Most adult men contemplating circumcision suffer from one of a number of conditions that are best treated by circumcision. But some men also opt for circumcision to improve their sex lives, please their partners, or boost their self–esteem
The controversy over infant circumcision
One need not only turn to the internet to sample the controversy. Anti–circumcision advocates focus on the potential psychological trauma, as in “How could a being who has been aggressed in this way, while totally helpless, develop into a relaxed, loving, trusting person?” And pro–circumcision advocates cite the health benefits ascribed to circumcised males.
Cultural, religious and ethnic preferences are legitimate factors to consider when deciding whether to circumcise your baby boy. In fact, there are some health benefits to being circumcised, but they aren’t “Essential to health” or significant enough to warrant routine infant circumcision.
Medical reasons for one to be circumcised as an adult
The difference between routine infant circumcision and circumcisions performed on older children and adults is that medical need usually influences the patient’s decision to undergo the knife.
Phimosis: The number one reason for circumcision after infancy is phimosis, a tightness of the foreskin that prevents it from being retracted. Phimosis can be normal in boys less than six months old. In males older than that, however, it can make urination and hygiene difficult and erection painful.
Paraphimosis: In paraphimosis, the second most common reason for post–infancy circumcision is that the foreskin is permanently retracted, constricting the shaft of the penis and causing swelling and pain.
Balanitis (infection of the head of the penis, often caused by accumulation of secretions) and posthitis (infection of the foreskin) can be treated without surgery. As a first measure, a urologist will likely prescribe an anti–fungal and anti–inflammatory ointment, which may help clear up the problem, there is often an associated yeast infection, which thrives in the warm, moist environment created beneath the foreskin. Unfortunately, these conditions often recur, and when they do, a circumcision is advisable.
Other foreskin problems
Tumors of the foreskin, loose foreskin, and tears in the fold of skin of the penis that attaches to the foreskin are all conditions that can be treated non, surgically.
There is a growing body of research that shows a relationship between AIDS and uncircumcised men. It seems that men who have been circumcised have a much lower chance of contracting AIDS, even with a high–risk partner. It is not clear however, whether circumcision as an adult would show this same effect.
Circumcision for sexual reasons
Less than 5% of men who undergo circumcision do so for reasons other than medical ones. Still, some men whose parents opted against circumcision 20, 30, 40 and even 50 years ago are indeed contemplating the procedure, for reasons other than medical ones. Some are prompted by wishes dating from childhood, or by the request of their sexual partners.
The women speak
It’s interesting to note that women seem to play a large role in the circumcision decision. Studies have found that mothers often have the final say over whether their sons are to be circumcised or not. Many men who have opted for the procedure for non–medical reasons say they were pressured by girlfriends or wives. Women who claim a preference for the circumcised penis usually say they are turned off by hygienic problems in uncircumcised men or turned on by the look of the circumcised penis.
In newborns, circumcision takes only a few minutes. But the procedure in older children and adults is a more intricate operation. General anesthesia for adult circumcision was once routine, but now local pain blocks are usually used, and the procedure itself is usually done on an outpatient basis, even in older men.
If phimosis or paraphimosis has caused a lot of swelling, the circumcision may require two procedures: one to make a slit in the foreskin that relieves the pressure and the pain, and another at a later date to finish the circumcision after the swelling has gone down.
In most cases, men should refrain from sexual intercourse or masturbation for about six weeks after circumcision – until the incisions are healed and the sutures are removed. Some men experience frequent and prolonged erections in the first days after the surgery. After the first 48 hours or so, ointments or bandages aren't usually needed, but wearing loose clothing for a few days is recommended.
As with any surgical procedure, bleeding and infection are risks. Other more rare complications include blood clots, tearing of the sutures (usually due to erections) and complications from the anesthesia.
Making the decision
If your medical condition warrants a circumcision, then by all means, have the surgery. But if you’re considering the procedure sheerly for aesthetic reasons, think again.
Dr. Al Cooper of the San Jose Marital and Sexuality Center in San Jose, California, explains, “Remember that there is no turning back. If you are doing it because you think that is what women want, consider this. All women are not alike… If you want to impress a woman, change your pants, your hairstyle or even your personality. Hold off on changing your penis. Remember, she’ll be evaluating the first few before she decides if she wants to see the last one”.
Biking Bad for your erection ! The Natural Support System
The human rear is perfectly designed to support the weight of the body on two “Sit bones”. Those structures are protected by muscle and fat and have no arteries or nerves that could be crushed by your weight. As long as you are sitting on a flat surface, like a chair or couch, your sit bones easily support your weight. It’s a different story when you sit for long periods on a narrow bicycle seat. The penis is part of a hydraulic system. When stimulated, its twin chambers fill with blood until it’s erect. After ejaculation, the blood leaves and the penis softens again.
