Contemporary Pediatrics, Volume 11: Page 61, November 2002.
By Cynthia J. Camille, FNP, CPNP, Ramsay L. Kuo, MD, and John S. Wiener, MD
A declining circumcision rate means more and more parents need to be educated about care of their son's foreskin and more pediatricians need to be prepared to manage problems associated with an uncircumcised penis.
Although still very common, routine neonatal circumcision has been declining in prevalence in the United States in recent years.1 Pediatricians are seeing more uncircumcised boys among their patients and, in turn, encountering more parents asking for advice on care of the prepuce. Many parents—and many physicians—are unfamiliar with normal development ofthe penis and foreskin.
In this article, we do not address in depth the pros and cons of neonatal circumcision. Rather, we focus on the development and routine care of the normal, uncircumcised penis, as well as management of commonassociated problems.
Circumcision has been a controversial topic in both professional and lay circles for a number of years. The procedure has historically been performed for cultural, religious, and medical reasons. Opposition to routine neonatal circumcision has been vocal, and medical indications have been revisited over the past three decades. The American Academy of Pediatrics (AAP) has issued several policy statements during this period, the most recent in 1999. Current AAP recommendations state that while there are potential medical benefits of newborn male circumcision, the data are not sufficient to recommend routine neonatalcircumcision.2
Although accurate data on the prevalence of routine circumcision are lacking, it is known that approximately 80% of males born in the US in the years after World War II were circumcised; that percentage increased with the percentage of hospital births.1 The number declined slightly when some voices in the medical establishment began to question the value of the procedure. Most recent estimates of the rate of neonatal circumcision are in the range of 60% to 65%, with a noted difference across racial and ethnic groups.2 When other variables are controlled, data from the National Health and Social Life Survey for the years 1933 to 1974 show that the rate of circumcision for whites was 81%; for blacks, 65%; and for Hispanics, 54%.1 Despite some convergence in the circumcision rate for the three groups across cohorts, differences among racial and ethnic groups persist.1 With the Hispanic population in the US growing, uncircumcised males are being seen even more often in pediatric practice.
At eight weeks' gestation, the skin of the body of the penis begins growing forward over the developing glans penis, initially as a ridge of thickened epidermis. The prepuce grows more quickly dorsally than ventrally, where full development depends on final formation of the glanular urethra. This explains why the foreskin is usually deficient ventrally in cases of hypospadias.
If all proceeds normally, the prepuce is complete by 16 weeks' gestation. The squamous epithelial lining of the inner prepuce is contiguous with the glans at this stage, so that preputial adhesions are a normal part of development, not a pathologic state.2,3 Desquamated skin cells become entrapped on the glans beneath the adhered prepuce, leading to formation of preputial cysts, also known as keratin pearls. The rupture of these cysts allows progressive separation of the inner prepuce from the glans. Penile growth, along with intermittent erection, aids in the process that eventually completely separates the prepuce from the glans to form the preputial space (Figure 1). This process begins late in gestation and proceeds at varying rates during childhood; therefore, the age when the prepuce is completely retractable also varies.2,3 Complete retraction past the corona is possible in at least 90% of boys by 5 years of age.
The previous statement is based on outmoded information. For more information on the age of foreskin retraction, see Normal.
In contrast, some boys will not have complete separation of the prepuce circumferentially beyond the corona until accelerated penile growth occurs at puberty.
Parents of a newly circumcised boy receive instructions on care of the infant's penis, but parents whose son is not circumcised typically receive no such advice. As a result, many parents have misconceptions. The most common misconception encountered in our practice is that the foreskin is completely retractable early in life and that complete retraction is necessary to keep the penis clean and prevent infection. Many consults are prompted by parental concerns about the presence of congenital adhesions or by questions about the need for circumcision to prevent irritation and infection. Many parents and physicians are unaware that preputial adhesions are normal and that they resolve on their own at an individual pace.
Parents should be educated to avoid forcible retraction of the prepuce; the tearing that may result could lead to fibrosis and subsequent true phimosis (discussed later) or pathologic adhesions, or both.4
In the infant, washing the penis with a cloth and water is adequate to keep the penis clean. If a mild soap is used, the penis should be rinsed well to avoid irritation. However, we typically counsel parents to avoid using soap. Once preputial adhesions have separated naturally, typically around the age of toilet training, the foreskin will be retractable and should be retracted with routine bathing. After cleaning, it is helpful to retract the foreskin again to dry the glans and prevent irritation from moisture trapped under the foreskin.
