Foreskin Explained

Foreskin
Latin:praeputium, preputium penis[1]
Width:190
Precursor:Genital tubercle, urogenital folds
System:Male reproductive system
Artery:Dorsal artery of the penis
Vein:Dorsal veins of the penis
Nerve:Dorsal nerve of the penis

In male human anatomy, the foreskin, also known as the prepuce, is the double-layered fold of skin, mucosal and muscular tissue at the distal end of the human penis that covers the glans and the urinary meatus.[2] The foreskin is attached to the glans by an elastic band of tissue, known as the frenulum.[3] The outer skin of the foreskin meets with the inner preputial mucosa at the area of the mucocutaneous junction. The foreskin is mobile, fairly stretchable and sustains the glans in a moist environment.[4] Except for humans, a similar structure known as a penile sheath appears in the male sexual organs of all primates and the vast majority of mammals.

In humans, foreskin length varies widely and coverage of the glans in a flaccid and erect state can also vary. The foreskin is fused to the glans at birth and is generally not retractable in infancy and early childhood.[5] Inability to retract the foreskin in childhood should not be considered a problem unless there are other symptoms.[6] Retraction of the foreskin is not recommended until it loosens from the glans before or during puberty. In adults, it is typically retractable over the glans, given normal development. The male prepuce is anatomically homologous to the clitoral hood in females.[7] [8] In some cases, the foreskin may become subject to a pathological condition.[9]

Structure

External

The outside of the foreskin is a continuation of the shaft skin of the penis and is covered by a keratinized stratified squamous epithelium. The inner foreskin is a continuation of the epithelium that covers the glans and is made up of glabrous squamous mucous membrane, like the inside of the eyelid or the mouth.[10] The mucosal aspect of the prepuce has a great capacity for self-repair. The area of the outer foreskin measures 7–100 cm2,[11] and the inner foreskin measures 18–68 cm.2[12] The mucocutaneous zone occurs where the outer and inner foreskin meet. The foreskin is free to move after it separates from the glans, which usually occurs before or during puberty. The inner foreskin is attached to the glans by the frenulum, a highly vascularized tissue of the penis.[13] The World Health Organization states that "the frenulum forms the interface between the outer and inner foreskin layers, and when the penis is not erect, it tightens to narrow the foreskin opening.

Subcutaneous

The human foreskin is a laminar structure made up of outer skin, mucosal epithelium, lamina propia, dartos fascia and dermis.[14] 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.[15] The dartos fascia extents within the skin of the prepuce and contains an abuncance of elastic fibers.[16] These fibers form a whorl at the tip of the foreskin, known as the preputial orifice, which is narrow during infancy and childhood.[17] The dartos fascia is sensitive to temperature and reacts to temperature changes by expanding and contracting.[18] The fascia is only loosely connected with the underlying tissue, so that it provides the mobility and elasticity of the penile skin. 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.[19]

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.[20] The somatosensory receptors that are found in the prepuce are both nociceptors and mechanoreceptors, with a predominace of Meissner's corpuscles.[21] Blood supply to the prepuce is provided by the preputial artery, a division of the axial and dorsal artery of the penis. 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. 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.[22] [23]

Development

Gestation

The penis develops from a primordial phallic structure that forms in the embryo during the early weeks of pregnancy, known as the genital tubercle.[24] Initially undifferentiated, the tubercle develops into a penis depending on the exposure to male hormones secreted by the testicles. The differentiation of the external sexual organs will be evident between twelve and sixteen weeks of gestation.[25] [26] Preputial development is initiated at around eleven weeks or earlier and continues up to eighteen weeks.[27] [28]

Historically, the theories regarding the stages of preputial development during gestation fall into two main ideas.[29] The earliest report by Schweigger-Seidel (1866)[30] and later Hunter (1935)[31] suggested the formation of the prepuce out of dorsal skin and its progressive distal extension to completely cover and eventually fuse with the epithelium of the glans. Glenister (1956)[32] 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.

By eleven and twelve weeks of gestation, the process of preputial formation is evident as a thickening of the epidermis that separates from the penis creating a raised fold, known as the preputial fold. On the underside of this structure forms the preputial lamina, which expands dorsolaterally over the base of the developing glans.[33] [34] At thirteen weeks, the prepuce has not yet extended to the distal tip of the glans covering only a part of its surface.[35] By sixteen weeks, the bilateral preputial folds cover most of the glans and the ventral sides of the prepuce fuse in the midline.[36] The penile raphe, the continuation of the perineal raphe in human males, occurs on the ventral side of the penis as a manifestation of the fusion of the urethral and preputial folds.[37] The dorsal nerve of the penis, which is present as early as nine weeks of gestation, completely expands through branches to the distal end of the glans and prepuce by sixteen weeks.[38] At nineteen weeks, foreskin development is complete.[39] Towards the end of the second trimester, the glans and the prepuce have completely fused together by the preputial, sometimes referred to as balanopreputial lamina.[40] At birth, this shared membrane is physiologically adherent to the glans preventing retraction in infancy and early childhood.[41] [42] The phenomenon of non-retractile foreskin in children naturally starts to resolve in varying ages; in childhood, preadolescence or puberty.[43]

