Dudley Seth Danoff's Blog, page 7

Is President Obama Different From The Rest of Us When It Comes To Prostate Cancer Screening?

President Barack Obama recently received a PSA (prostate-specific antigen) test to screen for prostate cancer during his yearly physical examination. Dr. Jeffrey C. Kuhlman, White House physician, released a report dated October 31, 2011, which said that the test was performed after the president made an "informed patient request."

I find it interesting that the president asked for the test, since the U.S. Preventive Services Task Force (USPSTF) recently recommended against PSA-based screening for prostate cancer in a recommendation statement that concludes that "there is moderate certainty that the harms of PSA-based screening for prostate cancer outweigh the benefits." Yet according to Dr. Kuhlman's report, the commander in chief felt that the screening was important enough to ask for the test personally. Perhaps President Obama realized that the USPSTF report was flawed, as most urologists and oncologists treating thousands of cases of prostate cancer believe. Perhaps the president was aware that there was no oncologist or urologist on the task force, or perhaps he was aware that, since the advent of PSA screening, the death rate from prostate cancer has been reduced by more than 40 percent.

This statistic leads me to ask, if the president of the United States, who has the country's best doctors and most current information at his disposal, chooses the PSA test, why shouldn't all men have the same choice?

President Obama is fortunate to have the means and knowledge to ask his doctor for a PSA test. If the USPSTF recommends against the test, millions of other men might not be so lucky. We all admit that the test is not perfect, but it is currently the easiest and least expensive method of detecting prostate gland abnormalities.

The key is to preserve patient choice and to prevent a government agency from stepping between a doctor and his patient when making decisions about prostate health. What is good enough for the commander in chief's health should be good enough for the health of all American men.

The Gold Standard: Robotic Surgery for Prostate Cancer Cure

For those men diagnosed with "aggressive", organ-confined carcinoma of the prostate, and who are candidates for surgery, the robotic-assisted laparoscopic prostatectomy is now the Gold Standard.

The use of this technique has increased dramatically, from approximately 9,000 such procedures done in 2004 to more than 66,000 in 2009, according to data presented at this year's meeting of the American Urologic Association.  The projected use of this technique is accelerating rapidly.

Both patients and surgeons are gravitating to this technique because there is no significant incision.  Therefore, there is less pain, little, if any, blood loss, and a more rapid return to full and normal daily activities.

Utilizing the daVinci robotic system at Cedars-Sinai Medical Center in Los Angeles, our team at Tower Urology has refined our nerve-sparing, continence-preserving technique to allow patients to be discharged from the hospital generally within 24 hours of their surgery with minimal post-operative pain.

What is unique about the daVinci robotic system is the enhanced manual dexterity the surgeon can employ, rotating the robotic arm 360 degrees (compared to a maximum of 180 degrees without use of the robotic arm), and angulating the instrument to permit minute dissection in areas not accessible with standard laparoscopic or open surgical techniques.  This makes possible a more precise attachment of the bladder neck to the urethra after the prostate is surgically removed, and better preserves the mechanisms of continence and potency, when compared to open or non-robotic assisted laparoscopic techniques.

The improvement in outcome has been dramatic!  The key to success is finding the experienced surgical team operating at a world-class, state-of-the-art facility.

Let's Put an End to the Confusion about the Prostate Cancer Screening Blood Test

Based on my more than 35 years of experience in urologic oncology, and having treated more than 10,000 men with prostate cancer, I recommend that if you are a male between 40 and 70 years old, you should get an annual prostate-specific antigen (PSA) blood screening test and a digital rectal exam (DRE).

If either of these tests is abnormal, consult a urologist you can trust. Further testing, which might include a CT scan, an MRI, and a bone scan, as well as a review of your medical condition—taking into account any problems such as hypertension, diabetes, or coronary artery disease; lifestyle; sexual activity; anxiety level; and accessibility to a center of excellence for the treatment of prostate cancer—must be weighed and considered.