Mild redness of the foreskin or glans is common, particularly in the infant and young child still in diapers, and usually requires only cleaning. Focal erythema may occur sporadically as preputial cysts break through adhesions to allow separation of the prepuce from the glans. These whitish cysts are sometimes mistaken for pus due to infection, but they merely represent sterile collections of desquamated skin (Figure 2). More significant dermatitis may require a barrier cream with zinc oxide.
Some physicians believe that the foreskin should be left alone until the child is old enough to retract it on his own. There is no consensus about the appropriate age to teach penile hygiene, including regular retraction of the foreskin. We recommend teaching the school-age child to retract and clean beneath the foreskin at least once a week as part of routine hygiene, whether complete retraction is possible or not. Others advocate waiting until puberty, when complete retraction is readily achieved.
Assessment at well-infant and well-child exams should address any concerns about the appearance of the genitalia. Retractability of the prepuce should be assessed by history as well as on examination. In the infant it is usually, but not always, possible to visualize the meatus (Figure 3). Rarely, in cases of pathologic phimosis, the urinary stream may be blocked, causing ballooning of the prepuce with urination or deflection of the urinary stream.
Evaluate the degree of foreskin retraction and meatal location and size by gentle traction. Avoid forcible retraction. As the child grows, the foreskin should gradually become more retractable.
Trauma or infection of the glans (balanitis) can cause erythema and edema. The term balanoposthitis refers to inflammation of the glans and prepuce. Purulent discharge from the thickened and erythematous preputial orifice is the usual sign (Figure 4). Patients often complain of dysuria, making the distinction between balanoposthitis and true urinary tract infection difficult.3 A reliable urine specimen cannot be obtained because voided urine or a "sterile" collection catheter must pass through the contaminated preputial space, which cannot be cleansed adequately. A suprapubic tap can obtain a urine specimen directly from the bladder without the risk of preputial contamination, but is not commonly done. Distinguishing between balanoposthitis and urinary tract infection is, therefore, often a matter of clinical judgment. Purulent drainage from the preputial orifice and preputial swelling and erythema are not usually seen with a urinary tract infection. The common causative organisms of balanoposthitis are coliform, such as Escherichia coli or Proteus vulgaris,3 so empiric antibacterial therapy would likely cover a diagnosis of either balanoposthitis or urinary tract infection.
In caring for the uncircumcised male, it is necessary to differentiate between physiologic phimosis and pathologic phimosis. Phimosis refers to a prepuce that is nonretractable, as is usually the case in the newborn. Physiologic phimosis is present in nearly all newborn males because of congenital adhesions of the prepuce to the glans proximal to the urethral meatus. As noted, in most infants retraction allows visualization of the urethral meatus but not of the remainder of the glans.
True, or pathologic, phimosis is defined as the presence of an abnormal ring of tissue, which prevents sufficient retraction of foreskin to allow visualization of the meatus. The fibrotic preputial ring, or cicatrix, of tissue is distal to the glans and prevents retraction and routine hygiene. A cicatrix may form following scarring from forcible retraction or following episodes of balanoposthitis.5 The symptoms of pathologic phimosis include secondary unretractability of the foreskin after retractability at an earlier age, irritation or bleeding from the preputial orifice, dysuria, ballooning of the prepuce upon voiding, acute urinary retention, and, rarely, chronic urinary retention and obstructive changes in the upper urinary tracts.5 Ballooning of the prepuce with voiding is common in infancy but is usually harmless, self-limited, and not indicative of urinary obstruction. (Ballooning after infancy is less common and may represent pathologic phimosis.)