Retraction

During the first years of life, the inner foreskin is fused to the glans making them hard to manually separate.[44] At that time, forced retraction can cause pain or microtearing and is thus not recommended.[45] [46] [47] The two surfaces may begin to separate from early childhood, but complete separation and retraction is a process that normally occurs over time.[48] [49] The phenomenon of non retractile or tight foreskin in childhood, sometimes referred to as physiologic phimosis, may completely resolve before, during or even after puberty. When the foreskin starts to become retractile, a pediatrician can recommend careful retraction at home and rinsing with water during bath. Mild soap may be used, but can be avoided, if it causes irritation. If full retraction is hard to achieve, the child may only wash the exposed area of the glans.[50] Since there is no specific age when non-retractile foreskin begins to resolve, the time of foreskin retraction can vary considerably among children.

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.[51] Smegma is an oily secretion in the genitals of both sexes that maintains the moist texture of the mucosal surfaces and prevents friction.[52] [53] In boys, it helps resolve the natural adhension of the glans and inner prepuce.[54] By the end of puberty, most boys have a fully retractable foreskin.[55]

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.[56] 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.[57] 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.[58] 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.[59]

Evolution and function

The foreskin is part of the human phylogenetic heritage and is present in the vast majority of mammals. Non-human primates, such as the chimpanzees, have prepuces that partially or completely cover the glans penis. In primates, the foreskin is present in the genitalia of both sexes and likely has been present for millions of years of evolution.[60]

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". 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.[61] 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.[62] The foreskin helps to provide sufficient skin during an erection.[63] 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.

In modern times, there is controversy regarding whether the foreskin is a vital or vestigial structure.[64] 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". During the physical act of sex, the foreskin reduces friction, which can reduce the need for additional sources of lubrication. 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".[65] 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".[66]

Clinical significance

The foreskin can be involved in balanitis, phimosis, sexually transmitted infection and penile cancer.[67] 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.[68] In some cases of recurrent pathologies, excessive soap washing may irritate the mucosa, therefore washing of the area should be done gently.[69]

Frenulum breve is a frenulum that is insufficiently long to allow the foreskin to fully retract, which may lead to discomfort during intercourse.

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.[70] 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.[70]

Lichen sclerosus is a chronic, inflammatory skin condition that most commonly occurs in adult women, although it may also be seen in men and children. Topical clobetasol propionate and mometasone furoate were proven effective in treating genital lichen sclerosus.[71]

Some birth defects of the foreskin can occur; all of them are rare. In aposthia there is no foreskin at birth,[72] in micropathia the foreskin does not cover the glans,[72] and in macroposthia, also called and congenital megaprepuce, the foreskin extends well past the end of the glans.[72]

It has been found that larger foreskins place men who are not circumcised at an increased risk of HIV infection[73] most likely due to the larger surface area of inner foreskin and the high concentration of Langerhans cells.[74]

Society and culture

Modifications

See also: Circumcision and Foreskin restoration.

Circumcision is the removal of the foreskin, either partially or completely. It is most commonly performed as an elective procedure for prophylactic, cultural, or religious reasons.[75] [76] Circumcision may also be performed on children or adults to treat phimosis, balanitis, and other pathologies.[77] The ethics of circumcision in children is a source of controversy.[78] [79] Some men use weights or other devices to stretch the skin of the penis to regrow a foreskin; the resulting tissue does cover the glans but does not fully replicate the features of a foreskin.[80] Other cultural or aesethetic practices include genital piercings involving the foreskin and slitting the foreskin.[81] Preputioplasty is the most common foreskin reconstruction technique, most often done when a boy is born with a foreskin that is too small;[82] a similar procedure is performed to relieve a tight foreskin without resorting to circumcision.

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.[83]

Foreskins of babies are also used for skin graft tissue,[84] [85] [86] and for β-interferon-based drugs.[87]

Foreskin-derived fibroblasts have been used in biomedical research,[88] and cosmetic applications.[89]

History

The foreskin was considered a sign of beauty, civility, and masculinity throughout the Greco-Roman world.[90] In ancient Greece, foreskins were valued, especially those that were longer.[91] The earliest known illustrative depiction of the foreskin dates back to Egyptian kingdoms.[92]

The foreskin has also been depicted in art from different historical ages:

