Foreskin Fallacies and Phimosis

Introduction

The foreskin, one of the smallest parts of our integument, is still shrouded in much controversy, In spite of the fact that circumcision has been practised for 4000 years, there is still argument surrounding the indications for circumcision. Some regard the foreskin as functionless piece of skin prone to infection and Phimosis, and recommend that it be dispensed with quickly in the neonatal period, before it has a chance to give rise to any problems.

Not many realise that it serves an important physiological role and much has been forgotten about the function of the foreskin, in our stampede to extirpate it out of existence.

Mindful of the controversy surrounding this issue, this article aims to examine the function of the foreskin, if indeed there is any, and some of the common problems encountered and the treatment available. Circumcision is also discussed, together with some of the complications arising from the procedure.

The Physiology of the Foreskin

The foreskin is unretractable at birth.¹ This is due to the glans penis and deep surface of the foreskin sharing a common layer of squamous epithelium.² As keratinisation of the epithelium occurs, the prepuce becomes progressively detached from the glans and becomes retractable. This process is completed in 90% of boys by the age of five but Oster states that full retractability does not occur until early teenage years.³ 3% of 16 year olds surveyed by him still had incompletely retractable foreskin, which subsequently became retractable at 17.

The term Phimosis (muzzled in Greek) therefore should not be used to describe a non retractable foreskin, as non-retractability is neither uncommon nor pathological in the young.

Hence, Phimosis seen in children is physiological, and serves to protect the glans from ammoniacal dermatitis. That this is so is attested to by the prevalence of meatal stenosis following circumcision, reported to occur in 8 to 31% of children circumcised.⁴ Similarly, meatal stenosis in the uncircumcised male, while reported, is an extremely rare entity.

Some parents express concern because of accumulation of thick whitish yellow creamy pus under the foreskin. This is smegma, a collection of shedding epithelial cells. Often smegma will accumulate, forming thick white smegma cysts. This gradually separates from the glans penis and inner prepuce, and spontaneously discharges. Again this is physiological and does not demand any form of treatment at all, except for reassurance that this does not consitute an infection. The smegma actually helps in separating the two layersof epithelium.

The foreskin can be liked to a rosebud which remains closed and muzzled. Like a rosebud, it will only blossum when the time is right. No one opens a rosebud to make it blossum. Most children will also grow out of their Phimoses without any need for manipulation or circumcision.

In spite of this, one is often asked to see children because the family doctor or the parents are concerned about the foreskin. Some of the commoner problems encountered are described, together with their management.

Phimosis

True Phimosis is caused by a thick white fibrous ring around the prepuce, which makes retraction impossible (Fig. 1) This condition is caused by Balanitis Xerotica Obliterans. In this condition, the skin becomes pale gray, thin and parchment like, and the foreskin looses its suppleness. There is atrophy and thinning of the epidermis, replacement of the underlying dermis with dense collagenous tissue infiltrated with chronic inflammatory cells.⁵ The epidermis separates easily from the underlying dermis.

Circumcision is indicated for this condition.⁶ An important consideration at operation is not to remove the leathery plaque from the glans if it is involved (as is often the casee) or meatal stenosis will ensue. This condition can also be progressive, involving the anterior urethra, and it may be necessary to administer topical hydrocortisone to arrest the spread.

Non Retractable Foreskin

Some children may develop balanitis, and on examination are found to have a firmly fused tip without evidence of true scarring. This may be regarded as Phimosis by many people, but again its due to physiological adhesions. If the foreskin is retracted, the Phimosis is no longer evident, being lax and freely retractable as illustrated (Fig. 2, 2a).

This can be treated with a high degree of success by liberal topical application of 1% hydrocortisone cream six times a day for four weeks, with less frequent applications for a further two months⁷ once the foreskin has started to become retractable.

Redundant Foreskin

The most common reason for a child to have redundant foreskin is obesity, where the penis is buried in pre-pubic pad of fat. Performing a circumcision for redundant foreskin in this situation will only lead to the more severe problem of a buried or hidden penis, cosmetically more devastating for the child and much more difficult to correct. Circumcision is contraindicated in the obese child with redundant foreskin.

Importantly, parents often bring a child with redundant foreskin for consultation because they are concerned not about the redundancy, but about the apparent micropenis. Here it is important to reassure the parents that the child is adequately endowed, demonstrating to them the length of the penis by retracting the pre pubic pad of fat away.

Recurrent Balanitis

It is not too uncommon for a growing child to develop balanitis during the process of separation of the epithelial surfaces normally adherent.⁸ Circumcision for this or because the prepuce is still adherent is a radical measure, though it is commonly requested.