But about half that hydraulic system is inside the body. When a man sits on a narrow bicycle seat, his body weight can crush the pudendal artery and nerves that serve the penis. That sensitive area between the anus and the scrotum is known as the perineum. So bike riding can result in temporary and permanent impotence. Extra padding or jell padding in the seat does not help because the padding bunches up and also cuts off circulation.
Researching The Problem
Researchers have discovered that nerves, arteries and veins in the perineum can indeed be damaged by bicycle seats. Moreover, some cyclists have fallen on the bike’s cross bar and injured the groin. The bike–related impotence problems vary. Some erections are not sustainable because although blood gets into the penis, damaged valves can’t hold it there. Others may have trouble ejaculating due to decreased sensation. Overweight riders and cyclists who pedal many miles weekly are at higher risk for impairment.
Guy–friendly bike seats
Of course, the picture isn’t totally bleak. The perfect seat would look like a toilet seat and would remove all pressure from delicate areas, some men in the West have switched to recumbent bicycles in which the rider sits reclined and pedals with his legs stretched out in front. Others use wider saddles or switch to one of the half dozen seats that claim to be more guy–friendly. Some of those seats are hollow in the middle so the perineum is not crushed, and some are basically two large circles upon which the sit bones rest. Some have a large wedge or oval cutouts in the middle while still others have a long groove down the middle. Researchers know exactly how numb the genitals become because they tested those areas with a device known as an esthesiometer–a gadget used to measure the sensitivity, or lack thereof, in people with diabetes who often lose feeling in their hands and feet.
Impotence & Heart Diseases in MenImpotence or erectile dysfunction, may indicate that a man is at increased risk for heart disease. Arterial disease is a common cause of impotence, and where impotence is in fact due to arterial problems, physicians should also screen patients for coronary artery disease. Erectile dysfunction may be the first clinical sign of vascular disease.
We should be more aggressive in looking for other evidence of vascular disease when a patient presents with erectile dysfunction… look at it as an opportunity to interact with a patient’s primary care physician. The study involved 57 men with erectile dysfunction who had no previous history of arterial disease or risk factors such as hypertension, diabetes, or high cholesterol or blood lipids. Between the ages of 23 and 60, these men were tested twice for blood cholesterol after fasting for 12 hours. Sixty percent of the men were found to have elevated cholesterol levels and 91% of the men showed signs of arterial insufficiency by doppler ultrasound. Of the 40% who showed normal cholesterol levels, Doppler ultrasound showed that 88% had signs of arterial disease.
Alternative MethodsAs many as 40% of couples seeking vasectomy have experienced a failure with their previous method of nonpermanent birth control. Such failures can occur from misplacement of a diaphragm, an incorrectly implanted IUD, or noncompliance with an oral contraception regimen.
Some people contemplate vasectomy when use of a condom, diaphragm, or foam interferes with their enjoyment of sex. Freedom from distraction during sex is a secondary benefit of vasectomy, but should not be considered the primary motivation for the operation.
Can Vasectomies be reversed?Although men should consider their vasectomy to be a permanent decision before undergoing the procedure, if they change their mind, there is a surgical procedure known as a vasovasostomy that may restore fertility. The main reasons for requesting a reversal are remarriage, the death of a child, or an improvement in finances. Reversal may also be performed to relieve postvasectomy pain, which occurs in a small percentage of men.
Causes of Vasovasostomy failureThe chances for pregnancy decrease the longer the duration between vasectomy and the reversal operation. The lower rates as time goes by is probably due to increasing chance for obstruction of the epididymis and the development of anti sperm antibodies. A successful reversal is more likely if the section removed during vasectomy was not long, if the original procedure was performed on straight sections of the vas, and if the joined pieces were of equal size.
Epididymis ObstructionIf the sperm count does not recover within a reasonable period after vasovasostomy, secondary blockage of the epididymis is most often the cause, which may be corrected with a second procedure.
Auto antibodiesIn the majority of cases, the reversal procedure reopens the epididymis, but fertility is not necessarily automatic. Autoimmunity is a condition in which the antibodies of the immune system attack specific cells in the body, mistaking them for micro foreign invaders. In the case of male infertility, such so–called auto antibodies target the sperm. Even if a procedure to reverse the vasectomy is performed, such antibodies often persist. Antibodies bind to specific parts of the sperm (e.g.., the head or tail) and cause problems depending on the site of attachment. Sperm may stick together (agglutinate), fail to interact with cervical mucous, or fail to penetrate the egg.