External links

Notes and References

  1. Book: Paulsen. Friedrich. Waschke. Jens. Sobotta Atlas of Anatomy, Vol. 2, 17th Ed., English/Latin: Internal Organs. Elsevier Health Sciences . 2023. 2971. October 11, 2023 . 978-0-70206-770-9 .
  2. Book: Kirby R, Carson C, Kirby M . Men's Health. Informa Healthcare. 2009. 978-1-4398-0807-8. 3rd. New York. 283. 314774041.
  3. Book: Male circumcision : global trends and determinants of prevalence, safety, and acceptability. . 2008 . World Health Organization . Helen Weiss, World Health Organization, Joint United Nations Programme on HIV/AIDS, London School of Hygiene and Tropical Medicine . 978-92-4-159616-9 . Geneva . 425961131 . "The foreskin is attached to the glans by the frenulum".
  4. Collier . Roger . 2011-11-22 . Vital or vestigial? The foreskin has its fans and foes . Canadian Medical Association Journal . 183 . 17 . 1963–1964 . 10.1503/cmaj.109-4014 . 0820-3946 . 3225416 . 22025652 . "It is also a warm, moist environment that may allow viral particles to linger longer on the penis".
  5. Dave . Sumit . Afshar . Kourosh . Braga . Luis H. . Anderson . Peter . 2018 . CUA guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants . Canadian Urological Association Journal . en . 12 . 2 . E76–E99 . 10.5489/cuaj.5033 . 29381458 . 5937400 . 1920-1214 . "At birth, the inner foreskin is usually fused to the glans penis and should not be forcibly retracted".
  6. Book: Potts, Jeannette . Essential Urology: A Guide to Clinical Practice . Humana Press . 2004 . 9781592597376 . 29 . Penis Problems . 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..
  7. Book: Crooks . Robert L. . Our Sexuality . Baur . Karla . 2010-01-01 . Cengage Learning . 978-0-495-81294-4 . en.
  8. Book: Sloane, Ethel . Biology of Women . 2002 . Delmar Thomson Learning . 978-0-7668-1142-3 . en.
  9. Book: Shah M. The Male Genitalia: A Clinician's Guide to Skin Problems and Sexually Transmitted Infections. January 2008. Radcliffe Publishing. 978-1-84619-040-7. 37–. 2015-10-27. 2016-02-01. https://web.archive.org/web/20160201011343/https://books.google.com/books?id=cwede8Un55YC&pg=PA37. live.
  10. Cunha . Gerald R. . Sinclair . Adrian . Cao . Mei . Baskin . Laurence S. . 2020 . Development of the human prepuce and its innervation . Differentiation; Research in Biological Diversity . 111 . 22–40 . 10.1016/j.diff.2019.10.002 . 0301-4681 . 6936222 . 31654825 . "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".
  11. Kigozi G, Wawer M, Ssettuba A, Kagaayi J, Nalugoda F, Watya S, Mangen FW, Kiwanuka N, Bacon MC, Lutalo T, Serwadda D, Gray RH . 6 . Foreskin surface area and HIV acquisition in Rakai, Uganda (size matters) . AIDS . 23 . 16 . 2209–2213 . October 2009 . 19770623 . 3125976 . 10.1097/QAD.0b013e328330eda8 .
  12. Werker PM, Terng AS, Kon M . The prepuce free flap: dissection feasibility study and clinical application of a super-thin new flap . Plastic and Reconstructive Surgery . 102 . 4 . 1075–1082 . September 1998 . 9734426 . 10.1097/00006534-199809040-00024 . 37976399 .
  13. Web site: 2007. Male circumcision: Global trends and determinants of prevalence, safety and acceptability. World Health Organization. 2009-06-12. 2015-07-15. https://web.archive.org/web/20150715135808/http://whqlibdoc.who.int/publications/2007/9789241596169_eng.pdf. live.
  14. Cold . C.J. . Taylor . J.R. . 2002-05-27 . The prepuce . BJU International . 83 . S1 . 34–44 . 10.1046/j.1464-410x.1999.0830s1034.x . 1464-4096 . 10349413 . 30559310 . free.
  15. Hsieh . Cheng-Hsing . Hsu . Geng-Long . Chang . Shang-Jen . Yang . Stephen Shei-Dei . Liu . Shih-Ping . Hsieh . Ju-Ton . 2020 . Surgical niche for the treatment of erectile dysfunction . International Journal of Urology . en . 27 . 2 . 117–133 . 10.1111/iju.14157 . 31812157 . 208870116 . 0919-8172.
  16. Book: Hadidi, Ahmed . Hypospadias Surgery: An Illustrated Textbook . Springer . 2022 . 9783030942489 . 115, 624.
  17. McGregor . Thomas B. . Pike . John G. . Leonard . Michael P. . 2007 . Pathologic and physiologic phimosis . Canadian Family Physician . 53 . 3 . 445–448 . 0008-350X . 1949079 . 17872680 . "physiologic phimosis consists of a pliant, unscarred preputial orifice".
