Further to the The Further Fate of the Foreskin

Update on the natural history of the foreskin.

The fortunate foreskin of an infant boy will usually be left well alone by everyone but its owner. Problems such as phimosis are not common, and can usually be treated medically without circumcision. (Med J Aust 1994; 160:134-135)

The natural history of the foreskin is a neglected subject. Gairdner, in an historic article entitled The fate of the foreskin …¹ described it in 1949. In 1968, Oster again addressed the subject in a paper entitled Further fate of the foreskin..²

Gairdner's otherwise masterly description contained one inaccuracy. He said that the foreskin should be fully retractable by three years of age. Clinical observation reveals that this is not true. It should be open and beginning to retract by three years of age but full retractability may not be achieved to many years later. Indeed nature will not permit the assignment of a strict timetable to this process.

In infancy retraction is limited by adhesions between the inner layer of the prepuce and the glans. These adhesions form early in fetal development³ and provide a protective cocoon for the delicate developing glans. At birth and in early infancy the normal foreskin is non-retractable and adherent to the glans. Separation occurs slowly, usually with smegma collecting beneath the prepuce,² but the process may not be complete until later childhood. Smegma (yellow sebaceous material) is often visible beneath the prepuce and may be erroneously diagnosed as a cyst, or worse, as infection. Its extrusion as the prepuce separates is often mistakenly called pus. Far from indicating circumcision, it is more a contra-indication.  [ Note: Dr. Wright uses the pathological term adhesions to describe the normal connections and bonding between the inner prepuce and the underlying glans penis. These are normal healthy connections, and bonding in the immature and still developing penis should not be confused with pathological adhesions which Dr. Wright discusses.] 

Mild episodes of inflammation are often part of the natural process of separation of glans and prepuce. True balanoposthitis is usually staphylococcal and responds rapidly to bathing and a simple antibacterial agent such as trimethoprim-sulfamethoxazole. It is no more an indication for circumcision than one attack of tonsillitis is for tonsillectomy.

Phimosis

This term used to be used in hospital records to justify social circumcision. Fortunately, this is less often performed, although there has been a resurgence of demand for circumcision with tacit medical compliance, in recent years.

It is easier to define what phimosis is not. It is not simply a non-retractable foreskin in infancy or early childhood. Phimosis means muzzling. It is an unnatural and therefore abnormal condition. The prepuce is designed to be non-retractable in infancy and early childhood when the developing glans needs complete protection from the mechanical trauma of the nappy and clothing, and the chemical trauma of ammoniacal urine. Non-retractability in later childhood is abnormal and may then be called phimosis. At any age, abnormal narrowing of the preputial opening with ballooning on micturation (not simple filling) is phimosis.

Thus true phimosis may be defined as an abnormal degree of narrowing of the preputial opening causing obstruction to urine flow, or non-retractability persisting well into childhood.

Phimosis is of two types:

1. Phimosis with supple but as yet inadequately yielding skin. This is a delay of normal development.
2. Phimosis associated with abnormal skin or scarring of the prepuce. This may be though natural causes such as lichen sclerosis et atrophicus (balanitis xerotica obliterans) or unnatural causes such an injury or trauma though premature and forceful attempts to withdraw the foreskin.

Management of the normal prepuce

After years of almost universal neonatal circumcision, Australian parents and the Australian medical profession became ignorant of the care of the normal (i. e., uncircumcised) penis. European migrants from countries where neonatal circumcision has never been practised are familiar with the natural history and are comfortable with the knowledge that the foreskin in infancy should be left alone. No attempt should be made to withdraw it or wash it inside.

The time to pull the foreskin back is when the child is old enough to do this himself. He will instinctively pull it forward in early childhood but will not be able to retract it at all until at least three or four years of age. The degree to which this can be done is determined by the residual attachment to the glans. It should be pulled as far back as possible without causing discomfort. If the child does this himself in a normal, hygienic manner in the bath, unnecessary force and trauma will be avoided.

The time to pull the
prepuce back is when
the child is old enough
to do this himself.

What of residual preputial adhesions? Should these be separated digitally? If this is done too early there is excessive discomfort after the procedure and even bleeding. Further, they can reform. Too early is variable but from clinical experience it is unwise to attempt it before six years of age. Beyond this age it is a simple procedure if the prepuce is supple and fully and freely retractable to the limit of these adhesions.

If these conditions are fulfilled, the procedure can be done painlessly with the aid of a local anaesthetic cream (EMLA cream, Astra Phamaceuticals, a eutectic mixture of lidocaine and prilocaine). This is inserted into the prepuce and left in place one hour, during which time the child must not void. The glans is then insensitive and adhesions can be separated painlessly provided they are not too extensive. The cream does not penetrate deeply and, if the adhesions are widespread, the procedure should be performed in two stages six to twelve weeks apart. It should be emphasised that this procedure should not be done in infancy or early childhood, and some experts advise against it at any age.

Management of the abnormal prepuce and phimosis

This is either surgical or, more recently, medical. Surgery may involve dilation, dorsal slit or circumcision. Dilation is likely to produce more scarring and make the condition worse. Dorsal slit, if not done adequately, causes scarring and recurrence. If done generously it produces an ugly foreskin with prolapse of the inner preputial layer, to produce a penis that looks neither circumcised nor uncircumcised. Circumcision is the best surgical procedure for phimosis. It is definitive and final. It is a good operation when performed for good reasons.

In recent year a medical treatment has been found effective in nearly 90% of boys with phimosis. A topical steroid such as betamethasone valerate 0.05% applied to the tip of the phimotic prepuce, which has normal supple skin, will effect cure in most instances.⁴ It must be applied to the tip of the prepuce regularly, at least three times a day for about one month. The pink distal end of the prepuce is the area concerned and there is no need to insert the steroid in the prepuce.

The response depends on the absence of scarring of the prepuce and the degree of parental compliance. If there is lichen sclerosus et atrophicus (balanitis xerotica obliterans) it will not be effective. It should be used for about one month, and for a further month in those who make good progress but do not achieve full response. It will not separate adhesions and it will not make the foreskin retractable beyond what may be expected for the child's age. Thus under three years of age it is sufficient to open up the prepuce and prevent ballooning on micturition. Beyond that age the foreskin should retract to the limit of adhesions, if any. These can then be treated, if deemed necessary, at the appropriate time.

Conclusion

The normal prepuce should be left alone, with no attempt to retract it until the boy is able to do it himself, at the earliest at three years of age. A non-retractable foreskin under three years of age is not phimosis unless the opening is so narrow that there is ballooning on micturition. Full retractability of the foreskin may not be achieved until late childhood. Preputial adhesions are not abnormal in early childhood. They can be separated digitally in later childhood with topical anaethesia. Phimosis in most boys can be successfully treated medically and is not a universal indication for circumcision. If medical treatment fails, as it will with phimosis caused by lichen sclerosus et atrophicus or starring, circumcision is the best procedure.

116 Everton Street, Hamilton, NSW 2303
J E Wright, MB BS, FRACS, FACS, Paediatric Surgeon,
Clinical Lecturer in Paediatric Surgery,
 University of New Castle Medical School.

No reprints will be available. Correspondence: Dr. J E Wright

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