If you have a positive family history for prostate cancer (a male relative with prostate cancer) and/or you are an African-American male over the age of 40, it is even more imperative that you get a PSA screening test, as the incidence of aggressive and potentially curable prostate cancer is far greater in these groups.

In addition, if you have already been diagnosed with prostate cancer or are being treated, regular PSA testing is essential and can help your physician determine if the cancer is under control or if it is progressing and requires further treatment.

The US Preventive Services Task Force was blatantly wrong when it recommended that healthy men should no longer receive PSA blood tests as part of routine cancer screening. The reality is that PSA screening, when properly interpreted and integrated into a comprehensive prostate cancer screening protocol, saves lives.

The argument against PSA screening is that it cannot tell the difference between fast-growing and potentially lethal prostate cancer and slow-growing, innocuous prostate cancer. However, no other test at present can do this more effectively. The PSA test is the best that we have and must be used, along with other data, to determine if and when treatment is indicated if a diagnosis of prostate cancer is made. Prostate cancer is a silent disease. Without PSA screening, there is no way to find the majority of organ-confined, early-stage, curable prostate cancers. We are still searching for a better test, but at this time none exists.

Another argument against PSA testing is that many (if not most) prostate cancers discovered are typically so slow growing that they will have no impact whatsoever on a man's life. The reasoning is that everyone dies of something, so it is better to die with prostate cancer than of prostate cancer. It is true that, given the relatively large number of men that are screened for prostate cancer, relatively few will die of this disease. But what about aggressive or multifocal cancers of the prostate that are diagnosed at an early (curable), organ-confined stage and that are amenable to safe and effective treatment? Remember, prior to the PSA era, more than 42,000 men died in the United States of this disease each year. Since the advent of the PSA screening test and its wide implementation, the number has dropped by more than 44 percent.

For men over 75 years of age, many groups recommend no PSA testing, assuming that the patient's actuarial life expectancy is less than ten years. However, there is no doubt in my mind that today's 75 is the 65 of the 1990s. When I started in practice, it was rare to see a functional 100-year-old man in my office. In 2011, I see three or four each month, some surprisingly fit and active.

The takeaway message regarding PSA testing for prostate cancer screening is this: It is an individual decision between the patient and his doctors and should be one of many factors mixed into a formula that dictates treatment or no treatment. This is not a decision that should be made by a government task force based on cost cutting and potentially biased analysis.

 

What to Do about the PSA (Prostate Cancer Screening Blood Test)

As mentioned in my last post "Controversy Over a PSA Blood Test" a virtual firestorm has erupted with the publication of the US Preventive Services Task Force draft recommendation that healthy men should no longer receive a PSA (prostate-specific antigen) blood test to screen for prostate cancer because "the test does not save lives overall and often leads to more tests and treatments that needlessly cause pain, impotence, and incontinence" (Gardner Harris' front page article "U.S. Panel Says No To Prostate Test For Healthy Men," NY Times, October 7, 2011).

It is well known that the PSA blood test is an imperfect test. However, it is the best one that we have available for early detection of prostate cancer at a stage that is curable, particularly in men ages 45 to 65. This test should not be rejected out of hand because we do not have anything to take its place.

The Prostate Cancer Foundation (PCF), the world's leading philanthropic funder of prostate cancer research, was founded in 1993 and has raised more than $475 million. It provides funding to more than 1,500 researchers at nearly 200 institutions in 12 countries. PCF advocates for greater awareness of the need for prostate cancer research and greater patient participation in research. In response to the task force's stance against PSA screening, PCF has made some specific recommendations, which include the following:

1. PSA routine screening should be continued, after the patient is informed of its limitations, until the American Urologic Association clinical guidelines on PSA screening are issued and disseminated. PSA screening is not treatment.

2. The decision to have a PSA test or not should be made between a man and his personal physician based on the man's age, symptoms, family history, and concerns about prostate cancer.