  18. Gibson . Alan . Akinrinsola . Adetokunbo . Patel . Tejesh . Ray . Arijit . Tucker . John . McFadzean . Ian . August 2002 . Pharmacology and thermosensitivity of the dartos muscle isolated from rat scrotum . British Journal of Pharmacology . 136 . 8 . 1194–1200 . 10.1038/sj.bjp.0704830 . 0007-1188 . 1573456 . 12163353.
  19. McCoombe SG, Short RV . July 2006 . Potential HIV-1 target cells in the human penis . AIDS . 20 . 11 . 1491–1495 . 10.1097/01.aids.0000237364.11123.98 . 16847403 . 22839409. free .
  20. Cunha . Gerald R. . Sinclair . Adrian . Cao . Mei . Baskin . Laurence S. . 2020 . Development of the human prepuce and its innervation . Differentiation; Research in Biological Diversity . 111 . 22–40 . 10.1016/j.diff.2019.10.002 . 0301-4681 . 6936222 . 31654825 . "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".
  21. García-Mesa . Yolanda . García-Piqueras . Jorge . Cobo . Ramón . Martín-Cruces . José . Suazo . Iván . García-Suárez . Olivia . Feito . Jorge . Vega . José A. . 2021 . Sensory innervation of the human male prepuce: Meissner's corpuscles predominate . Journal of Anatomy . 239 . 4 . 892–902. 10.1111/joa.13481 . 0021-8782 . 8450466 . 34120333 . "Certain preputial sensory corpuscles, such as Meissner's corpuscles, Pacinian corpuscles, and Merkel cell‐neurite complexes, function as mechanoreceptors in human glabrous skin ".
  22. Hinman . F. . 1991 . The blood supply to preputial island flaps . The Journal of Urology . 145 . 6 . 1232–1235 . 10.1016/s0022-5347(17)38584-1 . 0022-5347 . 2033699.
  23. Hsieh . Cheng-Hsing . Hsu . Geng-Long . Chang . Shang-Jen . Yang . Stephen Shei-Dei . Liu . Shih-Ping . Hsieh . Ju-Ton . 2020 . Surgical niche for the treatment of erectile dysfunction . International Journal of Urology . en . 27 . 2 . 117–133 . 10.1111/iju.14157 . 31812157 . 208870116 . 0919-8172 . "The superficial dorsal vein drains blood from the foreskin into saphenous and external pudendal veins".
  24. Book: W.George, D.Wilson, Fredrick, Jean. https://www.sciencedirect.com/science/article/pii/B9780407003668500083. Fetal Physiology and Medicine. 2 - Sexual Differentiation . 1984. 57–79 . Butterworth-Heinemann . 10.1016/B978-0-407-00366-8.50008-3 . 9780407003668 . Second, Revised .
  25. Book: Merz, Eberhard . Ultrasound in obstetrics and gynecology . 2005 . Thieme . F. Bahlmann . 978-3-13-131882-4 . 2nd ed., fully rev . Stuttgart . 57251410.
  26. Book: Schünke, Michael . Thieme atlas of anatomy. General anatomy and musculoskeletal system . 2006 . Thieme . Erik Schulte, Udo Schumacher, Lawrence M. Ross, Edward D. Lamperti . 978-3-13-142081-7 . Stuttgart . 62906603.
  27. Liu . Xin . Liu . Ge . Shen . Joel . Yue . Aaron . Isaacson . Dylan . Sinclair . Adrian . Cao . Mei . Liaw . Aron . Cunha . Gerald R. . Baskin . Laurence . 2018 . Human Glans and Preputial Development . Differentiation; Research in Biological Diversity . 103 . 86–99 . 10.1016/j.diff.2018.08.002 . 0301-4681 . 6234068 . 30245194 . "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".
  28. Cunha . Gerald R. . Sinclair . Adrian . Cao . Mei . Baskin . Laurence S. . 2020 . Development of the human prepuce and its innervation . Differentiation; Research in Biological Diversity . 111 . 22–40 . 10.1016/j.diff.2019.10.002 . 0301-4681 . 6936222 . 31654825 . "...the earliest stages (8 weeks) of human preputial development to advanced preputial development at 17 weeks of gestation.".
  29. Cunha . Gerald R. . Sinclair . Adrian . Cao . Mei . Baskin . Laurence S. . 2020 . Development of the human prepuce and its innervation . Differentiation; Research in Biological Diversity . 111 . 22–40 . 10.1016/j.diff.2019.10.002 . 0301-4681 . 6936222 . 31654825.
  30. Schweigger-Seidel . F. . 1866 . Zur Entwickelung des Praeputium . Archiv für Pathologische Anatomie und Physiologie und für Klinische Medicin . 37 . 2 . 219–225 . 10.1007/bf01935635 . 26136414 . 0945-6317.
  31. Hunter . Richard H. . 1935 . Notes on the Development of the Prepuce . Journal of Anatomy . 70 . Pt 1 . 68–75 . 0021-8782 . 1249280 . 17104576.
  32. Glenister . T. W. . 1956 . A consideration of the processes involved in the development of the prepuce in man . British Journal of Urology . 28 . 3 . 243–249 . 10.1111/j.1464-410x.1956.tb04763.x . 13364260 . 0007-1331.
