houses" the glans.
- ^ a b "Newborn male circumcision | Canadian Paediatric Society". cps.ca. Retrieved 2023-02-01.
In the male newborn, the mucosal surfaces of the inner foreskin and glans penis adhere to one another; [...] Until this developmental process is complete, the best descriptor to use is 'nonretractile foreskin' rather than the confusing and perhaps erroneous term 'physiologic phimosis
- ^ PMID 29381458.
the incidence of non-retractable physiological phimosis was 50% in grade 1 boys and decreased to 35% in grade 4 and 8% in grade 7 boys
- ^ a b Lissienko, Katherine (2011-09-13). "How To Care For Your Child's Foreskin". KidsHealth NZ. Retrieved 2022-12-21.
- ^ a b "How to take care of a baby's uncircumcised penis". Mayo Clinic. Retrieved 2022-12-20.
- ^ a b "Care for an Uncircumcised Penis". HealthyChildren.org. Retrieved 2022-12-21.
- ^ a b Philadelphia, The Children's Hospital of (2014-08-23). "Care of the Uncircumcised Penis". www.chop.edu. Retrieved 2022-12-20.
- ^ a b "Circumcision of baby boys: Information for parents". caringforkids.cps.ca. Retrieved 2023-02-01.
- ^ "Newborn male circumcision | Canadian Paediatric Society". cps.ca. Retrieved 2023-02-02.
- ^ PMID 17872680.
most foreskins will become retractile by adulthood.
- ^ Philadelphia, The Children's Hospital of (2014-08-23). "Care of the Uncircumcised Penis". www.chop.edu. Retrieved 2022-12-21.
As long as the foreskin doesn't easily retract, only the outside needs to be cleaned. If the foreskin retracts a little, just clean the exposed area of the glans with water.
- PMID 5689532.
The production of smegma increases from the age of 12-13, but our actual figures of the incidence of smegma can only be of limited significance, as the boys received regular instruction about preputial hygiene.
- ^ "Smegma: What It Is, Prevention & How To Get Rid Of It". Cleveland Clinic. Retrieved 2022-12-20.
- S2CID 69175186.
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The collection of smegma (a white exudate of skin cells and keratin) separating the prepuce from the glans and repeated reflex erections are the primary mechanisms that lead to resolution of physiological adhesions over time.
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- ^ Chengzu L (2011). "Health Care for Foreskin Conditions". Epidemiology of Urogenital Diseases. Beijing: People's Medical Publishing House.
- ^ Xianze L (2012). Tips on Puberty Health. Beijing: People's Education Press.
- ^ Guochang H (2010). General Surgery. Beijing: People's Medical Publishing House.
- ISBN 978-0-691-08565-4.
- ^ The American Academy of Pediatrics Task Force on Circumcision "Technical Report" (2012) addresses sexual function, sensitivity and satisfaction without qualification by age of circumcision. Sadeghi-Nejad et al. "Sexually transmitted diseases and sexual function" (2010) addresses adult circumcision and sexual function. Doyle et al. "The Impact of Male Circumcision on HIV Transmission" (2010) addresses adult circumcision and sexual function. Perera et al. "Safety and efficacy of nontherapeutic male circumcision: a systematic review" (2010) addresses adult circumcision and sexual function and satisfaction.
- Dave S, Afshar K, Braga LH, Anderson P (February 2018). "Canadian Urological Association guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants (full version)". Canadian Urological Association Journal. 12 (2): E76–E99. PMID 29381458.
There is lack of any convincing evidence that neonatal circumcision will impact sexual function or cause a perceptible change in penile sensation in adulthood.
- Shabanzadeh DM, Düring S, Frimodt-Møller C (July 2016). "Male circumcision does not result in inferior perceived male sexual function - a systematic review". Danish Medical Journal (Systematic review). 63 (7). PMID 27399981.
- Friedman B, Khoury J, Petersiel N, Yahalomi T, Paul M, Neuberger A (September 2016). "Pros and cons of circumcision: an evidence-based overview". Clinical Microbiology and Infection. 22 (9): 768–774. PMID 27497811.
- Staff. "Statement on Newborn Male Circumcision". American College of Obstetricians and Gynecologists. Archived from the original on 21 March 2023. Retrieved March 21, 2023.
Some parents also may worry that circumcision harms a man's sexual function, sensitivity, or satisfaction. However, current evidence shows that it does not.
- Shezi, Mirriam Hlelisani; Tlou, Boikhutso; Naidoo, Saloshni (February 16, 2023). "Knowledge, attitudes and acceptance of voluntary medical male circumcision among males attending high school in Shiselweni region, Eswatini: a cross sectional study". PMID 36797696.
It was interesting to note that the young males in this study had misconceptions about sexual pleasure post male circumcision...
- Todd Sorokan, S; Finlay, Jane; Jefferies, Ann (September 8, 2015). "2015 Policy Statement on Newborn Male Circumcision". PMID 26435672.
...medical studies do not support circumcision as having a negative impact on sexual function or satisfaction in males or their partners.
- UNAIDS; Jhpiego (December 2009). "Manual for Male Circumcision Under Local Anaesthesia" (PDF). Archived from the original (PDF) on January 15, 2012.
...there are many myths about male circumcision that circulate. For example, some people think that circumcision can cause impotence (failure of erection) or reduce sexual pleasure. Others think that circumcision will cure impotence. Let me assure you that none of these is true.
Alt URL Archived 30 March 2023 at the Wayback Machine
- Dave S, Afshar K, Braga LH, Anderson P (February 2018). "Canadian Urological Association guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants (full version)". Canadian Urological Association Journal. 12 (2): E76–E99.
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- ^ a b "Phimosis (tight foreskin)". NHS Choices. 26 August 2015. Archived from the original on 22 September 2017. Retrieved 21 September 2017.
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- ^ "Paraphimosis : Article by Jong M Choe, MD, FACS". eMedicine. Archived from the original on 2008-11-23. Retrieved 2012-07-16.
- ^ ISBN 978-1-4471-2858-8.
- ^ McKie R (1999-04-04). "Foreskins for Skin Grafts". The Toronto Star.
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- ^ Grand DJ (August 15, 2011). "Skin Grafting". Medscape. Archived from the original on October 8, 2008. Retrieved August 18, 2012.
- ^ Amst C, Carey J (July 27, 1998). "Biotech Bodies". www.businessweek.com. The McGraw-Hill Companies Inc. Archived from the original on December 24, 2013. Retrieved 2017-09-17.
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External links
- Infant foreskin care at Kidshealth.org.nz
- "Care for an Uncircumcised Penis". Healthy Children. American Academy of Pediatrics. 19 June 2017. Retrieved 9 September 2018.
- Management of foreskin conditions Archived 2014-04-06 at the Wayback Machine – Statement from the British Association of Paediatric Urologists on behalf of the British Association of Paediatric Surgeons and The Association of Paediatric Anaesthetists (2007).