Other Vasectomy–Induced Anti fertility FactorsThe important immune factors that trigger the autoimmune process are called leukocytes. Among their other harmful effects is the production of particles called oxygen–free radicals (also called reactive oxygen metabolites), which are particularly injurious to sperm. Vasectomy may also change other factors that affect fertility.
FailureAfter a vasectomy, there is still a 1.5% chance of pregnancy usually due to either live residual sperm or operative failure. Some reasons for failure of a vasectomy include incomplete sealing of the vasectomy differentia and the development of openings in the tubes that allow sperm to pass through.
Residual Live Sperm. After the operation there are always some active sperm left in the semen for several months, so it is essential that the patient and his partner continue to use another method of birth control until his sperm count is zero. Fifteen to 20 ejaculations are required to clear the viable sperm from the reproductive system, usually it takes a few months before sterility is complete.
A semen analysis is done about six to twelve weeks after the surgery to ensure that no live sperm remain in the semen. The semen is usually collected at home in a small jar and delivered to the doctor’s office where it is examined under a microscope. A second semen analysis is usually performed again about four months after the vasectomy. The patient is considered sterile only when there is no live sperm in his semen. The presence of non-motile sperm presents no problem.
The primary reason for vasectomy failure occurs when the cut ends of the vas deferens reconnect through a process known as spontaneous recanalization. This is very rare but may occur if a sperm granuloma and its resultant interconnecting channels form a new route for sperm to move from one cut end of the vas deferens to the other. Recanalisation has been known to occur as soon as a man has achieved a zero sperm count and as late as 17 months after vasectomy, but the overall risk for recanalization is only about .025% or one in 4,000 vasectomies. This natural vasectomy reversal can occur regardless of the type of vasectomy surgical procedure. Men should have a follow-up examination a year after the procedure to be sure that there are no residual or new sperm.
Future ChangesThose considering vasectomy should consider whether recent changes or stresses (an illness, temporary financial crisis, death in the family, or birth of a child) rather than rational, long–term consideration, are influencing a decision about permanent contraception. Vasectomy should not be thought of as a way to cope with short–term problems. Experts recommend that couples wait for a while if they face such situations or that they seek marriage counseling or psychotherapy to be sure that they are not making a decision they will regret later.
Before deciding on a vasectomy, the patient and his partner should be clear about their reasons for going through with the procedure. The couple should consider all scenarios for possible future life changes. If the man changes his mind after a vasectomy, he will have to undergo a major operation to reverse the procedure with no guarantee of restoring his fertility. The couple needs to consider how they would feel if their current relationship ended, either by divorce or the wife’s death.
In such cases, the man might find a new partner who wanted a child by him. What would happen if one or more children died? If financial stress is triggering the decision for a vasectomy, would improved affluence make a difference in determining the desire for children? Age is also a factor, for many young men who still have many major life changes ahead of them, vasectomy is probably not a wise choice.
Is Vasectomy the Appropriate Choice?Worldwide, more than 30 million couples use vasectomy as a method of birth control. The great majority of men who seek a vasectomy have been married for 10 years or more and have a stable relationship. Some reasons for a vasectomy include are having all the children the couple wants, not wanting or able to use other methods of contraception, a health problem in the woman that makes pregnancy unsafe, a genetic disorder, or a desire to enjoy sex without fear of unwanted pregnancy.
Even if all these factors are present, a couple must consider their options carefully before proceeding, and both partners should completely agree that they no longer want to have children. After deciding that permanent birth control is the best solution, the couple has the option of either vasectomy for the male or tubal legation for the female partner.
Studies indicate that between 5% and 10% of men have regrets after vasectomy. Men should not make the decision frivolously. Vasectomies may not be right for those who are unsure about having children in the future, whose current relationships are unstable or going through a stressful phase, who are considering the operation just to please their partners, or who are counting on having children later on either by storing sperm or surgical reversal of their vasectomies.
Long–Term RisksLong–Term Testicular Pain. Research has indicated that up to a third of men have some pain that lasts longer than three months. The source of the pain is not fully known. Some experts believe there are two specific causes. scarring from the surgery and obstruction of part of the epididymis that causes another section to widen. Some believe that granulomas may cause more chronic pain than generally believed, but others point out that open–ended procedures, which actually stimulate granuloma production, result in less pain than closed–ended techniques.