  33. Liu . Xin . Liu . Ge . Shen . Joel . Yue . Aaron . Isaacson . Dylan . Sinclair . Adrian . Cao . Mei . Liaw . Aron . Cunha . Gerald R. . Baskin . Laurence . 2018 . Human Glans and Preputial Development . Differentiation; Research in Biological Diversity . 103 . 86–99 . 10.1016/j.diff.2018.08.002 . 0301-4681 . 6234068 . 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.".
  34. Cunha . Gerald R. . Sinclair . Adrian . Cao . Mei . Baskin . Laurence S. . 2020 . Development of the human prepuce and its innervation . Differentiation; Research in Biological Diversity . 111 . 22–40 . 10.1016/j.diff.2019.10.002 . 0301-4681 . 6936222 . 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".
  35. Favorito . Luciano Alves . Balassiano . Carlos Miguel . Costa . Waldemar Silva . Sampaio . Francisco José Barcellos . 2012 . Development of the human foreskin during the fetal period . Histology and Histopathology . 27 . 8 . 1041–1045 . 10.14670/HH-27.1041 . 1699-5848 . 22763876 . "The glans was partially covered by the foreskin in the fetus at 13 WPC".
  36. Liu . Xin . Liu . Ge . Shen . Joel . Yue . Aaron . Isaacson . Dylan . Sinclair . Adrian . Cao . Mei . Liaw . Aron . Cunha . Gerald R. . Baskin . Laurence . 2018 . Human Glans and Preputial Development . Differentiation; Research in Biological Diversity . 103 . 86–99 . 10.1016/j.diff.2018.08.002 . 0301-4681 . 6234068 . 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.".
  37. Liu . Xin . Liu . Ge . Shen . Joel . Yue . Aaron . Isaacson . Dylan . Sinclair . Adrian . Cao . Mei . Liaw . Aron . Cunha . Gerald R. . Baskin . Laurence . 2018 . Human Glans and Preputial Development . Differentiation; Research in Biological Diversity . 103 . 86–99 . 10.1016/j.diff.2018.08.002 . 0301-4681 . 6234068 . 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".
  38. Cunha . Gerald R. . Sinclair . Adrian . Cao . Mei . Baskin . Laurence S. . 2020 . Development of the human prepuce and its innervation . Differentiation; Research in Biological Diversity . 111 . 22–40 . 10.1016/j.diff.2019.10.002 . 0301-4681 . 6936222 . 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.".
  39. Favorito . Luciano Alves . Balassiano . Carlos Miguel . Costa . Waldemar Silva . Sampaio . Francisco José Barcellos . 2012 . Development of the human foreskin during the fetal period . Histology and Histopathology . 27 . 8 . 1041–1045 . 10.14670/HH-27.1041 . 1699-5848 . 22763876 . "The complete foreskin was formed only in the fetuses at 18 and 19 WPC, in which the foreskin totally covered the glans.".
  40. Carmack . Adrienne . Milos . Marilyn Fayre . 2017 . Catheterization without foreskin retraction . Canadian Family Physician . 63 . 3 . 218–220 . 0008-350X . 5349724 . 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.".
  41. Liu . Xin . Liu . Ge . Shen . Joel . Yue . Aaron . Isaacson . Dylan . Sinclair . Adrian . Cao . Mei . Liaw . Aron . Cunha . Gerald R. . Baskin . Laurence . 2018 . Human Glans and Preputial Development . Differentiation; Research in Biological Diversity . 103 . 86–99 . 10.1016/j.diff.2018.08.002 . 0301-4681 . 6234068 . 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.".
  42. Web site: Newborn male circumcision Canadian Paediatric Society . 2023-02-01 . cps.ca . en . "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".
  43. Dave . Sumit . Afshar . Kourosh . Braga . Luis H. . Anderson . Peter . 2018 . CUA guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants . Canadian Urological Association Journal . en . 12 . 2 . E76–E99 . 10.5489/cuaj.5033 . 29381458 . 5937400 . 1920-1214 . "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".
  44. Web site: Lissienko . Katherine . 2011-09-13 . How To Care For Your Child's Foreskin . 2022-12-21 . KidsHealth NZ . en.
  45. Web site: How to take care of a baby's uncircumcised penis . 2022-12-20 . Mayo Clinic . en.
  46. Web site: Care for an Uncircumcised Penis . 2022-12-21 . HealthyChildren.org. September 2007 .
  47. Web site: Philadelphia . The Children's Hospital of . 2014-08-23 . Care of the Uncircumcised Penis . 2022-12-20 . www.chop.edu . en.
  48. Web site: Circumcision of baby boys: Information for parents . 2023-02-01 . caringforkids.cps.ca . en.
  49. Web site: Newborn male circumcision Canadian Paediatric Society . 2023-02-02 . cps.ca . en.
  50. Web site: Philadelphia . The Children's Hospital of . 2014-08-23 . Care of the Uncircumcised Penis . 2022-12-21 . www.chop.edu . en . "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.".
