CIRCLIST - another survey result

Circumcision and the Waterworks - Survey Results
by James Badger

Objectives
This survey was set up in 1997 to look at some of the questions left unanswered from my earlier surveys, which dealt with people’s views on male circumcision and how it affected their sexuality. Some medical issues - including urinary tract infections and balanitis - were included in these surveys, but broader questions relating to urination were not and that was the purpose of the present survey.

Results
Forty-one replies were received, 17 from uncircumcised men and 24 from circumcised men. Ages ranged from 20 to 68. 13 of the circumcised men had been done as infants, the remainder at ages ranging from 9 to 59. The sample could really be divided into three groups - uncircumcised (17), infant circumcisions (13) and adult/childhood circumcisions (11 - almost all done as adults). Uncircumcised men were younger, on average (37) than circumcised. Those circumcised in infancy averaged age 43, while those circumcised later in life were (as one would expect statistically) the oldest group with an average age of 47. Some of this group had been circumcised for a year or less, others for most of their life. Many of them also filled in the foreskin details for their state before circumcision.

21 responses were from the US, another 5 from Canada, 7 from the UK and 4 from Australia. The remaining four were from non-English-speaking countries: Germany (2), Finland and Hungary. Geographical bias in circumcision rates was small, from 40% circumcised in Canada, through 50% in both Australia and the non-Anglo countries, 57% in the UK and 66% in the US. Because responses were solicited from circumcision and prostatitis discussion groups as well as the wider community, adult circumcisees and sufferers from prostate problems were expected to feature prominently in the responses and this was the case.

Uncircumcised men mostly had a fully covered head - 40% had skin just covering the glans, and a surprising 33% had surplus skin in front. The remaining 27% had a partly or totally uncovered knob. Most uncircumcised men retracted their foreskins completely when urinating and many more retracted them partially. 20% did not retract them at all. Their reasons for not doing so seem obscure - one man with a long skin, which he didn’t retract, commented “I feel that covered glans collects pee drops and becomes smelly. I try to clean [my] penis thoroughly during daily AM shower.”. Reasonable enough, but one wonders why he doesn’t minimise the problem by pulling his skin back. However the only topic covered in this survey in which foreskin retraction seemed to be an issue was 'bashful bladder' or paruresis.

It is frequently claimed that circumcision tends to cause narrowing of the urinary meatus (the pee slit at the tip of the penis). This survey showed no sign of this. Those circumcised in infancy had if anything a larger meatus (9mm) than the average (8mm). A meatus shorter than 6mm (¼") was arbitrarily taken as 'small'. Of the seven men with a meatus in the small class only one was circumcised in infancy. One (uncircumcised) had had a formal meatotomy, enlarging his meatus from 3mm to 11mm. The others had sizes ranging from 2mm to 5mm, and almost all indicated that they urinated with a fine stream, showing that meatus size does have an effect on micturition.

Most men urinated between 4 and 10 times in a 24 hour period; 93% of all respondents fell within this grouping. Older men and those who had suffered prostate problems tended to urinate more frequently. The average for prostate sufferers was 8 times a day, while for those with no such problems it was 6 time a day. Looking at the extremes, the 3 men who urinated only 2 or 3 times a day were mostly young - one was 20, another 25 - but the third was 53. Two of the three had been circumcised in infancy - this is more than the sample average but the group is too small for this to mean much. The three who urinated more than 10 times were aged 34, 45 and 60. The 60-year old one might expect to have had some degree of prostate enlargement even if none had been formally diagnosed - almost all the men older than him had suffered such problems. He was, incidentally, the oldest uncircumcised respondent - the 5 men older than him were all circumcised. However I don’t think this is evidence for circumcision promoting longevity! The 45-year old was a sufferer from severe prostate problems. The 34 year old urinated an astonishing 18 times a day (by far the highest figure in the survey) yet reported that he peed in a strong broad stream and had no prostate problems. His working hours were midday to 10 pm, so perhaps he was a barman who had a fair few beers during the day!

If you work normal business hours or similar, or attend school or college,...... This question was partly intended as a check on the accuracy of the daily figure, and in fact some answers failed to tally and a corrected estimate was made of the daily rate (both reported figures and corrected estimate were included in the database). It also gave a look at how some of the problems covered in the survey might affect men in the workplace. Surprisingly, perhaps, 'bashful bladder' sufferers actually urinated more often at work (4 times, on average) than those who didn’t suffer from this problem (3 times). Both groups worked, on average, 9-hour days. (Excluding prostate sufferers made no difference to the figures.)

Needing to get up in the night showed a quite straightforward correlation with overall frequency of urination. Those who answered 'often' peed on average 10 times in 24 hours, those who said 'sometimes' peed 7 times, those who said never, on average, urinated 5 times. There was an equally strong correlation with age - older men had to get up at night more often.

There was also a correlation with circumcision - circuumcised men were, overall, more likely to get up at night. However, this was entirely because circumcised men tended to be older. If we look only at men under 30, we find that four of the 6 natural men sometimes needed to get up at night, whereas the four circumcised men never did.

Urgency is the medical term for 'a short fuse' - having to go straight away once the need arises. Most men (22, or just over half) answered that they could wait awhile, while 12 could wait an hour at least. As one would expect, prostate sufferers tended to be in the former group. Even when adjusted for age, there was no clear correlation with circumcision status. Only three men answered that they needed to go immediately, and they were a very mixed bunch. The only one who was circumcised was a man of 67 with prostate trouble - the type of person one would expect in this group. The others were both uncircumcised, one 38 and the other 21, and urinated no more often than average in the course of a day. One is inclined to suspect urinary tract infections - to which uncircumcised men are more prone - for their marked urgency symptoms. Looking at the other extreme - men who could wait hours if they had to - there were four respondents, two circumcised, two not. One was a 67 year old who actually peed quite often - 8 times a day - so his ability to hold on was evidently not exercised very often. The other 3, who were all much younger, urinated only 4 or 5 times a day.