3. The process of informed patient decision making both prior to and after PSA screening in healthy men should be encouraged.

4. Research should be intensified by the National Cancer Institute with a focus on better early detection tests for lethal prostate cancers.

Hopefully, these recommendations will encourage new public-private research partnerships between the American Cancer Society, the American Urologic Association, the National Cancer Institute, and the Prostate Cancer Foundation. These types of public-private partnerships have the potential to accelerate the discovery, testing, and validation of new biotechnologies for lethal-cancer detection that are superior to PSA screening. Until a new test is developed, however, prostate cancer screening is best served with the continued utilization of the PSA blood test.

The U.S. Preventive Services Task Force report has clearly created a heightened awareness regarding the shortcomings of the PSA test. Certainly, the one positive result would be to encourage the development of a more precise prostate cancer screening blood test. Until that day, the baby should not be thrown out with the bath water. It should not be forgotten that in the pre-PSA era, approximately 80 percent of the patients who were diagnosed with prostate cancer were already in advanced stages of the disease with metastases.

Today, the number of patients who are diagnosed with metastatic disease at the time of initial diagnosis is about 20 percent. Finally, in the past 15 years (the PSA era), the death rate has been reduced from approximately 40,000 men annually to 30,000 men annually in the United States. Screening is the best way to ensure that these trends continue.

Controversy over a PSA Blood Test: The Real Story

Controversy over a Key Prostate Cancer Screening Blood Test (PSA): The Real Story

Earlier this month, the US Preventive Services Task Force recommended that healthy men should no longer receive a PSA (prostate-specific antigen) blood test to screen for prostate cancer as part of routine cancer screening. This has created an uproar in both the urologic community and the medical community at large. It is a decision made by a panel that does not include a urologist or an oncologist.

The task force is headed by Dr. Virginia Moyer, professor of pediatrics at Baylor College of Medicine, who said in a recent NY Times article, "This test cannot tell the difference between cancers that will and will not affect a man during his natural lifetime. We need to find one that does."

It is widely known that the PSA blood test is not a perfect test. Its main shortcoming is that it cannot differentiate between "aggressive" prostate cancers, which can kill you, and "lazy" prostate cancers, which can be treated with watchful waiting or active surveillance.

The most recently updated study from Sweden "The Goteborg Randomized Population-Based Prostate Cancer Screening Trial (reference Hugosson, J., Carlsson, S., et al., Lancet Oncol 2010, Aug; 11(8)..725-32) found that with screening, deaths from prostate cancer dropped 44 percent over a 14-year period, the same period of time in which the PSA test has been widely used by urologists and oncologists for routine cancer screening. Full article, here.

Although the incidence of prostate cancer has remained stable for the last 20 years with about 230,000 cases per year being diagnosed, the death rate from prostate cancer has decreased with early screening. Those of us who are active in the field of prostate cancer in both screening and treatment attribute this directly to our ability to make an early diagnosis of prostate cancer, which is virtually impossible without PSA screening. Before PSA testing, more than 40,000 US men died annually from prostate cancer.

One would expect that this total would rise sharply because of the growing population of aging baby boomers over the same time frame. Instead, deaths have dropped to about 30,000 per year. The key is early diagnosis. Of course, it is true that we now use more advanced therapeutic modalities, including da Vinci robotic nerve-sparing radical prostatectomies, advanced radiation therapy techniques, and chemotherapy. But without the early diagnosis made possible by PSA screening, none of these advances would be applicable.

Prior to PSA testing, 80 percent of all prostate cancers had metastasized—that is, gone beyond the capsule of the prostate—at the time of diagnosis. Screening PSA has changed all that.

It is important to remember that the PSA test is only one small piece of the puzzle with regard to the early diagnosis and potential treatment of prostate cancer. Many other factors—such as pathology, stage, medical condition of the patient, comorbidities (other medical problems), sexuality, life expectancy, and lifestyle—must be taken into consideration when approaching the treatment or non-treatment of prostate cancer. PSA screening is not treatment.