  51. Øster J . April 1968 . Further Fate of the Foreskin: Incidence of Preputial Adhesions, Phimosis, and Smegma among Danish Schoolboys . Arch Dis Child . 43 . 228 . 200–202 . 10.1136/adc.43.228.200 . 2019851 . 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.".
  52. Web site: Smegma: What It Is, Prevention & How To Get Rid Of It . 2022-12-20 . Cleveland Clinic . en.
  53. Chung . J. . Park . Chang Soo . Lee . Sang Don . 2019 . Microbiology of smegma: Prospective comparative control study . Investigative and Clinical Urology . en . 60 . 2 . 127–132 . 10.4111/icu.2019.60.2.127 . 6397923 . 30838346 . 69175186.
  54. Dave . Sumit . Afshar . Kourosh . Braga . Luis H. . Anderson . Peter . 2018 . CUA guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants . Canadian Urological Association Journal . en . 12 . 2 . E76–E99 . 10.5489/cuaj.5033 . 1920-1214 . 5937400 . 29381458 . "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.".
  55. McGregor . Thomas B. . Pike . John G. . Leonard . Michael P. . 2007 . Pathologic and physiologic phimosis: Approach to the phimotic foreskin . Canadian Family Physician . en . 53 . 3 . 445–448 . 17872680 . 1949079 . "most foreskins will become retractile by adulthood.".
  56. Velazquez . Elsa F. . Bock . Adelaida . Soskin . Ana . Codas . Ricardo . Arbo . Manuel . Cubilla . Antonio L. . 2003 . Preputial variability and preferential association of long phimotic foreskins with penile cancer: an anatomic comparative study of types of foreskin in a general population and cancer patients . The American Journal of Surgical Pathology . 27 . 7 . 994–998 . 10.1097/00000478-200307000-00015 . 0147-5185 . 12826892 . 34091663.
  57. Book: Chengzu L . Epidemiology of Urogenital Diseases. Health Care for Foreskin Conditions. Beijing: People's Medical Publishing House. 2011.
  58. Book: Xianze L . Tips on Puberty Health. Beijing: People's Education Press. 2012.
  59. Book: Guochang H . General Surgery. Beijing: People's Medical Publishing House. 2010.
  60. Book: Martin RD . Primate Origins and Evolution: A Phylogenetic Reconstruction. New Jersey: Princeton University Press. 1990. 978-0-691-08565-4.
  61. 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 . 10.5489/cuaj.5033 . 5937400 . 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 . 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 . 10.1016/j.cmi.2016.07.030 . 27497811 . free.
    • Web site: Staff . Statement on Newborn Male Circumcision . live . https://web.archive.org/web/20230321004554/https://www.acog.org/en/womens-health/faqs/newborn-male-circumcision . 21 March 2023 . March 21, 2023 . . en . 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 . . 23 . 1 . 349 . 10.1186/s12889-023-15228-3 . 1471-2458 . 9933013 . 36797696 . It was interesting to note that the young males in this study had misconceptions about sexual pleasure post male circumcision... . free.
    • Todd Sorokan . S . Finlay . Jane . Jefferies . Ann . September 8, 2015 . 2015 Policy Statement on Newborn Male Circumcision . . en . 20 . 6 . 311–320 . 10.1093/pch/20.6.311 . 4578472 . 26435672 . ...medical studies do not support circumcision as having a negative impact on sexual function or satisfaction in males or their partners..
    • Web site: World Health Organization . World Health Organization . UNAIDS . UNAIDS . Jhpiego . Jhpiego . December 2009 . Manual for Male Circumcision Under Local Anaesthesia . https://web.archive.org/web/20120115175057/http://www.who.int/hiv/pub/malecircumcision/who_mc_local_anaesthesia.pdf . 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
  62. Cox G, Krieger JN, Morris BJ . June 2015 . Histological Correlates of Penile Sexual Sensation: Does Circumcision Make a Difference? . Sexual Medicine . 3 . 2 . 76–85 . 10.1002/sm2.67 . 4498824 . 26185672.
  63. Dobanovacki D, Lucić Prostran B, Sarac D, Antić J, Petković M, Lakić T . 2012 . [Prepuce in boys and adolescents: what when, and how?] . Medicinski Pregled . 65 . 7–8 . 295–300 . 10.2298/MPNS1208295D . 22924249 . free.
  64. Collier R . Vital or vestigial? The foreskin has its fans and foes . CMAJ . 183 . 17 . 1963–1964 . November 2011 . 22025652 . 3225416 . 10.1503/cmaj.109-4014 .
