Pediatric Foreskin

Phimosis (An indications for circumcision)

Phimosis refers to the inability to retract the distal foreskin over the glans penis.

There are three clinical manifestations:

• Inability to retract the foreskin over the glans penis
• The foreskin is partially retractable, only part of the glans could be exposed
• The foreskin is retractable to expose most of the glans, but there would be discomfort caused by the tight foreskin

Phimosis may (1) affect the urination of boys, (2) induce diseases, (3) affect the proper growth of the penis, and development of the penis. 

Phimosis often affects the pediatric patients as in the followings:

• Patients with phimosis may have difficulty in passing urine resulting in ballooning of prepuce during urination.
• There is often trapping of urine in between prepuce and glans of penis after urination. This trapped urine may subsequently leak out and wetting the underwear or the pant of the boy, causing poor hygiene and odor.
• Phimosis may lead to inaccurate urine stream or urine stream bifurcation resulting in urine wetting the patients' body, clothing or the surrounding environment.
• Patients with phimosis usually cannot retract and clean their foreskin and glans of penis.  There is often urine and dirt (smegma) accumulating between the glans of penis and prepuce resulting in bacteria overgrowth, unpleasant odors, balanitis, posthitis or even urinary tract infections. 
• Other complications: As the tight foreskins prevent the patients from cleansing the prepuce, there is often smegma accumulation, bacteria overgrowth, chronic balanitis, chronic posthitis or even recurrent infection and inflammation. Subsequent to recurrent infection and inflammation, the prepuce, glans of penis, urethral opening, frenulum or penile shaft may develop fibrous tissue and scar, resulting in adhesions between glans of penis and prepuce, worsening of phimosis secondary to scarring, frenulum breve with scarring, fibrotic urethral stricture, penile distortion, glans of penis distortion or deforming etc.  

Paraphimosis (An indications for circumcision)

Paraphimosis is the entrapment of a tight retracted foreskin to the shaft of penis in uncircumcised males. The tight retracted foreskin cannot return to its normal position and forms a tight constricting ring over the shaft of penis. It causes vascular and lymphatic obstruction leading to redness and swelling of the penis and prepuce distal to the constricting prepuce ring. Paraphimosis is a medical emergency requiring urgent attention. With time, severe vascular and lymphatic obstruction could lead to penile infarction/necrosis, gangrene and rarely auto amputation if untreated.

Long prepuce (An indications for circumcision)

Long prepuce means that the prepuce / foreskin covers the glans of penis and urethra during erection.

It may have the following effects:

• Patients with long prepuce may have spraying of urine or difficulty in controlling the urine stream resulting in urine wetting the body, the clothing, or the environment

As patients seldom clean the prepuce, there is often smegma accumulation, bacteria overgrowth, chronic balanitis, chronic posthitis or even recurrent infection and inflammation.  Subsequent to recurrent infection and inflammation, the prepuce, glans of penis, urethral opening, frenulum or penile shaft may form fibrous tissue and scar, resulting in adhesions between glans of penis and prepuce, worsening of phimosis secondary to scarring, frenulum breve with scarring, fibrotic urethral stricture, penile distortion, glans of penis distortion or deforming etc.

Foreskin / Prepuce diseases (An indications for circumcision)

There may be diseases in the prepuce requiring surgical treatment, e.g. partial prepuce excision or circumcision. These foreskin diseases are common indications for circumcision: sebaceous cyst, recurrent balanitis, recurrent posthitis, seborrhoeic keratosis etc.,

Balanitis and Posthitis (An indications for circumcision)

There are a lot of secreting glands on the prepuce and glans of penis surface. As the tight foreskins prevent the patients from cleansing the prepuce, there is often smegma accumulation, bacteria overgrowth, chronic balanitis, chronic posthitis or even recurrent infection and inflammation. Subsequent to recurrent infection and inflammation, the prepuce, glans of penis, urethral opening, frenulum or penile shaft may form fibrous tissue and scar, resulting in adhesions between glans of penis and prepuce, phimosis secondary to scarring, frenulum breve with scarring, fibrotic urethral stricture, penile distortion, glans of penis distortion or deforming etc.

Other reasons

Religious reasons, national tradition, family tradition or personal preference are the common non-medical reasons of circumcision

Neonatal circumcision is commonly requested by parents for religious reasons, national tradition, family tradition, or personal preference, other than medical indications. Religious reason is a common reason for circumcision: Khitan refers to Islam circumcision ritual; Brit milah is a Jewish religious male circumcision ceremony performed by a mohel on the eighth day of a male infant's life.

So far, no major medical organizations recommend circumcision for newborn because of non-medical reason; no major medical organizations discourage circumcision of all newborn children.

HIV / AIDS prevention

As the development of epidemic of HIV / AIDS in Southern African and studies showing that circumcision reduced the HIV transmission from female to male, medical institutes recommended the circumcision as a mean of HIV / AIDS prevention in Southern Africa countries. Patients have to undergo circumcisions with informed consent, confidentiality and under non-threatening situation.

Parents bringing their sons for circumcision have to understand the need for the circumcision, the pros and cons of different kinds of circumcision, and to give informed consent before the surgery. Foreskin and glans of penis varies greatly from one person to another. If you have any enquiry, you should bring your son to an experienced doctor for advice.