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Circumcision Styles

Not all circumcisions are the same!


In this section of the CIRCLIST website you will find a wealth of information about the terminology used to describe styles of circumcision. Being able to communicate one’s expectations prior to the procedure is vital if disappointment is to be avoided, so be sure to establish a common terminology with your surgeon and discuss your style preferences before the circumcision takes place.


Last updated: 07 March 2014, 13:26 UTC



Definitions of Style   Establishing a common terminology.
Unusual Styles   Buttonhole circumcisions, Partial and Dorsal Slit circumcisions.
Styles and Religion   The styles associated with Judiasm and Islam.
Styles in relation to Health and Hygiene   The non-religious aspects of circumcision style.
Photo Gallery : Part 1
Photo Gallery : Part 2



Anatomy and Circumcision Terminology

First, let’s revise our knowledge of anatomy. (There’s more detail in our Anatomy chapter if you need it).

The diagram below is a longitudinal section through an uncircumcised penis. Note especially that the Inner Foreskin and Outer Foreskin are separate entities, not the opposite sides of a single layer of tissue. They are not attached to each other and in consequence are mobile with respect to each other. Thus it is possible to remove unequal amounts of the two layers. Understanding this is crucial to an understanding of circumcision styles.


Figure 1 : Longitudinal section through an uncircumcised penis:

Longitudinal section through the uncircumcised penis (14121 bytes) Colour Key:

        Dull red:  Glans of the penis
        Bright red:  Coronal rim of the glans
        Violet:  Sulcus
        Pink: Frenulum
        Green:  Inner foreskin
        Lime:  Frenar band
        Cyan:  Outer foreskin
        Blue:  Shaft skin
        Brown:  Other skin
        Yellow:  Urethra
        Grey:  Various body tissue

And in Figure 2 below...

        Orange:  Tissue to be removed


Now let’s consider the first two of the "variables" relating to styles of circumcision - the high/low parameter and the loose/tight parameter.

The high/low parameter is a way of stating what is removed. The loose/tight parameter is a way of stating how much is removed. These variables are almost totally independent, hence there are four extremes: and an infinite number of possibilities in-between.

The terms Loose and Tight are fairly self-explanatory, but a frequently-asked question is “What’s meant by 'High' and 'Low'? Where does the nomenclature come from?”

The answer is simple. Imagine two circumcised men of the same stature standing alongside each other, both flaccid. One has a circumcision style that retained inner foreskin (the 'high' style) whilst the other has a circumcision style that removed inner foreskin (the 'low' style). The circumcision scar line of the man with the high style will be part-way up his penis whereas the circumcision scar line of the man with the low style will be close to the rim of his glans. The scar line of the man with the high style will therefore be higher off the ground than the scar line of the man with the low style; that scar will be closer to the ground and therefore lower. Hence "high" and "low".

The four extremes are illustrated in the table below. Few circumcisions will actually resemble those illustrated in the "After" column; the drawings slightly exaggerate the situation in order to highlight the differences.


Figure 2 : Extremes of High/Low and Loose/Tight. What gets removed?

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BEFORE

Condemned tissue in orange
AFTER

Flaccid in each case
COMMENTS
Low and
Loose
Low and Loose, before. Low and Loose, after
Almost all the inner foreskin has been removed along with an equal amount of outer foreskin. No tension has been placed in the shaft skin, with the result that the flaccid penis droops and the sulcus is not held fully open. Thus, despite circumcision, it remains possible for smegma to accumulate.
Low and
Tight
Low and Tight, before Low and Tight, after
The maximum possible amount of inner foreskin has been removed along with the whole of the outer foreskin plus a considerable portion of shaft skin. This has placed the residual shaft skin under tension, with the result that the flaccid penis appears to be short and semi-erect. The sulcus is held fully open; therefore it is not possible for smegma to accumulate.
High and
Loose
High and Loose, before Artwork awaited
Much of the of inner foreskin has been retained, folded back on itself to face outwards and assume the role of shaft skin. The outer foreskin has been removed along with some shaft skin, but not enough to place the residue under tension. Thus the flaccid penis still droops as it did before circumcision. The sulcus is not held fully open; therefore it is still possible for smegma to accumulate.
High and
Tight
High and Tight, before Artwork awaited
Much of the of inner foreskin has been retained, folded back on itself to face outwards and assume the role of shaft skin. The outer foreskin has been removed as has a considerable amount of shaft skin. This has placed the residual shaft skin under tension, with the result that the flaccid penis appears to be short and semi-erect. The sulcus is held fully open; therefore it is not possible for smegma to accumulate.
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To enlarge these images, please use the magnification controls of your browser. Detailed advice here.




The high/low debate in respect of sensitivity

One hotly debated issue in the world of circumcision is the question of the effect of style choice on sexual sensitivity. Proponents of the high style often assert that the exposed inner foreskin is for them a particularly erogenous zone, leading them to the conclusion that the high style is more sensitive than the low. Only men who have been recircumcised can have experienced both states and they are few in number. Thus the gathering of scientifically reliable data on this issue is difficult; too small a sample and only subjective, narrative reports to work with.

