By Rachel Gelman
In my previous post I talked about the anatomy of the male pelvic floor. The blog stirred up a lot of conversation among readers, with many requesting a part two. So here we are! This time, we’ll take a look at a small part of the male anatomy that comes with a large amount of controversy: The foreskin.
This little piece of skin has inspired a coalition of activists to form called the Intactivists. Known for opposing circumcision, their goal is to educate the world about the benefits of foreskin. They sport T-shirts with witty catchphrases including “Take the whole baby home!” or “His Body, His Choice!” (Feel free to check out all the options and maybe do some early holiday shopping here). All this fuss over an area of the body made me wonder, what’s the big deal over something so small? Why did doctors even decide to remove it in the first place? Why are people fighting so hard to get parents to keep their sons intact? So, I put on my detective hat and went searching for the answers!
First, let’s start with a basic anatomy lesson. Foreskin is a sheath of skin that covers the tip or glans of the penis. It is also called the male prepuce and is homologous to the clitoral hood, which covers and protects the clitoris in women. Foreskin is comprised of an inner and outer layer, with the outer layer being continuous with the skin of the shaft of the penis, while the inner layer is mucosal tissue, much like the inside of your mouth. In uncircumcised boys, the foreskin and glans are fused together at birth, and slowly separates as a boy ages. Once he hits puberty, the foreskin should easily retract (this is also the recommended strategy to keep the glans and area under the foreskin clean). The foreskin attaches to the base of the penis at the frenulum which is an elastic band and helps retract the foreskin during an erection. When the penis is flaccid, foreskin may completely or partially cover the glans. However, when the penis is erect the foreskin will fully retract and look the same as a circumcised penis. So if in the end they both look identical, why should we even care about it?
Well as it turns out, other than covering the glans of the penis the foreskin has several beneficial functions (keeping the glans warm for the winter is still debatable) that you may not be aware of. The foreskin keep the glans moist and well lubricated due to the mucosal nature of the inner layer of skin. When dry skin combines with the skin oils it produces smegma, which is what helps lubricate the glans and some report this added lubrication can help during sexual activity. Some argue that the foreskin is like a little suit of armor for the head of the penis because when circumcised, the penis is exposed to more external stimuli such as clothing, which may cause discomfort or chaffing.
Enter the Intactivists, they believe that this increase in exposure to the glans may lead to decreased sensitivity and sexual pleasure. Furthermore, they also argue that the foreskin is important for sexual function and is considered an important erogenous zone in men. Many believe the foreskin creates a gliding action that aids in masturbation and intercourse to allow for increased sexual satisfaction. Some research has reported increased nerve endings, which are also found in the fingertips and the lips, at the frenulum and in the foreskin itself. However, research continues to be inconclusive. Now you may be thinking what I’m thinking; foreskin sounds great! Why would physicians ever remove it? The answer may lie in tradition.
Circumcision is actually one of the oldest planned medical procedures performed. Mostly associated with the Jewish faith, circumcision is part of a ritual performed shortly after a boy is born. However, many other cultures perform circumcisions for religious reasons or as a rite of passage to signify a boy has become a man, or as a sign of bravery. Circumcisions in America became more prevalent in the Victorian Era as a means to prevent males from maturbating. Doctors also recommended removing foreskin to prevent a variety of conditions including: clubfoot, epilepsy, mental illness, convulsions, tuberculosis and hydrocephalus. I even found records that the military recommended circumcisions in the event soldiers needed to fight in the desert to avoid infections due to sand accumulating under the foreskin.
Some research indicates that circumcision helps reduce STDs and HIV infection rates. However, many of the research was performed in regions of Africa so the data may be skewed. The World Health Organization does continue to recommend circumcision for populations at high-risk for contracting HIV to help prevent the spread of the disease. Finally, many people have their son’s circumcised to prevent certain complications that can occur if the foreskin becomes too tight/can no longer retract and restricts the glans (phimosis) or inflammation and infection of the glans, usually due to poor hygiene (balanitis). As you may have caught on, the Intactivists disagree with this too, and argue that these conditions are rare and can be easily prevented with proper hygiene
Perhaps, the biggest, and what I found to be the most compelling argument from the Intactivists as to why one should not circumcise their son, is because one would not circumcise their daughter. Again, the clitoral hood is the same as the male foreskin. So why is it ok to remove something from one gender, but not the other? The cultural and religious ceremonies that make male circumcision a rite of passage rather than a medical procedure make answering this question more complex, hence the controversy around it. Still, Intactivists argue that a man should be in charge of deciding if he wants to be circumcised, and males should be left intact so that they can decide when an adult.
It is definitely easier to keep a foreskin and decide to have it removed later in life; than to remove it only to have the male want it back. With that said, I found a lot of wild D.I.Y foreskin restoration methods online. I doubt these are on many Pinterest boards, but they made it onto ours! Check them out here: However, I highly advise that one DOES NOT attempt to restore his own foreskin with any of these “at-home” methods. They can easily cause damage to your penis or can result in pelvic floor dysfunction because of the consequences of the suggested strategies (trust me, I’ve seen it happen)!
