Australian Family Physician, Volume 27, Issue 5, Pages 381-383. May 1998.
Australian Family Physician, Volume 27, Issue 5, Pages 381-383. May 1998.
There are many conflicting opinions among health professionals and parents regarding care of the normal foreskin in young boys as well as the highly controversial subject of circumcision.
Minor foreskin related complaints are very common in the first few years of life. Most of these can be managed conservatively with advice and reassurance, or with medical treatment alone. Circumcision is very rarely indicated in young boys, particularly under the age of 5 years. The issue of circumcision for non medical reasons, that is, religious, ethnic or personal, remains controversial.
Errol T Simpson, MB, ChB, FRACS, is a paediatric surgeon at 
The Canberra Hospital, ACT. Phillip Baraclough, MBBS, is a general practitioner, Hall Medical Service, Hall, ACT.
During the past 20 years, there has been a progressive reduction in the number of circumcisions performed in Australia for social, religious, ethnic or personal reasons.1,2 Most Australian males over about 20 years of age are circumcised, while only about 20% of boys born in 1995/96have been circumcised.1,2
As a result of this changing social trend, with many adult males circumcised while their sons may not be, many parents and health professionals have a degree of uncertainty in relation to the anatomy and physiology of the foreskin. Consequently, parents frequently receive conflicting advice about a perceived problem with their youngson's foreskin.
At birth, the inner layer of the prepuce is firmly adherent to the glans and is unable to be retracted at all. These adhesions are formed early in foetal development and serve to protect the developing glans.3 Separation of these adhesions occurs slowly over the next few years and there is great variability in the timing of this event. It has been classically stated that the foreskin should be fully retractable by the age of three years. However, this can occur as early as the first few months in some boys and not until 9 or 10 years in others.4 Almost all the perceived foreskin problems in young boysrelate to the existence of subpreputial adhesion.
The term phimosis is broadly regarded as describing a foreskin that is unable to retract. However, it is very important to distinguish between true pathologic phimosis from the normal anatomic situation where the infantile adhesions have not yet separated. In the latter situation, the tip of the foreskin is supple and unscarred and is likely to retract normally and fully in time(Figure 1).
True pathologic phimosis occurs when fibrosis, induration and scarring occur in the tip of the foreskin usually secondary to inflammation or trauma (Figure 2). Phimosis may also be due to lichensclerosus et atrophicus.5,6
Ballooning refers to the swelling of the subpreputial area as urine becomes temporarily trapped under the foreskin during micturition. This probably occurs as a result of the stream being diverted by the adhesions. This phenomenon is not pathologic, usually causes no distress or discomfort to the boy and generally requires no treatment.
Smegma is a creamy yellow sebaceous material that is secreted by the glans and often accumulates in clumps under the foreskin. These are often mistaken for cysts or pus collections, but require no treatment and will release once the foreskin retracts naturally.
Mild inflammatory changes with redness and some discomfort are often encountered in young boys, particularly while still in nappies, as a result of ammonical dermatitis (Figure 3). True balanitis or posthitis is usually staphylococcal in origin and responds well to simple cleaning andappropriate oral antibiotics.
No attempt should be made to retract a foreskin in a child unless significant separation of the subpreputial adhesions has occurred. Failure to observe this basic rule may result in tearing with subsequent fibrosis and consequent true phimosis. However, once the foreskin is able to be retracted, this should be performed every time bathing occurs and the penis cleaned as part of normal male hygiene.
Penile cancer and sexually transmitted diseases have been reported as occurring more commonly in uncircumcised adults.7,8 However, it seems illogical in the extreme to advocate circumcision to prevent these afflictions. Penile hygiene and safe sex education are likely to be far more effective in this pursuit.
Mild redness of the foreskin requires only cleaning., while significant ammonical dermatitis may require some form of barrier cream.
Ballooning and smegma collection require no treatment, unless they are responsible for specific symptoms.
True pathologic phimosis with fibrosis and scarring may result in permanent non-retractability, obstruction to urine flow and recurrent balanoposthitis and constitutes the only reliable absolute indication for circumcision. Lichen sclerosus et atrophicus is a skin disease of unknown origin that affects the genital area of males and causes phimosis, glandular scarring and meatal stenosis.6 It is responsible for about 15-20% of cases of true phimosis in boys requiring circumcision.
In boys over about 5 years of age who have delayed separation of subpreputial adhesions, the use of topical steroid cream will improve the situation in the majority of cases.9 Even some cases of true phimosis may respond to steroid application and this modality is certainly worth attempting for a month or so before considering circumcision.10
Paraphimosis is an acute condition that develops when the foreskin is fully retracted but is then unable to be returned to its pre-retraction situation (Figure 4), with the subsequent onset of swelling and discomfort. This condition requires urgent intervention in the form of manual reduction by applying sustained gentle pressure to the swollen prepuce. This usually requires a general anaesthetic, however, in early cases, it can be achieved with sedation and analgesia alone. It is unusual for paraphimosis to recur and a single episode is not an indication for circumcision.
Balanitis or balanoposhitis, in the absence of true phimosis will usually respond to oral antibiotics or topical cleaning. A single episode of balanitis is certainly not an indication for circumcision and recurrent balanitis in the absence of true phimosis can usually be managed non-surgically, particularly in boys under about 5 years of age.
The Australasian Association of Paediatric Surgeons does not support the circumcision of normal male neonates, infants or children in Australia.11 However, many parents still wish to have their boys circumcised for religious, ethnic, or personal reasons. If these procedures are performed, they should be done after 6 months of age, under general anaesthetic in safe, controlled, appropriate paediatric facilities.
Contraindications to circumcision include hypospadias or other congenital conditions of the penis, sick and unstable infants and a family history of a bleeding disorder.
Virtually the only indication for circumcision in boys under 5 years of age are those who have major structural urinary tract abnormalities, such as posterior urethral valves or significant vesico-ureteric reflux. It is well documented that bacteruria is more common in uncircumcised boys12 and circumcision in some of these children may prevent some of the serious consequences of bacteruria associated with other abnormalities of the urinary tract. However, circumcision is not indicated in boys with normal urinary tracts.
Note:
It is usual for the foreskin to be non-retractable in the early years of life, even up to age 8-10 years. There is wide variability in terms of the age at which retraction occurs. Until complete retraction occurs, episodes of redness, smegma collections and ballooning of the foreskin are very common and can be managed symptomatically. Frequently, reassurance is all that is required.
There are very few medical indications for circumcision and this is particularly true under 5 years of age. Circumcision for non-medical reasons should be discouraged. However, if parents feel strongly about the issue, safe circumcision outside of the newborn period should be made available to them. While circumcision is regarded as a minor operation, consideration should be given to meticulous anaethesia, analgesia and surgical technique. With continued social trends away from routine non medical circumcision, the general awareness of the community relating to the mystique of the foreskin should improve.
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