Penile hygiene for intact (non-circumcised) males

This page offers factual information to help medical personnel and parents understand the proper care of the natural, complete, intact penis.

The word hygiene comes from Greek, and means "the protection and promotion of health." Keeping the body clean is only part of what it takes to be healthful. In some cases, excessive washing can actually cause health problems as will be explained below.

This page provides a brief overview of penile hygiene with links to library holdings.

Why this page is needed

Many physicians today are totally ignorant of the care of the intact penis, and frequently give inappropriate advice to parents. For example, we have received numerous reports of incidents in which physicians have improperly attempted to retract the foreskin of infants and young boys prematurely.5

For the majority of American males, having been circumcised at birth, the intact (not circumcised) penis may seem strange and mysterious. Many American medical doctors, themselves circumcised, are ignorant of the subject5 because care of the intact penis is rarely mentioned in medical school.

Improper advice and care of the intact penis often leads to injury and subsequent circumcision. When this happens, it is often turned around and used as reinforcement for the claims that "circumcision should have been done in the first place!"

Many individuals within the American medical community have been promoting male neonatal circumcision for over a century. Circumcising doctors have claimed in many publications that the foreskin is the source of all manner of illnesses and disease.17 Many have claimed that "extraordinary precautions" must be taken to prevent infection in the intact male. To a large extent these claims serve to maintain the status quo by which doctors are paid on a fee-for-service basis.

Today, more and more parents and doctors know that optimum emotional and physical health is achieved by avoiding circumcision. There are more and more intact non-circumcised boys in the North American community, so the intact boy no longer stands out in the locker room.

Protective functions that contribute to health

The foreskin is actually designed by nature to provide protection against disease and injury.17 By understanding these protections, we allow the foreskin to function in its role of protecting the human body from infection and disease. This page will serve to increase that understanding.

The foreskin of the newborn is:

  1. fused with the underlying glans penis in most boys.1 7
  2. relatively long in many boys in relation to the length of the penis as compared with adult males.20, Fig. 3
  3. usually narrow at the tip.1
  4. filled with muscle fibers that keep the foreskin opening closed and pathogens out.4 17
  5. protected from infection by oligosaccarides from breast milk.9 11 17

The fusion of the foreskin with the glans penis7 means that no sub-preputial space or cavity exists in most infant boys.20 Nature intends the glans penis (head) to be an internal organ before puberty and a covered, protected organ after puberty. The narrow tip of the foreskin in most boys cannot be retracted because the diameter is less than that of the glans penis. Even if the tip were wider, the fusion of the foreskin with the glans would still prevent retraction.7 The narrow non-retractile foreskin protects the urethral opening from foreign matter and infection and from the ammonia that is created by chemical action in wet diapers (nappies).16 The shape of the immature infant foreskin does not indicate the appearance of the adult foreskin.

The muscle fibers allow the tip of the foreskin to open to allow a stream of urine to flow out but draw the prepuce closed again after urination is finished, thereby preventing entry of fecal matter that contains pathogens.17

Breastfed babies excrete oligosaccharides in their urine.9 17 The oligosaccharides prevent bacterial adhesion to the foreskin and other uroepithelial tissue,11 17 19 so if bacterial adhesion is prevented the risk of urinary infection is greatly reduced.19

Boys with an intact foreskin have health advantages over those who have been circumcised. The intact foreskin protects the glans penis from ammoniacal diapers (nappies) and prevents meatitis, meatal ulceration, and meatal stenosis. The sub-preputial moisture contains lysozyme, an enzyme that attacks and destroys pathogens.17 Intact boys don't have an open circumcision wound that may become infected and so they have fewer infections.17 Intact boys are not troubled with adhesions or skin bridges, which are complications of circumcision.

Optimum penile health starts before birth when parents make a decision to protect their son from circumcision and to breastfeed him.19

The separation of the foreskin from the glans penis

The separation of the prepuce from the glans penis may occur at any age.7 Separation often starts around age 3-4 but it may not be complete until much later.1 Ballooning of the prepuce while urinating cannot occur until separation is underway. The occurence of ballooning indicates that separation has started.15 Babu et al. have proven that ballooning does not interfere with urination.21 Ballooning is a normal developmental stage and is not a cause for concern and does not require treatment.16 20 A child temporarily may report some discomfort or pain while urinating during this period. This occurs because the ballooning may tear at any residual connection to the glans. The discomfort will stop when separation is complete. The foreskin may still not be retractable at this point because the opening is still narrow. With increased growth and maturity, the ballooning will end when opening of the foreskin widens.