It is not yet known if no–scalpel techniques will further reduce this complication. Many physicians believe that in most cases it is probably caused by pinched nerves. Surgery, including removal of the epididymis and surrounding tissue, may be required if more conservative measures fail. A surgical procedure that blocks nerves in the sperm cord can bring relief in severe cases. Surgery to reverse vasectomy also may relieve pain in men who have the procedure for this purpose.
Vasectomy & Prostate CancerLong–term high–normal levels of testosterone are associated with an increased risk for prostate cancer. Because testosterone levels remain higher for a longer period in men who had vasectomy, experts have been concerned that such men have a greater chance for developing the cancer. Studies investigating the relationship between vasectomy and prostate cancer have been conflicting. Research on the relationship with prostate cancer is continuing, although if any link is found, it is likely to be very weak. Men with a family history of prostate cancer should discuss the risks and benefits of vasectomy with their physicians.
Immune System ChangesVasectomy is known to provoke immune system changes. Because sperm continue to be produced after vasectomy but disposed of in the body, the patient’s immune system may recognise them as foreign proteins and produce anti–sperm antibodies. Up to two–thirds of vasectomised men develop antibodies that get attach to the sperm and interfere with the sperm's motility (ability to move).
Infections in the genital tract, such as orchitis or sexually transmitted diseases, increase the risk for anti–sperm antibodies. Experts are concerned that changes in the immune system might cause damage in other parts of the body, including hardening of the arteries, blood clotting, kidney disease, and arthritis. Two major studies of large groups of men, however found no significant risk to a man’s overall health. Most medical experts, including special panels convened by the National Institute of Health and the World Health Organization, have concluded that vasectomy is a safe procedure.
Kidney StonesStudies are indicating that men younger than their mid-forties who have vasectomies have twice the risk for kidney stones as their peers who have not had vasectomies. The increased risk persists for up to 14 years after the operation. Kidney stones are not life threatening but they can be extremely painful, and just to be on the safe side, men who have had vasectomies should drink plenty of fluids to help prevent them.
OsteoporosisThere has been some concern that vasectomies increase the risk for osteoporosis in men. One study, however, found no higher incidence of bone loss in vasectomised men.
Heart DiseaseAnimal research has suggested that heart disease accelerates after vasectomy, but one study on men who had vasectomies found no significant increase in risk for angina even over the long term.
Psychological Reactions and Long–Term Dissatisfaction. Most men who have vasectomies feel relieved that the worry about pregnancy is over, and most couples respond well to their new–found contraceptive freedom. About 30% of couples report that they have sex more often following vasectomy, enjoy it more, consider their marriages stronger, feel healthier and more relaxed, and have no regrets about the operation. Younger and older couples, with or without children, were all equally likely to have favorable reactions to vasectomies.
Some men go through a brief period of self–consciousness, wondering whether others notice some difference in their masculinity. About half of vasectomy patients keep their operations a secret. They may believe that the operation is tainted by the stigma of emasculation and that knowledge of it would degrade them in the eyes of their friends and family. For most men, this tentativeness passes quickly. In a few men, however, problems of poor self–image persist and require counseling. Some men may experience depressed and angry emotions similar to mourning over the loss of their reproductive ability. These negative feelings usually resolve over time as the patient moves on to the next stage of his life. A small percentage of couples experience serious difficulties with the adjustment. Their emotional distress most often manifests itself in sexual dysfunction, such as impotence, premature ejaculation, or painful intercourse. In such cases, however, the vasectomy is probably the catalyst but not the cause of such extreme reactions. Studies have indicated that men who experienced impotence after vasectomy were more likely to have female partners who were unable to accept the operation.
Other forms of Contraception
Contraceptives for MenWithdrawal: Withdrawal before ejaculation is a form of natural contraception, but it is extremely risky and most people find it unsatisfactory Condoms. The only other form of male contraception currently available is the condom. The average rate of pregnancy for couples who rely on condoms for protection is 12%. Even for those who use a good–quality condom correctly, the annual risk for pregnancy is 3%. When the condom is used with spermicidal lubricants, either foams, creams, or jellies, protection is increased. The spermicidal lubricant also prevents tearing.
Condoms:Condoms made of latex rubber that are contoured for better fit and that contain a spermicide are effective but are less protective than if a man uses a condom and the women a spermicidal vaginal contraceptive. The condom should be put on before intercourse when the penis is erect, long before ejaculation, the male can discharge drops of semen that can cause pregnancy. Even with a vasectomy, men who are not in a monogamous relationship with an HIV–negative partner should always wear a latex condom during sex for protection against sexually transmitted diseases, vasectomy is not protective.
