Selected Passages from Schöberlein
Original German text
DR. MED. WERNER SCHÖBERLEIN
The Significance and Frequency of
Phimosis and Smegma
Münchener Medizinische Wochenschrift 7. pages 373-377 (1966)
Summary: 3000 young men, most of them between 18 and 22 years old,
were medically examined. The relationship between the prepuce and
the glans penis was examined and the frequency of smegma was recorded.
In 8.5% no prepuce was present, among approximately half of these
there had been no previous operation. A phimosis was determined among
8.8%. Smegma was found among 19.2%, including a 'large amount' among
a 1/3. A comparison of the education and occupational groups of these
young men revealed no difference in the frequency of uncleanliness.
A hypospadie was found in 0.37%.
"Today cancer prevention is still a problem, however tomorrow the
main concern will be the fight against cancer" (K. H. Baüer,1).
Despite all progress with diagnostics and therapy, the percentage
of deaths due to cancer constantly increases, from 13,5% (1935) to
20,04% (1961) (1). Part of cancer prevention concerns the recognition
and elimination of cancerous materials. No more doubts exist about
the cancerous effects of tobacco tar derivatives related to lung
cancer (1, 39). Just as undisputed, but admittedly less known, is
the cancerous effect of smegma (1, 3, 15, 19, 23, 24, 29, 33, 39).
Penis cancer is observed in Europe and North America in 1-3% of
all male cases of cancer (1, 4, 6, 17, 19, 21).
In the USSR in recent years 0.5 to 1% of male cancer cases were
registered as penis cancer (33). In North Vietnam 15.6%, in India
up to 25.6% in China 15.8 to 18.3% and in Siam 22.0 to 33.0% of the
male cases of cancer are penis cancer (1, 23, 33).
Thierch (1865) described the continuous friction of a phimosis
as a cause of penis cancer and Czerny (1899) determined, that
circumcision against penis cancer "immunised and encourages thorough
cleanliness and removal of preputial secretions" (7, 37). Many authors
later confirmed that penis cancer occurs practically only with phimosis
(1, 6, 11, 17, 18, 20, 23, 31, 32, 38).
The observation that there is no penis cancer among the circumcised
Jews is further proof of the causal connection between prepuce, smegma
and penis cancer (1, 4, 21, 31).
The ever recurring idea that this concerns a Jewish race immunity
(18), can be disproved by investigations in different countries and
among other peoples. In India among 2260 cancer patients, penis cancer
was found among uncircumcised Hindus in 25.6% cases, in contrast
among the circumcised Muslims only 2.9% (25). Marchionini confirms
this ratio for the Islamic population of Turkey (23). In 1964 it
was reported in Kazachstan, that among 87 cases of penis cancer only
4 (4.6%) were found among the Muslims who circumcise at the age of
4 - 6 years, however they constitute 36% of the population. This
difference can only be explained by circumcision. However the later
this is performed, the smaller is the protection against the occurrence
of penis cancer. Cancer has a characteristic time of latency even
in this area (1, 33). Penis cancer, occurs at the average age of
54.5 years and is located 41% on the Glans, 32% on the inside of
the prepuce and 25% at the sulcus coronarius of the glans (collum
glandis: internally. Nomenclature, Paris, 1963) (21).
This fact is explained by a cancer stimulating agent within the
preputial room: smegma, which is composed of degenerated fats, rubbed
off and dead epithelial cells and not the secretion of any glands.
Stieve could find glands neither on the surface of the glans nor
on the inner foreskin. There are no tallow glands there (35). Smegma
production occurs among newborns and reaches its high point during
the teenage years (33).
The embryonic development of the prepuce begins in the 8th week
as the epithelium sinks into connective tissue at the base of the
glans. Thus a fold forms, which extends up until the 5th month as
a fold of prepuce over the glans.
With the growth of this fold, the later epithelium of the glans
and the inner foreskin remain together in a common layer, the glandarlamelle.