  65. Web site: College of Physicians . Surgeons of British Columbia . 2009 . Circumcision (Infant Male) . dead . https://web.archive.org/web/20120215182208/https://www.cpsbc.ca/files/u6/Circumcision-Infant-Male.pdf . February 15, 2012 . April 22, 2012.
  66. Morris BJ, Krieger JN, Klausner JD . March 2017 . CDC's Male Circumcision Recommendations Represent a Key Public Health Measure . Global Health, Science and Practice . 5 . 1 . 15–27 . 10.9745/GHSP-D-16-00390 . 5478224 . 28351877.
  67. Simmons MN, Jones JS . Male genital morphology and function: an evolutionary perspective . The Journal of Urology . 177 . 5 . 1625–1631 . May 2007 . 17437774 . 10.1016/j.juro.2007.01.011 .
  68. Male circumcision . Pediatrics . 130 . 3 . e756–e785 . September 2012 . 22926175 . 10.1542/peds.2012-1990 . free . Blank . Susan . Brady . Michael . Buerk . Ellen . Carlo . Waldemar . Diekema . Douglas . Freedman . Andrew . Maxwell . Lynne . Wegner . Steven . The technical report was published in conjunction with an updated statement of policy on circumcision: Circumcision policy statement . Pediatrics . 130 . 3 . 585–586 . September 2012 . 22926180 . 10.1542/peds.2012-1989 . 2017-10-04 . live . 207166111 . free . https://web.archive.org/web/20170901152938/http://pediatrics.aappublications.org/content/pediatrics/130/3/585.full.pdf . 2017-09-01 . Blank . Susan . Brady . Michael . Buerk . Ellen . Carlo . Waldemar . Diekema . Douglas . Freedman . Andrew . Maxwell . Lynne . Wegner . Steven .
  69. Birley . H. D. . Walker . M. M. . Luzzi . G. A. . Bell . R. . Taylor-Robinson . D. . Byrne . M. . Renton . A. M. . 1993 . Clinical features and management of recurrent balanitis; association with atopy and genital washing . Genitourinary Medicine . 69 . 5 . 400–403 . 10.1136/sti.69.5.400 . 0266-4348 . 1195128 . 8244363.
  70. Web site: 26 August 2015 . Phimosis (tight foreskin) . live . https://web.archive.org/web/20170922050755/http://www.nhs.uk/conditions/phimosis/Pages/Introduction.aspx . 22 September 2017 . 21 September 2017 . NHS Choices.
  71. Chi CC, Kirtschig G, Baldo M, Brackenbury F, Lewis F, Wojnarowska F . Topical interventions for genital lichen sclerosus . The Cochrane Database of Systematic Reviews . 12 . CD008240 . December 2011 . 2011 . 22161424 . 7025763 . 10.1002/14651858.CD008240.pub2 .
  72. Book: Fahmy M . Congenital Anomalies of the Penis – Springer. 2017. Springer. 978-3-319-43310-3. en.
  73. Van Howe RS, Sorrells MS, Snyder JL, Reiss MD, Milos MF . Letter from Van Howe et al Re: Examining Penile Sensitivity in Neonatally Circumcised and Intact Men Using Quantitative Sensory Testing: J. A. Bossio, C. F. Pukall and S. S. Steele J Urol 2016;195:1848–1853 . The Journal of Urology . 196 . 6 . 1824 . December 2016 . 28181790 . 10.1016/j.juro.2016.05.127 .
  74. Szabo R, Short RV . How does male circumcision protect against HIV infection? . BMJ . 320 . 7249 . 1592–1594 . June 2000 . 10845974 . 1127372 . 10.1136/bmj.320.7249.1592 .
  75. Book: Alan Glasper . Edward . A Textbook of Children's and Young People's Nursing . Richardson . James . Randall . Duncan . . 2021 . 9780702065033 . 382 . Promote, Restore, and Stabilise Health Status in Children.
  76. Book: Cox G, Morris BJ . Bolnick DA, Koyle M, Yosha A . Surgical Guide to Circumcision. 2012. Springer-Verlag. London. 978-1-4471-2858-8. 243–259. Chapter 21: Why Circumcision:From Prehistory to the Twenty-First Century.
  77. Book: McClung C, Voelzke B . Bolnick DA, Koyle M, Yosha A . Surgical Guide to Circumcision. 2012. Springer-Verlag. London. 978-1-4471-2858-8. 165–175. Chapter 14: Adult Circumcision.
  78. Web site: Policy Statement On Circumcision. 2007-02-28. September 2004. PDF. Royal Australasian College of Physicians. The Paediatrics and Child Health Division, The Royal Australasian College of Physicians (RACP) has prepared this statement on routine circumcision of infants and boys to assist parents who are considering having this procedure undertaken on their male children and for doctors who are asked to advise on or undertake it. After extensive review of the literature the RACP reaffirms that there is no medical indication for routine neonatal circumcision. Circumcision of males has been undertaken for religious and cultural reasons for many thousands of years. It remains an important ritual in some religious and cultural groups.