Some micro-anatomical investigations have been conducted to determine the precise distribution of nerve endings within the penis but the results appear not to definitively map the relative sensitivity of erogenous zones. (Halata and Munger [1986] also Halata and Spaethe [1997].)



The loose/tight choice - can an adult be circumcised too tightly?

The short answer is "yes". In order to describe the problem of excessive tightness in adult circumcisions, it is first necessary to define two further terms: A Grower with a tight circumcision may find that skin from the abdomen and/or the scrotum is drawn up onto the shaft of the penis when it is erect. This can be both uncomfortable with respect to the tension and inconvenient insofar as pubic hairs are drawn onto the shaft. Such hair, if not shaved, can interfere with deep penetration intercourse. On the other hand a Shower (pronounced Show-er, as in one who shows) is unlikely to experience over-tightness when erect precisely because the penis does not change length significantly as between the flaccid and erect states.

The way to avoid problems of over-tightness in an adult circumcision is to mark out the intended circumcision with the penis erect. Any tendency for abdominal or scrotal skin to be drawn up onto the shaft will then be obvious and the planned degree of tightness can be adjusted accordingly. The relative positions of the lines shown in the following illustration will vary hugely from individual to individual.


Figure 3 : Quantifying the tightness of a planned adult circumcision.

An uncircumcised adult penis marked out erect (16,035 bytes) An uncircumcised adult penis marked out flaccid (17,152 bytes)
CIRCLIST Member’s photographs : An uncircumcised "grower", 50s age group.


The green line marks the position of the sulcus when the penis is erect.

The black line marks the position of the sulcus when shaft skin is pulled forward over the erect penis as far as is possible without drawing either abdominal or scrotal skin onto the shaft.

The red line shows the position of the sulcus when the shaft skin is pulled forward over the flaccid penis as far as is possible without drawing either abdominal or scrotal skin onto the shaft.


First let’s assume that a fully "low" circumcision is in prospect. Placing the circumcision scar at the position of the green line would then result in a fully loose circumcision; remove any less and the circumcision would only be partial. Placing the circumcision scar at the black line would result in a circumcision that was fully tight when erect but not when flaccid. Placing the circumcision scar at the red line would produce a circumcision that was super-tight when erect (possibly painfully so in an adult) and would also be fully tight when flaccid.

If a "high" style is in prospect, then in order to give the same degree of tightness each line must be notionally shifted proximally by a distance equal to the length of inner foreskin retained.



The loose/tight choice - can an a child be circumcised too tightly?

The short answer is "no", but with caveats. In respect of pre-pubertal circumcisions, tightness is an issue both in terms of cosmetic appearance and with respect to the immediate hygiene benefits of the procedure. Unless the circumcision is tight when flaccid, the sulcus will not be held open and smegma will still accumulate. Note, though, that a very tight circumcision in late boyhood may result in painful erections during puberty - a situation best avoided by circumcising at a younger age. Parents who have chosen circumcision for their son should take all these factors into account and then specify the degree of tightness envisaged in terms that are unambiguous.


Figure 4 : Quantifying the tightness of a planned pre-pubertal circumcision.

A method for quantifying the tightness of a circumcision (26,166 bytes) Subjective descriptions of tightness are liable to be interpreted differently both at a cultural and at an individual level. Thus CIRCLIST suggests that it is helpful to quantify the tightness parameter so that misinterpretation is avoided.

This diagram illustrates how the ratio between the length of the glans and the length of the shaft when flaccid can be used as a guide to the tightness of a planned infant or boyhood circumcision. The system isn’t perfect because it uses residual shaft length as a quasi-variable for shaft skin tightness, but it is the best method that has been devised to date.




Frenulum removal

Irrespective of the choices made in respect of the high/low and loose/tight variables, two issues arise when it comes to deciding whether to remove or retain the frenulum, the web of tissue connecting the underneath of the glans to the inner foreskin.

Consider first the health issue. The frenulum contains the densest concentration of Langerhans cells in the whole body. Langerhans cells are the portal of entry for sexually transmitted retroviruses, the best-known of which is HIV. Removing tissue containing Langerhans cells reduces but does not wholly eliminate the risk of acquiring HIV during normal heterosexual intercourse with an infected female partner. Despite the residual risk, there is a strong case to be made on health grounds for frenulum removal.

Next comes the matter of sexual sensitivity. Some uncircumcised men report that the frenulum is the principal seat of sensitivity, implying that removal desensitises the penis and so reduces sexual satisfaction. Yet CIRCLIST members who have had their frenulum removed in adulthood (and therefore have experienced it "both ways") report either no change or an increase in sensitivity. This implies that the nerve endings are not in the web of tissue itself, but in the glans directly under its point of attachment.

There is a constraint upon free choice here, which only becomes relevant if a wholly low style is in prospect. The frenulum is attached to the inner foreskin; therefore it is not possible to circumcise fully 'low' without also removing the frenulum. Not to remove it in such circumstances would leave it flapping loose, hanging from the glans having lost its other point of attachment.