Toward the end of the foetal life the central cells of this lamella
begin to disintegrate. Cavities develop and unite forming a common
preputial hollow area (9, 10) This procedure is only rarely completed
at birth and it is unfounded to speak at this stage of anything being
stuck or adhesions. For this condition the term "physiological phimosis"
is particularly used by the pediatricians - coined by Winiwater 70
years ago - (13, 28). This expression is not completely harmless
and should be avoided due to the danger of late recognition of a
phimosis and problems increasing. The process under examination is
the incomplete separation of the prepuce and the glans, which without
active assistance can take place spontaneously up to the 6th month
in 20%, up to the 12th. month in 50%, up to the 2nd year in 80% and
to end of the 3rd year in 90% of boys (10). A phimosis with
the marginal connective tissue narrowing the foreskin opening, should
be recognised early and be operated as soon as possible.
The cancerous effects of smegma could be proven several times so
far in studies on animals (5, 27).
Operationally created phimosis increased the frequency of experimentally
produced penis cancer among Rabbits (33). The observations are interesting
among horses, where due to the abundantly folding foreskin smegma
is found in large quantities and penis cancer occurs particularly
frequently, counting for 23% of all cancer illnesses in this animal
species. Whales, among whom without erection the smegma is not emptied,
become ill with penis cancer ten times more frequently than Studs
Apart from other factors, the cancer encouraging agent smegma is
responsible for cervical cancer among woman (1, 3, 11, 21, 39). Jewesses
become substantially more rarely ill with cancer of the cervix than
non-Jewish women; the relationship uterus to cervical cancer is among
Jewesses 6:1, among non-Jewish women 1:8. This ratio is also confirmed
in all countries where a proportion of the male population is circumcised
"The smegma theory cannot be excluded as the cause of penis cancer
among men, among women it is an important fact" (K. H. Farmer ).
To prevent the effect of this smegma which is recognised as so
dangerous, in the USA for the last 15 years 80-90% of all male newborn
children are circumcised straight after birth. Apart from episiotomy,
which is likewise performed as a preventive measure, circumcision
is the most frequent operation of the American birth aids (2l, 26).
It is usually done with the "Gomco clamp", which in Germany has also
proven to work satisfactorily as a safe and simply performed operation
From a personal report from Wynder (1965) the American insurance
independently honour these preventive measures. The general introduction
in Germany would fail due to this among other reasons, because for
a long time other preventive measures demanded by the medical profession,
for example a general Tetanus immunisation, has so far not been accepted
by any health insurance companies .
In England 24% of the boys up to 4 years old, and at the same time
84% of Cambridge students were found to be without a prepuce. Physicians
and midwives recommend circumcision there. Many Englishmen know the
particularly impressive advantages of circumcision from the colonial
times in India (16). In Germany the results of first experiences
with routine circumcision were published in 1959 (14). 80% of the
previously asked parents decided to give their permission for this
operation, without knowing anything about the value and the meaning
of this operation beforehand. Such open-mindedness was unexpected.
The small operation with the Gomco Clamp did not result in any complications.
In Germany a statement from the medical profession has long been
demanded on the question of the general ablatio praeputii among new
born boys (16, 23, 30). The main argument against a general circumcision
is stated again and again, that this problem can also be resolved
by regular cleaning with soap and water (1, 7, 23, 33).
In order to make an objective evaluation about this statement possible,
3000 young men were given a detailed medical examination of the penis,
the prepuce, the glans, the sulcus coronarius and the foreskin's
retractability. Whether "smegma" was present or even "a lot of smegma"
was registered. The investigations were carried out by Dr. E. Moessmer,
Specialist for Urology in Munich, whom I thank here for his assistance,
and myself, each conducted half of the examinations in order to increase
the objectivity. These were young men from Southern Germany. 2527
(84.2%) were of an age between 18-22 years; the exact breakdown of
the age distribution is shown in tab. 1
(Age 18-22 = 2527 = 84,2%)
In anatomical text books the relationship between the prepuce and
glans is described as normal when the penis is not erect and the
prepuce only partly covers the glans (2). The following 5 different
forms of this relation prepuce : glans were specified by us:
A) Glans and sulcus coronarius lying exposed; prepuce missing or
B) Glans partly covered by prepuce.