The decision on whether or not to have a PSA test cannot be made by any governmental agency or task force but must be made between a patient and his doctor on a very individual basis.

We must rely at the present time on the PSA blood test, imperfect though it may be in predicting the "good" from the "bad" cancers. It is still an essential tool for early diagnosis and treatment. Should the new task force recommendation be followed, there is no doubt that the government (Medicare, for example) will save money, but it will undo 20 years of progress and will result in the needless deaths of thousands of men, particularly between the ages of 40 to 65, who could be diagnosed with early and curable prostate cancer.

 

It's A Real Deal: Free Prostate Cancer Screening Exam

IT'S A REAL DEAL: FREE PROSTATE CANCER SCREENING EXAM

September was Prostate Cancer Awareness Month, and most hospitals, whether they are community hospitals, for-profit hospitals, or university hospitals, were offering free prostate cancer screening examinations throughout the month. This is not only a good deal but a big deal, as more than 240,000 new cases of prostate cancer will be diagnosed in the United States in 2011, according to the National Cancer Institute. In this country, prostate cancer is the most common cancer diagnosed in males and the second most common cause of death in men from all cancers. The importance of screening and early diagnosis cannot be emphasized enough. Early diagnosis and treatment are the key to a cure and long-term survival.

The prostate cancer screening examination is simple and straightforward. It requires a blood test called the prostate-specific antigen (PSA) test and a digital rectal examination (DRE), in which a doctor gently inserts a gloved finger into the rectum and examines the prostate for nodules, firmness, irregularities, asymmetry, lumps, or bumps. This screening examination should be done annually for all men over 40 years of age. It is especially important for African Americans because the incidence of prostate cancer is highest among this group.

At the time of diagnosis, if the prostate cancer is confined to the prostate gland itself and has not spread to any adjacent or distant organs, the treatment of choice today is laparoscopic da Vinci robot-assisted nerve-sparing prostatectomy, as long as the patient has an actuarial life expectancy of greater than ten years and no other significant diseases such as severe hypertension, atherosclerosis, or diabetes mellitus.

In addition, many small, localized prostate cancers can be treated by watchful waiting or active surveillance. This requires no surgical, chemotherapeutic, or radiation therapy intervention but merely meticulous follow-up, including yearly exams and perhaps biopsies, to be certain that the disease is not progressive. Indeed, many small, early-diagnosed cancers remain completely localized, innocuous, and nonprogressive. But in order to ensure that we do not "close the barn door after the horse has run out," meticulous surveillance and follow-up are mandatory.

As we often hear on television advertisements, "Take advantage of the free offer." I strongly advise all men over age 40 to find a local hospital that is offering a free prostate cancer screening examination this month and make an appointment as soon as possible. It may save your life.

Dudley Seth Danoff, MD, FACS, is a practicing board-certified urologist with more than 30 years of experience and the author of Penis Power: The Ultimate Guide to Male Sexual Health (Del Monaco Press, 2011) and Superpotency (Warner Books).

 

Staxyn– A New Drug Treatment Of ED

STAXYN—A NEW DRUG FOR THE TREATMENT OF ERECTILE DYSFUNCTION

A new drug that has a unique mode of administration has just been released on the market for erectile dysfunction (ED). Best described as a "breath mint," the tablet is merely placed on the tongue and dissolves in about one minute—no chewing, no swallowing, no absorption through the stomach or intestine.

It tastes good, acts fast, and is extremely effective in producing an erection in a very short time. Sold under the brand name Staxyn, the drug is similar in structure to the previously released oral ED medication Levitra.

Staxyn comes in a standard 10 mg dose, while Levitra, which is absorbed in the stomach, comes in both a 10 mg dose and a 20 mg dose. The beauty of Staxyn is that it can be taken on short notice, can be popped on the tongue discreetly, can be disguised as a breath mint, and produces the same performance-enhancing results as Viagra, Cialis, and Levitra.