Misunderstandings caused by the 1975 AAP statment

One misunderstanding was inadvertently fostered by the American Academy of Pediatrics in 1975, when it published a statement that said:

"A program of education leading to continuing good personal hygiene would offer all the advantages of circumcision without the attendant surgical risk."3

The doctors on the ad hoc committee who wrote that statement in 1975 knew that poor personal cleanliness is associated with development of penile cancer and showed sound medical judgment in advising against circumcision. But they did not know why because the links between tobacco and penile cancer and between human papilloma virus (HPV) and penile cancer had not yet been discovered.

Later discoveries showed that HPV infection often is a precondition for penile cancer.18 Persons who did not keep their penis clean were more likely to have HPV, and more likely to develop penile cancer. Also, the use of tobacco in any form is a risk factor for the development of penile cancer.12

The 1975 AAP statement has caused many to believe that frequent regular retraction of the foreskin and washing is necessary to prevent disease (especially cancer) in boys.20 However, this is not the case. Boys are not exposed to the risks for penile cancer because they usually do not use tobacco or engage in sexual intercourse. Penile cancer usually is seen only in elderly men. Doctors now recommend that no forcible attempt should be made to retract the foreskin of newborns, infants, and young boys.5 7 8 14 20 Premature attempts to retract the foreskin are ill advised.7 8 The natural protections of the foreskin20 work best when the foreskin is not disturbed. The foreskin usually is non-retractable in the young. Forcible attempts to retract it cause pain and trauma, may result in paraphimosis, and should be avoided.15

In the newborn, infants, and children, only the outside of the foreskin should be washed.7 15 20 The foreskin should never be retracted in the bath because retraction stretches the foreskin sphincter open, allows dirty bathwater to enter and may start infection.19 Retraction of the foreskin in dirty bathwater is not hygenic.

After puberty, however, the sexually active male should wash his penis before and after sexual intercourse. This applies to both circumcised and intact males. Sexually active males may contract HPV through sexual intercourse. Men who use tobacco have carcinogens circulating in the blood and excreted in urine. Washing removes HPV and the carcinogens from tobacco and may help to prevent cancer.12 Of course, it is far better to not use tobacco at all.

When does the foreskin become retractable?

There is no "right" time for the foreskin to become retractable. Two things must happen before the foreskin becomes retractable and each usually takes many years.1

  1. The fusion between the glans penis and the inner surface of the foreskin must become separate.
  2. The narrow tip that prevents retraction must become large enough in diameter to permit retraction.

The time varies widely from individual to individual. Complete separation of the foreskin from the glans may not occur until after puberty.1 20 About 44 percent of boys have a fully retractable prepuce by age 10, by age 16, 90 percent, by age 18, 99 percent.1

Care before puberty

No special care is necessary.7 14

The infant male has a non-retractile self-cleaning foreskin. In most boys no preputial space exists because the foreskin is fused with the glans penis.7 The tip of the foreskin is flushed out several times a day by sterile urine. The protective functions of the foreskin work best if it is left alone and not disturbed.

Parents and caregivers should wash only the outside.7 10 No attempt should be made to retract the foreskin.10 14 15 "Leave it alone" is good advice.7 8 Only the child will know when his foreskin can be retracted without pain and trauma,10 so the first person to retract the foreskin should be the child himself.14 15 20

The foreskin protects the glans penis from the ammonia that is formed by chemical action in the diaper (nappie). One may see some redness of the foreskin from exposure to ammonia while an infant is still in diapers (nappies).15 Frequent diaper changes may prevent this. In severe cases, a protective barrier ointment may be necessary.16 20

In older boys the foreskin may be retractable. Older grammar school boys may be taught to retract their foreskin,7 14 20 rinse the area, and return the foreskin to its normal forward protective position.15 20 If the foreskin is non-retractile, there is no cause for concern. Only the outside needs to be washed.7 10

When visiting the doctor, the doctor should be instructed that the child's foreskin is not to be touched or retracted.10 Parents should remain with the child and physically protect the child from a possible forcible premature retraction by the physician.10

Care after puberty

If the foreskin has not been retractable before puberty, it usually becomes retractable when puberty is complete.1 7 10 15 20

The foreskin keeps the mucosal surfaces moist, emolliated, and maintains optimum health,10 while preventing drying, and keratinization of the mucosa.17 The sub-preputial moisture contains pathogen-fighting substances.17

Washing becomes more important for the sexually active adult male.7 15 After washing, the foreskin should be returned to its normal forward protective position.15 20 If the individual is a smoker, washing removes carcinogens that may be excreted in urine.13 Also, washing removes any accumulation of HPV, the viral carcinogen.

