In the adult, the foreskin (or ‘prepuce,’ the more formal medical term for this body part) is in general completely retractable, meaning that from its normal forward position covering the glans (the head of the penis), it can be retracted back toward the abdomen so as to uncover and reveal the entirely of the glans and the inner mucosal surface of the foreskin (called the preputial mucosa). From this temporarily retracted position, it can be brought forward again. In this fashion, the foreskin in the adult is a moveable part. [For the resolution of a tight, non-retractable foreskin in adulthood, see last paragraph, “The resolution of true phimosis in the adult or late adolescent.”]

In the child, by contrast, one should not automatically expect the foreskin to be retractable; it becomes so only over time, spontaneously and very gradually, without any need for this growth process to be precipitated (see below). The vast majority of males are born with the foreskin fused to the glans, with the development of separation between glans and foreskin a process that continues long after birth.

Thus, the forced retracting of the child’s foreskin, or any other manipulation intended to make the baby’s or child’s foreskin retractable by force (as, for instance, the “breaking of adhesions”) is now recognized by the highest authorities in these matters — the Canadian Paediatric Society (CPS), the American Academy of Pediatrics (AAP), etc. — as being not only unnecessary, but also potentially harmful. Such a manipulation results in the forced, premature separation of two surfaces — the inner foreskin lining and the surface of the glans — which are not yet developmentally ready to be separated, one from the other, and exposed. Forced retraction of a child’s foreskin can cause enormous pain, bleeding, and tears in the skin which can result in scarring and other reactions such as a reduction of foreskin suppleness — called iatrogenic (meaning ‘caregiver-induced’) phimosis — and paraphimosis (see more on this latter, below). NOTE: Iatrogenic phimosis is to be distinguished from physiological phimosis, a normal characteristic of child anatomy, described below.

Unfortunately, many people, included misinformed health professionals, are working under widespread outdated misconceptions as regards the normal course of development of the child’s penis [endnote 1] and are not aware of the advice of the CPS, the AAP, and other medical organizations regarding correct and incorrect (harmful) hygiene practices for the child. All too often, parents receive the flawed advice, from their health professional or others, to force their son’s foreskin back (before it has naturally separated and become retractable).

Given the present state of persistent widespread misconceptions about the foreskin, it is very likely people you yourself know — aunts, mothers-in-law, neighbours, colleagues, friends, etc. — are labouring under these myths, having been misinformed (albeit with perhaps the best of intentions) by their medical practitioner, years ago, or even today!

Normal characteristics and development of the child’s penis

The baby’s foreskin is characterized by three things: it is usually non-retractable; its opening is narrow; and it extends beyond the glans, sometimes significantly. (This last aspect also frequently characterizes the foreskin of the adult.) These three aspects of the baby’s foreskin are altogether normal.

Over the course of infancy and childhood, two very gradual developmental processes occur naturally and spontaneously, without any need to be precipitated by the caregiver:

1) the separation between the inner lining of the foreskin and the surface of the glans, and 2) the gradual widening and increase in elasticity of the opening (or extremity) of the foreskin, called the preputial ring (or preputial opening). The time-frame of these developmental processes can vary considerably from one child to another, this wide variation being perfectly normal. The moment that these respective processes begin, as well as the time (weeks, months, or years) they take to be completed, is different for each individual. It can take up to late adolescence for these two processes to be completed.

In the course of the development of certain boys, the foreskin can be seen to balloon during urination. This is normal and indicates that the inner foreskin and the glans have begun to separate from one another, creating a space (the preputial space). This ballooning is due to the fact that the preputial opening is still narrow. This is no cause for worry, except if there is serious urinary retention whereby the urine flows drop by drop over minutes, in which case a steroidal or non-steroidal ointment or cream can be prescribed to precipitate the widening of the opening enough to attenuate this situation.

CORRECT HYGIENE FOR THE BABY AND CHILD

We’ve all heard it said, sometime, that “hygiene of the uncircumcised child is so complicated.” In fact, as all paediatric organizations indicate, nothing could be further from the truth. It is indeed this single outdated myth (practically a superstition) — to the effect that the parent must forcibly “open” the child’s foreskin to cleanse it — that has been the source of the majority of foreskin problems (infections, inflammations, iatrogenic phimosis, paraphimosis) in boys in North America over the course of the twentieth century.