The warnings for Staxyn are the same as those for the other three drugs; that is, it cannot be taken with nitroglycerin, and it may produce headaches, flushing, nasal congestion, or dizziness.

In clinical studies, Staxyn was shown to be extremely effective in its ability to achieve erections suitable for intercourse, maintain erections long enough for successful intercourse, and improve overall erectile function.

So there you have it: the new "breath mint" for ED, which tastes good, acts fast, can be taken discreetly, and is as safe as Viagra, Levitra, and Cialis.

Prostate Cancer: The Good News

PROSTATE CANCER: THE GOOD NEWS

This is Prostate Cancer Awareness Month all across America. Prostate cancer is one of the most serious health problems in the United States. It has touched almost everyone by involving either a family member or a friend. More than 240,000 new cases of prostate cancer will be diagnosed in the United States this year. It is the most common male malignancy, and the second most common cause of death from all cancers.

A Bit of History

In the late 1980s, the number of prostate cancer cases detected each year began to rise sharply, due in part to the rising median age of our population, as well as our ability to detect the tumors at an earlier, more curable stage. However, there are no symptoms associated with early prostate cancer. The key to curing prostate cancer is early diagnosis.

The primary tool for early detection is a screening blood test—the PSA (prostate-specific antigen) test. All men aged 40 and over should get a yearly screening PSA blood test, as well as a digital rectal examination by a qualified physician. Heightened public awareness, which makes the early diagnosis of prostate cancer easier, has resulted in an increase in effective treatment and cure.

The PSA Test

There is considerable controversy about PSA testing. It is certainly not perfect. Many factors can elevate PSA levels. Unfortunately, one of them is prostate cancer. In addition, some prostate cancers do not produce PSA and therefore cannot be identified with a PSA test. Though the test is controversial, it is the best that we have. The results can be interpreted by a skilled medical professional and a biopsy can be done if warranted. Many argue that PSA results can be confusing and not conclusive. This is true. As a patient, however, I would rather have a test that may be confusing and controversial than no test at all. Lay the facts on the table and allow me to discuss all the variables and the relative viability of that test with my doctor, and let me, the patient, decide my course of treatment.

Until something better comes along, most urologists think that the PSA test and a rectal examination on an annual basis is still the best approach for the early diagnosis and treatment of prostate cancer.

Early Diagnosis

The most essential aspect of ensuring the preservation of normal life expectancy and high quality of life is the early diagnosis and treatment of prostate cancer. If the cancer is detected while still confined to the prostate, it can best be cured surgically. The approach to treatment varies and is heavily dependent on the extent of the prostate cancer at the time of diagnosis. In general, patients whose cancer is confined to the prostate and who have an actuarial life expectancy of at least ten years are ideal candidates for nerve-sparing surgical removal of the diseased organ.

Today, most active urologic surgeons dealing with prostate cancer utilize the laparoscopic da Vinci robotic surgical technique. In the hands of a skilled, experienced surgeon, this method has an especially good outcome with regard to maintaining urinary continence and erectile function. The enormous success of the laparoscopic robotic technique is based upon an improved understanding of the anatomy and mechanism of the prostate. Another huge advantage of the da Vinci robot is the significant magnification of the operative field and the ability of the robotic arm to rotate and angulate with infinitely more efficiency than even the most skilled surgeon's hands.

In spite of the new and improved technique afforded by the da Vinci robot, surgery is suited only for patients whose cancer is completely confined to the prostate. The key to finding these patients is early diagnosis.

Treatment

Once the diagnosis of prostate cancer is made, treatment is based on the underlying stage of the disease. It is essential to differentiate between prostate cancers that are confined to the prostate and those that have spread beyond the margins of the prostate gland. The development of magnetic resonance imaging (MRI) has revolutionized prostatic imaging and has allowed us to visualize the internal architecture of the prostate. We can now map all the fatty connective tissue around the prostate, including the neurovascular bundles, the vessel complexes, and the regional lymph nodes, to make a precise diagnosis.