Excessive washing and the use of soap

Apparently, a few adult males wash under their foreskin quite frequently with the use of soap.12 We cannot define excessive washing, but over washing can deplete the natural oils from the mucosa of the inner lining of the foreskin that covers the glans penis.12 Depletion of natural oils causes non-specific dermatitis (NSD) that may be mistaken for balanoposthitis.12 Excessive washing and the use of soap generally should be avoided15 because it may cause balanoposthitis or yeast overgrowth. If soap is used, any residual soap should be rinsed away before the foreskin is returned to its forward protective position.

Penile hygiene for the adult male with a non-retractable foreskin

In one to two percent of males, the foreskin does not spontaneously become retractable. The swirling of the sterile urine under the foreskin usually keeps that area free of smegma buildup.2 Nevertheless, a non-retractile foreskin is listed as a risk factor for penile cancer in the adult male, apparently because removal of HPV and tobacco carcinogens may not be fully accomplished.12 Adult males who have a non-retractile foreskin (phimosis) should consider having their foreskin made retractable. See phimosis for options. Circumcision should be avoided because of pain, trauma, loss of erogenous tissue, and diminished erectile function. If desired, adult males with a non-retractile foreskin may irrigate and flush the sub-preputial cavity with a rubber bulb syringe. Some men healthily and happily live their entire lives with a non-retractile foreskin.15

Library Holdings:

  1. Øster J. Further fate of the foreskin: Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child 1968;43:200-203.
  2. Parkash S, Jeyakumar K, Subramanya K, et al. Human subpreputial collection: its nature and formation. J Urol 1973;110(2):211-12.
  3. Thompson HC, King LR, Knox E, et al. Report of the ad hoc task force on circumcision. Pediatrics 1975;56(4):610-611.
  4. Lakshmanan S. Prakash S. Human prepuce: some aspects of structure and function. Indian Journal of Surgery 1980;44:134-137.
  5. Osborn LM, Metcalf TJ, Mariani EM. Hygienic care in uncircumcised infants. Pediatrics 1981;67:365-367.
  6. Prakash (sic, Parkash) S, Raghuram R, Venkatesan, et al. Sub-preputial wetness - Its nature. Ann Nat Med Sci (India) 1982;18(3):109-112.
  7. Newborns: Care of the Uncircumcised Penis (pamphlet). Elk Grove Village: American Academy of Pediatrics, 1984.
  8. Watson SJ. Care of uncircumcised penis. Pediatrics 1987;80(5):765.
  9. Coppa GV, Gabrielli O, Giorgi P, et al. Preliminary study of breastfeeding and bacterial adhesion to uroepithelial cells. Lancet 1990;335:569-571.
  10. Peron JE. Care of the intact penis. Midwifery Today (November) 1991; Issue 17:24.
  11. Pisacane A, Graziano L, Mazzarella G, et al. Breast-feeding and urinary tract infection. J Pediatr 1992;120:87-89.
  12. Birley HDL, Luzzi GA, Bell R. Clinical features and management of recurrent balanitis: association with atopy and genital washing. Genitourin Med 1993;69:400-403.
  13. Harish K, Ravi R. The role of tobacco in penile carcinoma. Brit J Urol 1995;75(3):375-377.
  14. Wright JE. Further to the "Further Fate of the Foreskin". Med J Aust 1994;160:134-135.
  15. Questions about your son's intact penis (pamphlet). San Anselmo: NOCIRC, 1997. (Link to www.nocirc.org)
  16. Simpson ET, Barraclough P. The management of the paediatric foreskin. Aust Fam Physician 1998;27(5):381-3.
  17. Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Inf 1998;74:364-367.
  18. zur Hausen H. Papillomaviruses causing cancer: evasion from host-cell control in early events in carcinogenesis. J Natl Cancer Inst 2000;92(9):690-8.
  19. Anonymous. The Effects of Circumcision on Breastfeeding. San Anselmo, CA, National Organization of Circumcision Information Resource Centers: 2002.
  20. Camille CJ, Kuo RL, Wiener JS. Caring for the uncircumcised penis: What parents (and you) need to know. Contemp Pediatr 2002;11:61.
  21. Babu R, Harrison SK, Hutton KA. Ballooning of the foreskin and physiological phimosis: is there any objective evidence of obstructed voiding? BJU Int 2004;94(3):384-7.

(File revised 8 August 2004)

http://www.cirp.org/library/hygiene/