Note also that, when circumcision takes place in infancy, it is difficult to predict the outcome as regards the frenulum. In the newborn, it is not well developed. The cut may leave it when the intent was to remove it, or circumcision may simply cause it not to develop even if the intent was to retain it.


Figure 5 : Photographs of the frenulum (or lack of it)

Frenulum Breve (9099 bytes)

Frenulum breve
Tight circumcision with frenulum retained, penis erect (7626 bytes)

Tight circumcision,
frenulum retained
Close-up of the ventral aspect of the sulcus, frenulum removed (4146 bytes)

Frenulum removed as a
separate procedure
Dorsal slit circumcision, penis flaccid (56283 bytes)

Frenulum substantially undeveloped
following infant circumcision




The angle of the scar line

It seems obvious... if the objective of circumcision is to dispose of the foreskin and expose the sulcus, then the cut should follow the line of the joint between the foreskin and the rest of the penis. Yet many circumcisions place the scar line perpendicular to the longitudinal axis of the shaft of the penis, rather than following the naturally oblique line of the corona and sulcus. Why?

The answer seems to be that the frequent occurrence of 'perpendicular-to-shaft' scars results from the use of shields and clamps. Many designs, including the highly popular Gomco re-useable clamp and the mass-market Plastibell disposable device, naturally place the scar line perpendicular to the shaft. In the case of the Gomco it is possible for an experienced user to work extra tissue through the top (dorsal aspect) of the device before closing it, but this requires both commitment and dexterity. The same is true of some of the modern clip-and-wear disposable clamps; only one of these (the Ali’sKlamp) naturally aligns with the corona.

Whilst it is undoubtedly true that clamps and shields protect the glans from accidental injury during circumcision, mis-alignment of the scar line is definitely a 'minus' to be taken into account when assessing most of them. The issue is one of trade-off between safety and style perfection, suggesting that the ultimate clamp design has yet to be devised.

Arguably the ideal scar position is the so-called “V-Scar”, one that closely mimics the alignment of the coronal rim of the glans especially in the vicinity of the frenulum. Photographs of such scars are rare because the V-Scar is rare. Not only that, but it requires a photograph of the underneath - the ventral aspect - of the penis and a distinctive colour difference in the tissues, without which the boundary does not show. Here we present the best illustration of a V-Scar found to date; if you know of better ones please forward them!


Figure 6 : A photograph illustrating the V-Scar

V-Scar (33,528 bytes)

An unannotated copy of this image can be found later in this Chapter.



Recircumcision

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Circumcision, if done at all, is something that normally happens just once. But recircumcision is not unknown; when it happens the motive is to change or improve upon the style of the original. So what’s possible?

A high style can be converted into a lower one, but an existing low style cannot be made into a high one. This is because a high style results from deliberate retention of inner foreskin, which is turned back on itself to assume a new role as shaft skin. But a previous low circumcision will have removed the inner foreskin, so there is none available to turn. What’s gone has gone.

Recircumcision cannot convert a tight style into a loose one, but a loose style can be tightened. Such tightening is the prime motivation for recircumcisions. Some tight circumcisions slowly stretch and someone who has in earlier years enjoyed the sensations of a tight circumcision may seek recircumcision in order to offset the slackening that comes with age.

Whilst circumcision is a fairly straightforward process, recircumcision is not. The task should only be entrusted to an experienced and sympathetic urologist.



Specifying what’s wanted

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Having made your choice of circumcision style, it really is a good idea to write it down! That way there is less room for error or misunderstanding when you discuss the matter with your urologist or paediatrician. Make a note of this web page’s URL too, so that you can refer to it during the consultation.

It follows from the definitions above that four parameters must be specified in order to adequately specify a circumcision. These are: These variables are almost independent of each other, but not totally so. For example, if the frenulum is retained it is impossible for the entire inner foreskin to be removed ventrally. The frenulum would have no anchorage point. Therefore "fully low" is incompatible with frenulum retention. Likewise, if the scar line is arranged perpendicular to the shaft it is impossible to remove the whole inner foreskin ventrally, even if it is fully removed dorsally.



Icon Continue to the next page of this Chapter - Unusual styles of circumcision.



Acknowledgements

The following resources were used in the preparation of this web page:
Globe (2409 bytes) Circlist Website logo (6480 bytes) Circlist Group logo (8847 bytes) Personal testimony of members of the CIRCLIST discussion group.
German flag (193 bytes) Hamburg University logo (1507 bytes) Halata Z and Munger BL. The neuroanatomical basis for the protopathic sensibility of the human glans penis. Brain Res. 1986 Apr 23;371(2):205-30. Also Halata Z and Spaethe A. Sensory innervation of the human penis. Advances in experimental medicine and biology 1997;424:265-6.
Australia flag (316 bytes) University of Melbourne logo (25514 bytes) McCoombe SG, Cameron PU, Short RV. The distribution of HIV-1 target cells and keratin in the human penis. Int Conf AIDS. 2002 Jul 7-12; 14.







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