In appropriately selected patients, laparoscopic da Vinci robotic-assisted radical nerve-sparing prostatectomy can provide a disease-free survival rate comparable to the expected survival rate of similarly aged, healthy men. With early diagnosis and appropriate surgical treatment by a skilled team, even young men diagnosed with prostate cancer can look forward to living full and rich lives.

Non-Surgical but Effective

Although we have discussed the surgical treatment of prostate cancer, a number of other options are available for the treatment of prostate cancer, each with negative and positive features. All treatment options must be shared with the patient, and the decision-making process must flow freely between the physician and the patient.

Briefly, other treatment options that can be considered when a patient is diagnosed with early prostate cancer include pinpoint external beam radiation (also known as intensity-modulated radiation therapy or IMRT) and the implantation of radioactive seeds. Even for patients with more advanced cancers, including cancers that have spread beyond the confines of the prostate gland, there is still a lot of hope for fully curing the disease. These patients may not be suitable candidates for surgery, but there are well-established treatments utilizing hormonal manipulation, radiation, and chemotherapy, often in combination, that offer excellent results.

Prostate Cancer Awareness Month

During Prostate Cancer Awareness Month, patients should educate themselves as much as possible about the disease. Patient awareness not only makes the urologist's job easier but also allows patients to assume a proactive and participatory role in the treatment process. There is no doubt in my mind that screening PSA blood tests in conjunction with standard digital rectal examinations dramatically increases the detection rate of early prostate cancer. Remember, early prostate cancer is rarely symptomatic.

There is no way to actually prevent prostate cancer—not by changing our diet or activity nor even by picking our parents wisely (although this helps). We must look to early diagnosis to beat the deadly potential of this disease. That way, if you are unfortunate enough to be a victim of the disease, you can survive and live to an old age and, in the end, die of something else. I have thousands of patients in my clinical practice who have lived long and productive lives with prostate cancer and have not died of prostate cancer.

The good news is that, provided the diagnosis of prostate cancer is made early enough to allow maximal effective treatment, life after prostate cancer and surgery, or other treatment options, can be full, rich, and rewarding, and a man can continue to be continent, sexually active, and vigorous in all areas of his life.

For more information: http://www.prostatehealthguide.com/.

Dudley Seth Danoff, MD, FACS, is a practicing board-certified urologist with more than 30 years of experience and the author of Penis Power: The Ultimate Guide to Male Sexual Health (Del Monaco Press, 2011) and Superpotency (Warner Books).

 

 

Anal Intercourse

ANAL INTERCOURSE: WHAT'S THE REAL DEAL?

I was being interviewed on a call-in radio show originating from Albuquerque, New Mexico, a few days ago and was quite surprised that several listeners asked questions about anal intercourse. I am no moralist nor arbiter of human sexual behavior and, in general, follow the principle that behind closed doors, anything goes between consenting adults—as long as the behavior is safe and no person is injured. Along these lines, I must emphasize an important caveat: I draw the line at unprotected anal intercourse.

Risky Business

Anal intercourse is highly risky, even with the use of a condom. I am surprised at how many heterosexual couples experiment with this practice and how many enjoy it. Some are simply looking for new thrills; others, interestingly, are looking for an alternative to vaginal intercourse due to religious or cultural reasons.

This issue has especially come to my attention in the last 30 years because people who practice anal sex, or are tempted to, have become increasingly concerned about HIV/AIDS. As a physician, I must confirm that their concern is justified. It is no longer safe to think of anal intercourse as an occasional treat. HIV/AIDS is arguably the bubonic plague of the 21st century. All studies indicate that a primary mode of transmission is through anal sex. The anus is particularly vulnerable to tears in the delicate tissue membrane, which expose the perianal blood vessels as a port of entry for the deadly retrovirus. Unprotected anal sex should be off limits on the basis of the HIV/AIDS risk alone.

