Premature Ejaculation (Discussion) – part 2

RESULTS (Premature Ejaculation)

A total of 208 patients were included in the study. The mean age of the patients was calculated as 34.9 ± 8.4 years, the mean height as 1.73 ± 0.05 m, and the mean weight as 79 ± 10 kg. The mean circumcision age of the patients was 5.7 ± 4.2 years, the mean penile length was measured as 12.5 ± 1.9 cm, and the mean dorsal and ventral mucosal size as 15.02 ± 4.58 mm and 16.31 ± 4.92 mm, respectively. Cialis certainly can not help with premature ejaculation, but can help in the issue of erectile dysfunction. After all, Generic Cialis can accelerate a faster recovery for the continuation of sexual intercourse.

PE was present in 106 of the participants. No statistically significant difference was found between the PE and non-PE groups in terms of age, height, weight, age at circumcision, penile length, and IIEF-5 scores. The patients with PE had significantly longer dorsal and ventral mucosal measurements than those without PE (p < 0.001). Similarly, the PE group had significantly lower IELT and significantly higher PEDT scores than the non-PE group (p < 0.001). Table 1 presents the comparative data obtained from the two groups.

There was no statistically significant difference between the PE and non-PE groups concerning the person that had performed the circumcision (surgeon, non-surgeon). Similarly, no statistically significant relationship was observed between PE and undergoing circumcision during the phallic period (3-6 years). Table 2 shows the detailed results of the relationship between PE and these two variables.


The pathophysiology of PE has not been fully elucidated. Among the organic causes listed are penile hypersensitivity, genetic predisposition, increased sexual excitability, and endocrine-related reasons [12]. Another cause of lifelong PE is considered to be the hyposensitivity of the 5-HT2c receptor or hypersensitivity of the 5-HT1A receptor [13].

Circumcision is considered to be the oldest known surgical procedure with circumcised penises having been detected in the drawings of the Paleolithic period [14]. Circumcision is one of the most performed surgical interventions worldwide, and 1/3 of men in the world are circumcised for religious, cultural, medical or personal reasons [15]. The effect of circumcision on sexual symptoms has been widely researched but there is no general consensus on the results. In a systematic review published in 2013, 19,542 uncircumcised and 20,931 circumcised men were included, and it was suggested that circumcision was not related to penile sensitivity, erectile dysfunction, PE, or ejaculation time [16]. In a prospective randomized trial involving 2,784 men, PE was found to be 17% less in the uncircumcised group [17]. In another study, the researchers stated that women preferred uncircumcised men as a sexual partner because PE was less common in this group [18]. In studies on the effect of adult circumcision on sexual function, IELT was found to be increased after circumcision [7,19]. As revealed by the literature studies, circumcision does not have an effect on erection, but it affects the time of ejaculation although there is no consensus in the results.

The prepuce (preputial foreskin) is one of the most sensitive places in the penis [6]. Removal of sensory receptors in the prepuce during circumcision may also have a positive effect on PE by decreasing sensitivity [20]. The normal length of the prepuce is 6.4 cm [21]. Gallo reported a longer prepuce and increased post-circumcision ejaculation time in patients with patients with lifelong PE [20]. In these patients, Gallo author almost completely excised the prepuce in a circumcision procedure [19]. Although our study group did not include uncircumcised patients, we found ejaculation time to be shorter in the group that had redundant mucosa following circumcision. This can be explained by the length of mucosa increasing stimulation, and thus triggering PE.

Gallo et al. reported that lifelong PE was associated with a short frenulum and patient complaints improved after frenulectomy [22]. The authors defined a short frenulum as a ventral curvature of 20° in the glans, which restricts the movement of the prepuce in retraction. In another study, Hosseini et al. found a significant relationship between reduced IELT and presence of frenular web (residual frenulum tissue after circumcision) [23]. A short frenulum [22] and frenular web [23] are concepts contributed by the respective authors in the literature, and due to the limited research in this area, we chose to use ventral length of mucosal cuff in the current study as a more objective discussion point. We determined that the ventral aspect of the penile mucosa was statistically significantly longer in patients with PE. We consider that this may be associated with the frenulum.

In a study that examined the relationship between PE and post-circumcisional mucosal cuff in 42 with PE and 42 without PE, it was found that the mucosal cuff length measured from the dorsal aspect was not a risk factor for PE [8]. In another study, Yuruk et al. compared the dorsal length of mucosal cuff between 49 patients with PE and 50 patients without PE and reported it to be longer in the former group, albeit with no statistical significance [9]. Similarly, Bodakcı et al. and Telli et al. did not find a statistically significant relationship between the dorsal measurement of mucosal cuff length [24,25]. In contrast to our findings, the authors found a shorter mucosal cuff length in patients that had been circumcised by a surgeon [24,25]. In the current study, the dorsal and ventral lengths of mucosal cuff were found to be significantly shorter in patients with PE than in the non-PE group (p < 0.001). The significant results of our study which opposed with the previous non-significant findings reported in the literature may be due to various reasons. Firstly, in two studies with a similar design [8,9], the number of patients was lower (42 and 49, respectively) compared to our study group (106). Although Bodakcı et al. investigated the relationship between IELT and mucosal cuff length in a similar number of patients, they did not mention how many people were diagnosed with PE [24]. Secondly, previous researchers measured the mucosal cuff length only on the dorsal aspect, whereas we also performed a ventral measurement. Although the authors did not include the measurement of mucosal cuff length in their respective studies, increased post-circumcisional ejaculation time reported by Gallo in patients with a lifelong PE complaint [20] and longer IELT reported by Senkul et al. after adult circumcision [7] support the results of our study.

The phallic period refers to the time between 3-6 years of age, in which the child’s sexual identity develops. In a study examining the effect of circumcision performed during this period on sexual functions, the results were not significant [26]. Similarly, we found that undergoing circumcision during the phallic period was not associated with PE.

Although many methods have been described concerning how to perform circumcision, to the best of our knowledge, there is no data providing information on the amount of mucosa that should be left behind (or the mucosal cuff length that should be considered) during circumcision. The results of this study led us to think “if only it was possible to foresee the mucosal cuff length in adulthood based on the amount of skin left behind during childhood circumcision”. Since most circumcisions are performed during childhood, we could not know what size the mucosal cuff length would be once the penis reaches complete development. Even though a solution to this situation may simply appear to perform circumcision, if necessary, in adulthood, we are almost certain that the majority of circumcisions in the world will continue to be undertaken in childhood for religious and cultural reasons. Future prospective studies starting from childhood may shed light on how much mucosa should be left behind after circumcision.

Based on the present study’s results it may be speculated that circumcision may be considered as a therapeutic option in men with a diagnosis of lifelong PE. We think that the effect of preputial excision in PE deserve to be investigated in future studies.

We consider that the dorsal and ventral lengths of the post-circumcisional mucosal cuff is a risk factor for PE. It may be helpful in preventing PE not to leave excessive dorsal and ventral mucosal tissue during circumcision.




The authors declare no conflict of interest and that no funding has been received for this work.


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By Dr. Carlos Campos, MD, PA On: May 17, 2019 at 09:03:53