C) Glans fully covered by prepuce. prepuce tube or trunk formed,
extends partially. Sulcus coronarius can be completely revealed by
D) Glans covered completely by prepuce. Foreskin opening fibrous
hardened, non-elastic; can be extended by retraction only to a few
mm in diameter. Orificium urethrae and small front part of the glans
can be seen. Revealing the sulcus coronarius not possible. Phimosis.
E) Prepuce covers glans completely. End of the foreskin opening is
completely stiff, rigid. No retraction possible. Glans and orificium
urethrae cannot be seen. Phimosis (rigid).
The results are arranged in tab. 2
Relationship of Prepuce to Glans and Incidence of Smegma.
|A . Glans and Sulcus free - lacking or atrophic
B . Glans partly free, partly covered
C . Glans fully covered by prepuce, sulcus can be laid free
||Smegma in BCD=19,2%
D . Glans covered by foreskin Sulcus can not be revealed,
E . Phimosis rigid no retraction possible
Regarding group A, we found 256 (8,5%) of the examined to be without
a prepuce. Among approximately one quarter of this group, reports
or scars from a circumcision could be established. Among a proportion
of these, the reports were questionable, the question of surgery
was denied among approx. half the young men without prepuce, and
no evidence of an operation could be found. In addition, among a
large percent I received confirmation from the mother that no surgery
had been performed on their son. There is no doubt, that the lack
of, or atrophy of the foreskin occurs spontaneously among approx.
4% of young men.
We defined 1258 (41.9%) of the examined as "B" and found smegma
among 149 (11.8%) of these; among approx.1/3 it was designated as
1223 (40.8%) of the 3000 examined were registered as "C". There
were 297 (24.3%) with smegma and likewise among half "very much"
was noted. In this group sometimes the long, tubular form of prepuce
was found, which has also been called "pseudophimosis" (19). If the
foreskin opening was elastic and retractable, this means the long
foreskin was functional and presented no substantial obstacle to
the possibilities of cleaning.
Due to the histological structure of the prepuce it is to be expected,
that in the course of time in many of these "C" cases the relation
of the glans to prepuce changes and develops into form "B".
Both groups belong therefore together, particularly in view of the
cleaning possibilities. It is clearly noticeable that the smegma
frequency increases with the length of the prepuce (35).
Regarding form "D"; the phimosis with an inelastic, fibrous hardened
preputial opening, where only with effort and under pressure small
front parts of the glans show, we determined this form among 181
(6.0%) of the young men; 64 (35.3%) of whom had smegma, with half
of these classified as "very much". The smegma here can only be partly
removed; it is evidently present, but not always visible.
The condition "E"; the phimosis with a rigid, stiff preputial opening,
without any possibility of expansion and where no glans or orificium
urethrae can be seen, we found this among 82 (2,8%). In this group
smegma is always present, objectively however not ascertainable.
Therefore we registered this group separately to "D".
The phimosis (D + E) gives a total number of 263 = 8,8%. These
are pathological conditions and should be eliminated operationally.
Most of the subjects had not realised the unhealthiness of their
condition. We advised them all to undertake the small operation and
always found a thankful open-minded reception for the explanation.
Also Haller (12) describes, that young men between 20 and 30 years
frequently complain, that the operation was neglected in childhood.
In 1960 Saitmacher (29) studied 229 young men of an age between
15 and 17 years, and found 8.7% had phimosis. Gairdner (10) studied
200 uncircumcised boys between 5 and 13 year old and discovered a
phimosis in 6%, and a foreskin which was only partially retractable
among 14%. Otherwise substantially lower numbers for the frequency
of the phimosis are indicated in the literature; thus Keil (16) quotes
l% and Koester (19) only 0.5 to I%, however without indicating a
source for this figure.