…In recent years there has been evidence of possible health benefits from routine male circumcision. The most important conditions where some benefit may result from circumcision are urinary tract infections, HIV and later cancer of the penis.…The complication rate of neonatal circumcision is reported to be around 1% and includes tenderness, bleeding and unhappy results to the appearance of the penis. Serious complications such as bleeding, septicaemia and may occasionally cause death (1 in 550,000). The possibility that routine circumcision may contravene human rights has been raised because circumcision is performed on a minor and is without proven medical benefit. Whether these legal concerns are valid will be known only if the matter is determined in a court of law. If the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment. In all cases where parents request a circumcision for their child the medical attendant is obliged to provide accurate information on the risks and benefits of the procedure. Up-to-date, unbiased written material summarizing the evidence should be widely available to parents. Review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for circumcision as a routine procedure in the neonate. . https://web.archive.org/web/20080720092409/http://www.racp.edu.au/download.cfm?DownloadFile=A453CFA1-2A57-5487-DF36DF59A1BAF527 . 2008-07-20.
  79. Web site: The law and ethics of male circumcision - guidance for doctors. 2006-07-01. Medical Ethics Committee. June 2006. British Medical Association. https://web.archive.org/web/20071112055050/http://www.bma.org.uk/ap.nsf/Content/malecircumcision2006?OpenDocument&Highlight=2,circumcision . 2007-11-12.
  80. Collier R . Whole again: the practice of foreskin restoration . CMAJ . 183 . 18 . 2092–2093 . December 2011 . 22083672 . 3255154 . 10.1503/cmaj.109-4009 .
  81. Web site: Paraphimosis : Article by Jong M Choe, MD, FACS. eMedicine. 2012-07-16. 2008-11-23. https://web.archive.org/web/20081123084628/http://www.emedicine.com/med/topic2874.htm. live.
  82. Book: Surgical Guide to Circumcision . Snodgrass WT . 2012 . Springer-Verlag . 978-1-4471-2858-8 . Bolnick DA, Koyle M, Yosha A . London . 177–181 . Chapter 15: Foreskin Reconstruction.
  83. News: McKie R . Foreskins for Skin Grafts . The Toronto Star. 1999-04-04.
  84. Web site: High-Tech Skinny on Skin Grafts. 1999-02-16. 2008-08-20. https://web.archive.org/web/20081010003545/http://www.wired.com/science/discoveries/news/1999/02/17912. October 10, 2008. dead.
  85. Web site: Grand DJ. Medscape. Skin Grafting. August 15, 2011. August 18, 2012. October 8, 2008. https://web.archive.org/web/20081008004513/http://www.emedicine.com/derm/topic867.htm. live.
  86. Web site: Amst C, Carey J . Biotech Bodies. July 27, 1998. The McGraw-Hill Companies Inc. www.businessweek.com. 2017-09-17. bot: unknown. https://web.archive.org/web/20131224201345/http://www.businessweek.com/1998/30/b3588001.htm . December 24, 2013.
  87. Web site: Cowan AL. Wall Street; A Swiss Firm Makes Babies Its Bet. April 19, 1992. New York Times:Business. 2008-08-20. 2009-02-13. https://web.archive.org/web/20090213102301/http://query.nytimes.com/gst/fullpage.html?res=9E0CE6D81E38F93AA25757C0A964958260&partner. live.
  88. Hovatta O, Mikkola M, Gertow K, Strömberg AM, Inzunza J, Hreinsson J, Rozell B, Blennow E, Andäng M, Ahrlund-Richter L . 6 . A culture system using human foreskin fibroblasts as feeder cells allows production of human embryonic stem cells . Human Reproduction . 18 . 7 . 1404–1409 . July 2003 . 12832363 . 10.1093/humrep/deg290 . free .
  89. Web site: The 'Baby Foreskin Facial' Is a Real Thing . Boston Magazine . Malamut M . 14 April 2015.
  90. Hall. Robert. August 1992. Epispasm: Circumcision in Reverse. Bible Review. 8. 4. 52–57.
  91. Hodges FM . The ideal prepuce in ancient Greece and Rome: male genital aesthetics and their relation to lipodermos, circumcision, foreskin restoration, and the kynodesme . Bulletin of the History of Medicine . 75 . 3 . 375–405 . 2001 . 11568485 . 10.1353/bhm.2001.0119 . 29580193 . 44445662 .
  92. Book: https://link.springer.com/chapter/10.1007/978-3-030-37621-5_2. 10.1007/978-3-030-37621-5_2. History of the Prepuce. Normal and Abnormal Prepuce. 2020. Raveenthiran V . 7–21 . Springer. 978-3-030-37620-8. 216446879.

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