It would appear illogical to circumcise a child for one episode of balanitis, in the same way as it is illogical to submit a child to tonsillectomy after one documented attack of tonsillitis However, there remains the occasional child in whom circumcision is justified because of repeated attack of balanitis.

Hypospadias

In very minor hypospadias, where the predominant problem is a dorsal hooded foreskin, circumcision alone will produce a satisfactory cosmetic and functional result. However, it must be stressed that any hypospadiac penis that is more severe should not be circumcised, as the dorsal hooded foreskin is required for corrective surgery.

Chordee without Hypospadias

Chordee without hypospadias requires correction to ensure adequate to ensure adequate sexual function. Most of these are isolated skin chordee, but a few are due to congenitally short urethras requiring a formal urethroplasty. In either case, the child should not be circumcised as the skin is needed for correction of the chordee.

Penoscrotal Web or Webbed Penis

Occasionally, the scrotal skin encroaches on the shaft of the penis producing a midline web extending often to the tip. This can be easily corrected without circumcision with a simple flap procedure.

Urinary Tract Infections

Phimosis as a cause of urinary tract infections is very rare, although reported. If a child has a documented urinary tract infection, then it is mandatory to exclude other problems and not attribute it to phimosis.

Eczema

This is surprisingly not uncommon and the presenting complaint is a persistently itchy foreskin. On examination, one sees a scaly rash usually at the tip of prepuce. This should be treated not by circumcision but by hydrocortisone.

Ballooning Foreskin

Ballooning of the foreskin is attributed to malalignment of the external urethral meatus and the preputial orifice.¹ It can also arise soley because of the laxity and length of the foreskin.⁸ Unless it is causing symptoms, no treatment is necessary. Symptomatic problems can be treated by hydrocortisone or by progressive gentle retraction.

Having discussed the various conditions that can afflict the foreskin, there remains a significant proportion of parents who remain proponents of circumcision. Before recommending this procedure to our patients, it would be worthwhile examining the complications that could arise, and weigh the risks against advantages gained.

Complications of Circumcision

The commonest complication as already discussed, is meatal stenosis. An exposed glans particularly in a neonate is prone to ammoniacal dermatitis. When this affects the meatus, a meatal ulcer ensues and heals with subsequent stenosis. (Fig. 3)

Haemorrhage

This is a well known complication of circumcision, and the incidence of post operative bleeding has been quoted at 7%.⁸

Urethral Trauma

Urethral fistula from a misplaced suture has been described, and is as difficult to treat as any urethral fistulae.

Inadequate Circumcision

This is probably the commonest complication requiring re-operation in the author's experience. It results when either too little or too much skin is removed. If too little prepuce is removed, the remaining hood can cover the glans. With ensuing cicatrisation, this produces an even more severe iatrogenic phimosis (Fig. 4) This will inevitably require circumcision.

Removing excess skin and denuding the shaft of penile skin is of particular danger in obese children, leaving them with a buried penis.

Gangrene

Fortunately, this is a very rare complication of neonatal circumcision (Fig. 5). It may be due to necrotising fasciitis (Fourniers Gangrene) or occasionally from indiscriminate use of electrocoagulation. Although rare, one cannot predict when this severe complication may arise.

Sepsis

The incidence of sever wound infection following circumcision has been reported to be of the order of 4%.⁸ One wonders if the incidence of low grade infection is not higher than this, considering that the fresh incision is bathed in a pool of urineand faeces, while it heals.

Meningitis and necrotising enterocolitis has been seen by this author as a complication of neonatal circumcision. In addition, the incidence of neonatal sepsis in newborn males in North American, a predominantly circumcised population is twice that of females.⁹ Is this due to an inherent weakness of boys, or could it be that neonatal circumcision provides an extra portal of entry for microorganisms?

Neonatal circumcision can no longer be considered a safe and harmless operation. The fact that both the American Academy of Pediatrics and the Australian College of Paediatrics have discouraged this practice attests to the concern shared by most paediatricians on the safety of the procedure.

There is no doubt that the circumcised penis is cleaner and the operation eliminates phimosis. Circumcision probably also reduces the incidence of cervical carcinoma in female partners as well as reducing the incidence of penile carcinoma.¹⁰ However one has to consider if the risks outweigh the advantages.

Currently, substantial literature evidence points to the fact that circumcision is not without significant complications. The foreskin plays an important protective role in the young. Let us therefore not interfere with it, but give it the respect it deserves.

Address for Reprints: Dr Tan Hock Lim, Department of Paediatric Surgery, Singapore General Hospital, Singapore 0316.

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