In addition, couples indulging in the practice should be aware that it brings other health risks as well. If the penis enters the rectum and comes in contact with fecal matter (which contains toxic bacteria, particularly E. coli), this can cause major infections in the prostate, bladder, or kidneys. If the infection spreads into the bloodstream, it can result in sepsis, an infection that causes the body's immune system to attack the body's own organs and tissues. Sepsis can be fatal. In addition, if the penis is inserted into the rectum and then inserted into the vagina, it can contaminate the nearby urethra with fecal matter and cause severe bladder  and urinary tract infections in the female.

So the bottom line is, when it comes to anal intercourse, BE CAREFUL!

 

Circumcision

To Be Or Not To Be–Circumcised, That Is!

Let's cut right to the chase. From a urologist's perspective, it is better (on balance) for a newborn male to be circumcised than not to be. There are many specific reasons for me to draw that conclusion, but more about that in a moment. In order to make a rational decision regarding neonatal circumcision, yes or no, one has to put aside a plethora of emotional, moral, ethical, cultural, and religious "biases."

Health & Safety

Let's talk first about safety. Circumcision is the most common "surgical" procedure performed in the USA. More than 20 percent of the world's male population is circumcised. Complications are rare.

In its most simplistic form, it is all about hygiene. If an uncircumcised man does not regularly retract the foreskin and wash underneath it, the natural secretions from the skin can produce a smelly, cheesy substance known as smegma. Lack of cleanliness can lead to irritation, pain, and even infection. Many women complain about the odor that results from a man's failure to wash frequently and thoroughly under the foreskin.

HIV Prevention

Generally speaking, circumcision remains a healthier choice. Uncircumcised men have a vastly greater chance of getting penile cancer. In fact, cancer of the penis, which is rare in any case, is virtually unheard of among circumcised men. Recent studies of AIDS prevention in Africa suggest that male circumcision can reduce the chance of HIV in men and perhaps in women. The validity of this theory is still being tested. Research shows that cells on the underside of the foreskin are prime targets for the virus; tears and abrasions in the foreskin serve as easy points of entry for the retrovirus. Studies have estimated that circumcised men have a greater than 40 percent lower risk for HIV infection. I think it is fair to conclude that circumcision for men should be promoted at least with regard to HIV prevention.

Assuming a man reaches puberty uncircumcised, I do not recommend adult circumcision unless the foreskin is problematic—meaning it is not easily retracted. Other medical problems such as persistent irritation, infection, rash, or even moderate difficulty in retracting the foreskin for cleaning may justify circumcision in the adult.

Another legitimate reason for circumcision in an adult male is if a man's sexual partner requests that he have one as a matter of personal preference.

With regards to penis health, the importance of hygiene, particularly in uncircumcised males, cannot be emphasized enough. If an uncircumcised male has a foreskin that is easily retracted and meticulously cleaned, the likelihood of problems is reduced. Interestingly, in the Scandinavian countries, where very few men are circumcised but meticulous penile hygiene is taught, practiced, and promoted, the incidence of penile cancer and other such problems is extremely low. It is all about genital hygiene, a retractable foreskin, and meticulous attention to genital cleanliness.

Penile Sensitivity

The concept of penile sensitivity is always added to the mix in the debate for or against circumcision. There are no scientifically controlled experiments regarding the sexual performance of circumcised versus uncircumcised men. Based on my clinical experience, there is no difference. Some people assume that a circumcised man has greater sensitivity because he has no foreskin covering the glans. Others believe that an uncircumcised man has greater sensitivity because he has a foreskin. Neither theory is true. The fact is that the foreskin retracts when an uncircumcised man has an erection. So in the aroused state, the penises are virtually the same.

In the final analysis, all bets are off if the adult foreskin is tight, non-retractable, or problematic. That adult needs a circumcision as soon as possible. In spite of that admonition, the debate goes on.