In fact, correct hygiene of the infant’s and child’s intact (non-circumcised) penis is very simple. Different from that of the adult, yes; but no less simple. There is thus no need to resort to any “complicated” manipulation whatsoever. It is neither necessary nor advisable (indeed now unadvised) to expose and clean the parts of the inner foreskin and the glans surface that have not yet separated, naturally, one from the other.

The way to go about cleaning the baby’s penis (or that of the child whose glans-foreskin separation process has not yet begun) is to wash the outside of the penis, and not to seek to access and wash inner parts of the penis that cannot easily be seen. Over the course of months or years (depending upon the individual), the foreskin will separate from the glans, and the foreskin opening (the preputial ring) will become wider and more elastic, such that more and more of the glans and the inner lining of the foreskin (or the foreskin mucosa) will become visible upon gentle retraction of the foreskin within the skin’s limits of retractability at the time. In keeping with the safest guidelines, it suffices to rinse with warm (not hot) water the parts of the glans and inner foreskin that one can easily see during a very gentle retraction of the foreskin to its point of resistance. (Note that soap, as well as hot water, can sometimes irritate sensitive mucosal surfaces. If you apply soap to your child’s penis, make sure it is a very mild, that you don’t overuse it, and that you rinse it off well. Moreover, it is unadvised to use a washcloth on the glans and the inner mucosal lining of your child’s foreskin, as a washcloth can irritate the foreskin’s sensitive mucosal inner lining. Note, as well, that bubble-baths or long sessions in soapy or shampoo-filled water can unbalance the pH, causing irritation and inflammation. If your child is given a bubble-bath, consider rinsing with clear water after to remove irritating soap residue.)

Certain children may still have a non-retractable foreskin by the age at which they become responsible for their own hygiene, in which case the child can be taught to wash his penis in the same way as mom or dad have all along. If he is older and curious to know more about his body, it can be explained to him, in terms he understands, the two developmental processes which he can expect to occur (described earlier) and invited to follow the above guidelines. Explain to him the importance of not forcing his foreskin back before it has separated from his glans. (You may have noticed that boys have the tendency to stretch their foreskin forward; this, along with erections, contributes to the increased elasticity of the foreskin generally, and the preputial ring in particular.) Retain the information in the paragraph on paraphimosis (further down), in case your son, in his ambition to prematurely uncover and see his glans, succeeds in displacing his foreskin behind his glans and then can’t return it easily to its forward position (due to an as yet narrow preputial opening).

Concerns without foundation: Foreskin “too narrow,” “too long,” or “redundant.”

It is altogether normal that the opening of the foreskin be quite narrow at birth and for several years, and that the infant’s or child’s foreskin be non-retractable. In some children, this narrowness and unretractability will remain the case for several years, while in others the foreskin opening (preputial ring) will be elastic and the foreskin retractable by age one.

All of these variations in morphology are normal.

In the majority of children, as in many adults, the foreskin extends beyond the glans, sometimes significantly. In some children, this portion of the foreskin may even resemble a little ‘elephant’s trunk.’ There is nothing abnormal in this. With age, this little elephant’s trunk will come to be filled, increasingly, with the body of the penis. And if the individual was intended by nature to have, even in adulthood, a long foreskin, well, as one author put it in the British Journal of Urology: “One can never be too rich…or have too much foreskin.”

Note on paraphimosis (“foreskin stuck behind the glans”)

Paraphimosis in the child is caused, almost all of the time, by the forced retraction of the child’s foreskin by a parent, a misinformed health professional, any other caregiver of the child’s, or, rarely, by the child himself.

Paraphimosis in childhood is caused when a foreskin still characterized by a physiologic (or normal) phimosis — that is, where the preputial ring is still in the developmental stage where it is narrow and not yet able to easily be drawn back and forth over the ridge of the glans (the coronal ridge) — is retracted by force behind the glans and then cannot be easily (or at all) brought back to its forward position. When this occurs, the glans fills up with blood (because of the tightness of the preputial ring behind the glans), which renders forward re-placement of the preputial ring and foreskin even more difficult.

In such an instance, compress the glans between your thumb and your (straightened or bent) index finger, more or less strongly, depending upon the need. This maneuver will empty the glans of its blood (for the glans is like a sponge), thereby diminishing its swollen size and making it possible to bring the foreskin forward again (Illingworth, 1983). In the rare instance that such manual compression does not succeed in resolving the situation, visit an emergency department where the use of ice in a rubber glove (Houghton, 1973) or an injection of hyaluronidase into the region (DeVries, 1996) can be deployed in order to reduce the swelling and resolve the paraphimosis. Surgery should the last resort, as these other methods, in cases of emergency, are usually successful.