Implants:Implants of levonorgestrel (Norplant) offer another effective, long–term contraceptive option. Like Depo–Provera, levonorgestrel is a progestin and contains no estrogen. Six pellets containing the hormone are surgically implanted beneath the skin of a woman’s upper arm. (a newer system, Jadelle, uses two implants and may prove to be as effective as the Norplant system.) The pellets slowly release progestin, thereby preventing pregnancy even more effectively than oral contraceptive pills. The method has some distressing side effects but they are not common, and only 10% of women request removal. Implants provide 99% effective contraception for five years.
Intrauterine Device (IUD ):The intrauterine device (IUD) is a small T–shaped plastic device that is inserted into the uterus. An IUD’s contraceptive action begins as soon as the device is placed in the uterus and stops as soon as it is removed. It is 97% effective, although within a year some women expel them. They also increase the risk for infection and should be replaced every four years.
Psychological ImplicationsThe word “Sterilization” has a deep emotional connotation for many people. Even though a couple may rationally accept the idea of a vasectomy, it is extremely important for each partner to be as open as possible about any negative feelings they might associate with the procedure. For instance, a woman might believe, incorrectly, that a vasectomy is emasculating, but she might not want to express this idea to her partner. On the other hand, some women may fear that vasectomy may make their partner more attractive to other women and encourage outside affairs.
Some studies have indicated that men with poor self–images, including concerns for their own physical health or sexual ability, are likely to have a difficult time adjusting psychologically to vasectomy. Men who have the operation only for the sake of their partner’s health and not because they want the procedure for their own reasons may also have difficulties. Such thoughts on the part of either partner can have devastating consequences on a relationship if they surface only after the procedure has been performed.
Re–operations after a failed VasovasostomyIf pregnancy fails, in some cases, a repeat operation may be effective. Success rates depend on several factors, including the doctor's skill, complications from the original operation, the effects of anti–sperm antibodies, and the time elapsed since vasectomy. Even though tubes are open and sperm is restored in as many as 85% of men, pregnancy rates only average about 30%.
Damage to the epididymis occurs in about 75% of men who request a repeat operation after vasovasostomy failure. This requires an operation called vasoepididymostomy, which creates a bypass around the obstruction. To appreciate the difficulty, one should realize that the epididymis is 1/300 of an inch wide with a wall thickness of 1/1000 of an inch. Microscopic techniques are critical for the success of this procedure and require a surgeon who specializes in them. Success rates are higher for repairing obstructions closer to the testicles because the epididymis is wider in this area.
Assisted reproductive technologies (ART) or intrauterine insemination are available for men who want to conceive children after a vasectomy. For men who have failed vasovasostomy, however, a repeat procedure appears to be less expensive than embarking on fertility treatments at that time. One very effective fertilization technique for men who have had vasectomies or failed reversal surgery is called intracytoplasmic sperm injection (ICSI). In this procedure, sperm are usually taken from the epididymis using a technique called epididymal sperm aspiration (ESA). The procedure injects a single sperm into an egg with the aid of a powerful microscopic and robotic instruments. The fertilized egg is then implanted in the woman. In general, Pregnancy rates are round 20%. Damage in other ducts and small tubes are a major reason for vasoepididymostomy failure. Ultrasound before the operation may be valuable to determine if these abnormalities exist, which would make it unlikely that the procedure would be successful.
Fertility TreatmentsAssisted reproductive technologies are the best approach at this time for men with evidence of anti sperm auto antibodies due to vasectomy or other causes. High doses of corticosteroids may be useful in conjunction with intrauterine insemination for infertile men who show antibodies to their own sperm, although their effectiveness is not proven. It should be noted that these drugs have potentially serious side effects with prolonged use.
Stability in their RelationshipIdeally, the couple should view the operation as a mutual commitment to an already successful marriage or relationship. Good candidates are those men who are part of a couple that considers their family complete and permanent birth control as one method of maintaining the family’s stability. Vasectomy generally is not a good idea if the couple’s relationship is under great stress, it is not a cure for emotional or sexual problems between a man and woman.
What are after–effects?
Postoperative ComplicationsVasectomy is a low–risk procedure and the complications, which occur in about 10% of patients, are usually easy to control.
Immediately Postoperative Pain. All men experience some acute pain in the scrotum after the operation. Acetaminophen (tylenol) with or without codeine is the primary choice for postoperative pain. Aspirin, ibuprofen (advil, Medipren, Motrin, Nuprin) or nap oxen (aleve) or other so–called NSAIDs can cause bleeding and should be avoided. This pain generally disappears within two days, although the patient may feel sore for a few more days.