Eight men had suffered from prostate problems. Half were over 60 - the age at which such problems are common - but the other four were much younger, ranging from 38 to 45. Of these four two were circumcised (in infancy), the other two had foreskins. It doesn’t seem, therefore, that circumcision has anything to do with it. Most had had multiple treatments for the problem. Four had had surgery, four had been treated with drugs, while 5 had tried herbal or other natural remedies. None of these treatments seemed totally successful - most still urinated with a weak or intermittent stream and at least 10 times a day. However, drug and natural therapy had been very successful in one case and surgery in another - both these men seemed to have no recognizable residual symptoms.

Four of the prostate sufferers had experienced retention of urine (inability to urinate) - including the man who was very successfully treated with surgery. There was only one other case of urinary retention, which was a consequence of severe 'bashful bladder' (paruresis) problems. In fact there was a very strong asssociation between paruresis and prostate trouble. 6 of the 8 prostate sufferers also had difficulty using public toilets and three out of the 4 men in the survey who answered "always" to the BB question also had prostate problems. This may suggest that there is a physical component to paruresis - perhaps early, preclinical prostate trouble may help to trigger the problem. However, there are also clear psychological components, as we will see below.

Bashful bladder, or paruresis, had affected an astonishing 25 men out of 41, or 61%. It is hard to believe that this is typical of the population in general, but no BB special interest groups took part in the survey. (I did contact one initially. They declined to participate on the reasonable, but as it turns out illfounded, basis that BB was only peripheral to my survey and they had no grounds to suspect a link with circumcision.)

Four men (10%) said that they always had problems with public urinals, one said often, six said sometimes, seven said rarely. One, while answering the other questions on this topic, didn’t answer this one. Three men described the problem as "a serious difficulty" while 11 said that it was "a minor inconvenience". The problem generally occurred only if other men were present - only two men indicated that they could not use a urinal even when it was empty. Most could urinate successfully if they used a cubicle, though one noted that it had to be sitting down.

Most sufferers coped with the problem by trying again and achieving success - presumably when nobody else was present. The next most popular strategy was relieving themselves elsewhere, not in a toilet, and for some this seemed to be the only answer. Returning home immediately, or holding on until the normal return home, were both used by some men sometimes but were never the only or usual strategy. Trying again to use a urinal without success, losing control and wetting onself, were both uncommon consequences.

Six men in the survey had suffered in the past, but no longer had the problem. They were a very interesting group, since four of them had been circumcised post-infancy and this seemed to have been the key to curing their symptoms. Two mentioned this point quite specifically: “As soon as I was circumcised I became more confident and could pee in a public toilet”, wrote one. This was in the UK where circumcision, though common, is not the norm. The other was from Finland: “I am more confident in relieving myself after circumcision even though I live in a non-cutting society”, he wrote. The other two were in the USA where circumcision had enabled them to conform. Even the two uncircumcised men who had got over their problem without the need for surgery commented that the foreskin was a factor. Essentially getting the ability and/or courage to retract the foreskin when passing water had been a key factor in overcoming the problem (both were residents in the US, where most men are circumcised). “Being uncut and younger did impair peeing but I now retract the skin and can pee freely” wrote one, while the other said that he had avoided public toilets until the age of 17 because of foreskin embarrassment. He now retracts the skin until the flow starts then partly rehoods, and it seems that 'ritualised' behaviour like this can be a key factor in overcoming phobic problems of this sort.

If circumcision and/or foreskin anxiety was so important to those who managed to overcome the problem, what of the others? Eight present or past BB sufferers were uncircumcised and residents of the USA, Canada or Australia, where circumcision is the norm among adult men. There were only two uncircumcised residents of the USA who did not suffer from BB, against five who did! Both uncircumcised Australians suffered from bashful bladder, and neither of the two circumcised ones did. Looking at countries where circumcision isn’t the norm, we find that a circumcised British man attributed his BB to his 'difference': “I think my inability to pee in public is due to being cut but I don’t really know why.” Why should one Englishman find circumcision cures his BB (above) while another thinks it causes it? Age is almost certainly the answer - the former man was born at a time was circumcision was both common and a badge of social status, the latter was born just eight years later when it was much rarer. So being different can clearly be a factor, though as the Finnish respondent showed (above) it is not a simple as that. And seven Americans who were circumcised at birth also suffered from BB. One blamed it squarely on his circumcision: “Yes. Messed up my sexual feeling which somehow resulted in urinary trouble.” It is clear that the situation is more complex. If a man feels bad about his penis he is likely to suffer from paruresis. Feeling bad may be because one is the 'odd one out' but it can equally be because a man feels 'mutilated' by his circumcision, or because he hates his foreskin.

Summary and Conclusions
The survey sample was fairly small and its conclusions can therefore only be indicative. But they do offer some interesting pointers. There is no sign at all that circumcision leads to narrowing of the urinary meatus. There is no connection between circumcision and frequency (or infrequency) of urination, though there is a very wide range in how often men urinate (from twice a day to eighteen times, in men with no reported clinical disorder). Nocturia (the need to get up at night) correlates straightforwardly with frequency, whereas urgency is more variable, but neither correlates with circumcision.

Prostate trouble is not related to circumcision, but does show a very strong correlation with paruresis (bashful bladder). However dissatisfaction with one’s circumcision status was clearly a strong predisposing factor in paruresis and where this dissatisfaction was with being uncircumcised, circumcision appears to provide an effective cure.

James Badger

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