Paraphimosis can also affect the very small percentage of adults in whom the preputial ring remains, due to a true phimosis (see below), too tight to easily be brought back and forth over the coronal ridge. In the case of adult paraphimosis, the same means of resolving it as mentioned above can be employed, as well as steroidal creams to resolve the phimosis. Consult <http://www.cirp.org/library/treatment/phimosis>.

Use of steroidal (or non-steroidal) creams in children

Even though certain steroid creams (and some non-steroid creams) can “resolve” a physiologic phimosis in the child, there is generally no need to resort to these, to the extent that there is, in effect, nothing abnormal there requiring “resolution.” As stated earlier, having a non-retractable, tight foreskin is a normal phase of development in the child which gives way to phases of increasing retractability over the course of months or years, depending upon the individual. It is thus wiser and more appropriate to recognize the normal nature of the child’s as yet non-retractable foreskin, and to not be alarmed and worry (or alarm and worry one’s child) unnecessarily. If, however, it ever becomes necessary, for whatever reason, to precipitate the widening of the preputial opening (or preputial ring), the option of steroidal (or non-steroidal) cream use is effective and available. (If in Quebec, contact us at the Circumcision Information Resource Centre for a referral to a foreskin-knowledgeable doctor, or visit: <http://www.cirp.org/library/treatment/phimosis/>.)

The resolution of true phimosis in the adult or late adolescent

A very small percentage (1% to 2%) of boys 18 years of age remains with some degree of foreskin non-retractability. This is called phimosis, or even more properly, true phimosis. (Adult true phimosis must be distinguished from childhood physiologic phimosis, this latter representing a normal phase of development prior to the foreskin’s gradual, spontaneous separation from the glans; see above.) An adult having a phimosis and wishing to render his foreskin retractable can, by visiting the Circumcision Information and Resource Pages at <http://www.cirp.org/library/treatment/phimosis/>) or by contacting us, educate himself regarding the various options at his disposal, non-surgical (steroidal cream use and gentle stretching) and surgical (skin plasties), which are generally effective in resolving phimosis. Circumcision, given that it doesn’t cure but instead amputates the foreskin, should be seen as a measure of last resort; all too often, however, uninformed practitioners deploy it as a measure of first resort. (If in Quebec, we can refer you to foreskin-knowledgeable medical practitioners familiar with the range of options.)

For any supplementary information or clarification of anything contained in this pamphlet that may strike you as unclear, please feel free to . We will be happy to assist you in any way we can.

Endnotes:

[1] The Canadian Paediatric Society (CPS) states that: “In general, there is inadequate recognition of the long period before the natural separation of the prepuce and the glans is complete. Some authors still refer to the presence of ‘adhesions,’ when, in fact, separation has not yet taken place; similarly, a nonretractile foreskin is sometimes incorrectly diagnosed as phimosis.” [Fetus and Newborn Committee, Canadian Paediatric Society. Neonatal Circumcision Revisited. Canadian Medical Association Journal, vol. 154, no. 6 (March 1996): pp:769-780. Reference No. FN96-01.] See “The Problem of Incorrect Diagnosis of Phimosis,” at <http://www.infocirc.org/phimosis.htm>.

Sources:

The Circumcision Information and Resource Pages (recommended by the British Medical Journal), <http://www.cirp.org>, and its reference library, <http://www.cirp.org/library/>).

American Academy of Pediatrics. Care of the uncircumcised penis (pamphlet, 1998). <http://www.aap.org/family/uncirc.htm>.

Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. British Journal of Urology, vol. 77, no. 2 (February 1996): pp. 291-295. <http://www.cirp.org/library/anatomy/taylor/>.

Cold CJ, Taylor JR. The prepuce. BJU International, vol. 83, Supplement 1 (January 1999): pp. 34-44.

Illingworth R. The normal child: some problems of the early years and their treatment. Churchill Livingstone, 1983: p. 101.

DeVries C. Reduction of paraphimosis with hyaluronidase. Urology 1996, vol. 48: pp. 464-465. <http://www.cirp.org/library/treatment/phimosis/devries/>.

Houghton GR. The ‘ice-gloved’ method of treatment of paraphimosis. British Journal of Surgery, vol. 60, no. 11 (November 1973): pp. 876-877.