Smegma was found in our investigations among 19.2% of the groups
B, C and D. Saitmacher (29) describes unceanliness of the preputial
area in 33.2% of his 229 young men. Our young men were invited to
the medical examination, thus some had surely washed themselves previously.
When we include group E, among whom smegma production and accumulation
are surely present, and consider the cleaning previous to an examination,
a frequency of 30-35% smegma accumulation is no overestimation among
young sexually mature men.
We determined a hypospadie among 11 of the 3.000 examined (0.37%).
We saw no case of infant "adhesions", better called incomplete release
of the foreskin.
It is often maintained, that genital hygiene is lacking, and general
uncleanliness is found predominantly among the poorer or less educated
sections of the population (19, 22). For this reason our 3000 young
men were categorised according to their education (tab. 3) and their
different occupational groups (tab. 4).
|High school graduates
|1. unskilled assistants,
|2. skilled workers, Craftsman.
|3. Employees, government officials,
middle school without occupation,
|4. high school graduates, Students
Both tables show, that neither the education nor the occupational
group make any considerable difference in the frequency of uncleanliness
(smegma). The social achievement levels examined by us do not correspond
exactly to proportions in the general population. We had less unskilled
workers and the percentage of high school graduates (19,6%) was nearly
three times the proportion of the high school graduates (7,2%) of
the resident population of the Federal Republic of 1964 among the
same age group.
153 (5%) of the 3000 men were married, among these we found only
8,5% with smegma. It is doubtful, whether this is to be explained
with greater cleanliness alone; regular cohabitation appears to help
a form of cleaning.
Up until this time the necessity of regularly cleaning the preputial
area as well as the dysfunctionality of phimosis was mostly unknown
to the sufferers. During instruction about these questions the young
men always showed themselves to be interested and open minded. There
is insufficient sexual education of young men, especially about these
problems, by the parents and by the school and house doctor. This
is primarily due to a taboo, the people around him maintain distance,
feeling embarrassed about instructing the boy on the subject of manipulation
of the glans, and thereby perhaps arousing his sexuality prematurely.
For decades such an education and instruction of young people has
been demanded again and again. Our investigations show however a
quite unsatisfactory picture.
By contrast, in view of the recognised danger of smegma, a general
circumcision of all newborn children, as in the anglo-saxon countries,
would mean a final and simple solution (4, 6, 14, 21). Apart from
the advantages already described like:
a) prevention of penis cancer,
b) probable reduction of cervical cancer, also recognised are:
c) less venereal diseases (23),
d) improvement of the sexual physiology and psychology, by extension
of the length of cohabitation among other aspects (8, 16, 23),
e) allegedly smaller frequency of prostate gland cancer (23),
f) avoidance of balanitis and balanoposthitis, e.g. with lack of
water, during catastrophes, in the tropics or during war (21, 34).
Disadvantages are not known. The operation among newborn children
using modern methods (Gomco clamp) is without danger and risk (14,
Whether and when the decision of the German medical profession
will fall, regarding the already often repeated demand by respectable
clinics recommending a routine circumcision, is uncertain (1, 14,
16, 19, 23, 29, 30). The purpose and intention of this work was the
rare possibility, to systematically examine and report on such a
large number of young men of sexually mature age in this subject
afflicted with so many prejudices
In conclusion then again, without weakening the request for general
circumcision, the urgent demand must be made for sexual education
from the parents, teachers, house doctors, pediatricians, school
and work doctors.
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Anschr. d. Verf.: Dr. med. W. Schöberlein, 8 München
27, Richard-Strauß- Str. 93.
DK 616.662 - 007.274/ - 008.8 : 616 - 006.6
Selected Passages from Schöberlein
Original German text