If getting your foreskin back is something you are really interested in, consult with a doctor to see what options may work best for you. More often than not, men seek out foreskin restoration in hopes of improving their sexual function, but other physiological or psychosocial factors may be the cause of their sexual dysfunction. For some men, it may be more beneficial to work with a sex therapist or a doctor who specializes in sexual medicine. On the flip side, some men may wish to undergo circumcision as an adult due to concerns over the appearance of their penis. However like my pal the vulva, each penis is unique so I recommend embracing what you’ve got, foreskin or not! Besides in the end they all look the same when erect, some just get to sport a nifty turtleneck afterwards.
If you are still super bummed your foreskin is no more, at least know that it most likely went to a good cause. Often the foreskin removed during a circumcision is used for research, to help graft new skin for medical procedures or burn victims or some are used to produce anti-wrinkle skin cream! Man, I love science! So what do you think? Foreskin or no skin? Any guys out there who wish they had or hadn’t been circumcised? I’d love to hear from you!
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Are you unable to come see us in person? We offer virtual appointments!
Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical therapists committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online.
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. The cost for this service is $75.00 per 30 minutes. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
Regards,
Rachel Gelman, DPT
Rachel is a Bay Area native, and currently practices in our San Francisco office. She received her bachelor’s degree in Biology from the University of Washington in Seattle and her Doctorate in Physical Therapy from Samuel Merritt University. Rachel grew up dancing and is excited to have recently returned to the dance studio. Outside of dance, Rachel enjoys going to the gym, discovering new brunch spots and spoiling her adorable niece and nephew.
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.
Comments
So glad to have another post about men. I read all of the posts, male or female, and get so much great info but as a male pelvic pain sufferer, so glad to get info directed at me too. Thanks for that! I’m 43 years old and have been dealing with pelvic pain for 4 yrs now. You’ll be glad to hear I’ve been seeing a pelvic floor PT specialist here in Austin Tx (Erin Arnold) for the last 3 yrs. The work has helped immensely but I’m still on the up and down road to recovery. Dealing with a flare of bacterial prostatitis amongst other issues at the moment. But, pertaining to the foreskin topic. One of my many pains is penis pain sometimes when flaccid, always with erection. While it’s still undetermined as to the root of the pain issue (dealing with more than just the bacterial infection) one thing I have noticed is tight scarring where I assume my circumcision took place, a red lump on the shaft just below the frenulum and an off center scar that goes down the bottom of my penis from the circumcision ring to about mid way down when flacid. The circumcision scar is not painful but there is a noticeable “tight ring” around the penis there when erect. The two other places are both sexually stimulating and painful at the same time-flaccid or erect. The pain starts at the lump or scar and connects through the perineum to the rectum. Any theories about these issues relating to circumcision? Any Therapy ideas about releasing the scar tissue or making these points less painful? Anyone else out there noticed issues with circumcision scars? Any help is greatly appreciated.
Thanks!
Wilson
Hello Wilson,
Thank you for sharing! Have you tried self massaging around the scar? It is difficult to know whether there are any other contributing factors without an evaluation. We recommend consulting with a local therapist for a full assessment.
Best,
Rachel
As a male being uncircumcised, could that be another reason that I have Pfd and penile pain and having infections? I’m afraid of bringing this up to my Pt. This is a great website!!
Hello Anonymous,
Without an evaluation, it is difficult to know for sure. I recommend that you consult with a local therapist for more information.
All my best,
Rachel
I am uncircumcised but I have been keeping my foreskin retracted for several years.
I love the way it looks and feels. The penis is a lot cleaner. By wearing foreskin permanently retracted (autocircumcision), you get the advantages of circumcised and uncircumcised penises at the same time. I think that all boys with healthy foreskins should be educated about skinning back and about the benefits of doing so.
What is your opinion on this matter?
Author Rachel Gelman says:
I get wanting the best of both worlds! However, keeping your foreskin retracted all the time could lead to problems. For instance, the foreskin could restrict blood flow to the glans (head) of your penis and that can be a medical emergency, which may lead to actual circumcision. I would recommend letting your foreskin be, but if you have concerns about appearance or cleanliness to talk to your primary care provider or local urologist for more information.
I’ve experienced both. I got circumcised two years ago in my late 20’s for cosmetic reasons and partners preference. I notice my erections are a lot firmer after getting circumcised. Hygiene is improved. Appearance wise it looks better… I had the urologist go as far back as possible so there is no mobile shaft skin when I’m erect. I also have more intense orgasms from all of the direct stimulation to the head and shaft. As for my girlfriend she loves it, says she feels everything now, extra friction in the right places. I’d say we have sex almost twice as much. I also ejaculate with more force. Wish I would have done this sooner!
What did mean when you said However, I highly advise that one DOES NOT attempt to restore his own foreskin with any of these “at-home” methods. They can easily cause damage to your penis or can result in pelvic floor dysfunction because of the consequences of the suggested strategies (trust me, I’ve seen it happen)!
Author Rachel Gelman says:
There are a lot of forums and sites online that recommend strategies to help “restore” the foreskin. The premise of most of these techniques is to stretch the penis in various fashions. These techniques can lead to over stretching and injury to the nerves and blood vessels in the penis and can negatively impact the muscles and connective tissue in the area as well. Basically, I recommend that a person doesn’t participate in these at home strategies. If someone has concerns regarding their penis they should consult a health care provider, like a urologist.