Pathologic phimosis has been traditionally treated surgically with circumcision. Although circumcision is effective, it is not without complications, particularly in older infants and boys who must undergo general anesthesia. The risks include anesthetic complications, bleeding, infection, meatal stenosis, penile or urethral injury, discomfort, and possible psychological consequences. These risks, as well as financial considerations, are all reasons to pursue nonsurgical alternatives to therapy. Parents often made a conscious decision not to circumcise their son and are reluctant to give consent for circumcision at a later age. Recently, the use of topical steroid treatment has been shown to be an effective and safe alternative to surgical intervention, with success rates ranging from 67% to 95% and no reported adverse effects.5–7
A retrospective review of boys with pathologic phimosis seen in our pediatric urology clinic in 2000 revealed 20 patients, age 8 months to 14 years (mean, 5.8 years), who were placed on topical steroid therapy.8 The parents were instructed to retract the foreskin until the phimotic band prevented further retraction and to apply betamethasone dipropionate 0.05% cream on the constricting band twice a day for four to eight weeks. A successful outcome was defined as resolution of the phimotic band allowing foreskin retraction proximal to the meatus. Partial retraction allowed visualization of the meatus and at least 50% of the glans in cases with persistent congenital adhesions preventing complete retraction proximal to the corona. Of the 20 patients, 17 (85%) had a successful outcome. Eleven patients had a completely retractable foreskin, whereas six became partially retractable. Often, a response was seen in less than two weeks. (For this reason, we now recommend a four-week, rather than eight-week, course of therapy.) Patients who were successfully treated have not had recurrence of phimosis. Two patients developed temporary paraphimosis (in which the retracted prepuce becomes trapped proximal to the corona) when their foreskins were left retracted, but these were easily reduced by the parents and no medical attention was needed. No patient has had any apparent side effect from the topical steroid treatment. Three patients did not respond to therapy. The mean age of patients with fully retractable foreskins following therapy was 6.7 years, compared with a mean of 3.8 years for those with partially retractable foreskins. These findings correlate with the finding of a higher prevalence of glanular adhesions inyounger patients.
The efficacy results of our study correspond to those reported previously. The major variable accounting for differences in the efficacy rate between studies is the definition of successful outcome. Some groups considered any result short of complete foreskin retractability a treatment failure.5 Others have defined success as achieving, at minimum, partial retraction to the limit of congenital adhesions.7 As expected, those studies adhering to the stricter definition for success have lower overall efficacy results. Our study chose to include partial retractions as success because adhesions of the foreskin to the glans are common in young boys, and resolve spontaneously. These proximal adhesions should not be considered a contributing factor to phimosis.
The cost-effectiveness of therapy for phimosis has been reviewed, comparing medical and surgical interventions. The most cost-effective management was topical steroid therapy, which resulted in a 75% savings compared with circumcision.9,10 In our hospital pharmacy, a 15 g tube of betamethasone dipropionate 0.05% cream sells for $9.52, and is usually sufficient for the typical four-week courseof therapy.
Despite the proven efficacy of topical steroids in treating persistent phimosis, concern exists about potential side effects—specifically, suppression of the hypothalmic-pituitary-adrenocortical (HPA) axis from systemic absorption of topical steroids. Systemic absorption is enhanced by inflammation, use over a large surface area, prolonged use, and use of an occlusive dressing.5 Golubovic and colleagues included measurement of the morning cortisol level in patients receiving betamethasone dipropionate cream for phimosis and found no differences in the treatment group vs. controls.11 Orsola and colleagues reported a series of 137 boys treated with betamethasone dipropionate 0.05% who had no signs of skin atrophy or systemic absorption.6 Four of these subjects were younger than 2 years. We, therefore, believe that betamethasone dipropionate can be used safely in small amounts for one or two months, despite lack of approval by the Food and Drug Administration for use in persons younger than 16 years. (Instructions for parents on treating phimosis with betamethasone dipropionate are provided in the "Guidelines for treating phimosis with steroid cream" box.)
The mechanism of effect of betamethasone dipropionate cream on the phimotic ring is thought to be local anti-inflammatory action.9 Resolution of the phimotic band then allows the prepuce to dilate and slide backward over the glans. Betamethasone cream may improve the elasticity of the foreskin and, together with the moisturizing effect of the cream, allow for easier retractability for hygiene measures, thought to help prevent recurrence of acquired phimosis. Whether moisturizing creams without an anti-inflammatory agent would have a similar efficacy is unknown.
The acute condition paraphimosis develops when the prepuce is retracted and then trapped proximal to the corona, with subsequent edema, pain, and venous congestion. A tight band is created around the penile shaft and the prepuce cannot be returned to its normal position. Immediate intervention is needed, beginning with manual reduction with gentle pressure. Four fingers from each hand are placed on each side of the trapped prepuce, and upward tension is applied while the two thumbs push the glans downward through the preputial opening.
Paraphimosis may progress to the point where urgent urologic consultation is needed, and surgical intervention may be indicated. Reduction under general anesthesia is almost always possible without need for a dorsal slit, and circumcision should be considered only for the unusual case of recurrent episodes.3 Avoiding forcible retraction and replacing the prepuce back over the glans after cleansing or catheterization can help prevent paraphimosis.
Urinary tract infection and acute balanoposthitis. Difficulty obtaining a urine specimen in the uncircumcised male makes it challenging to diagnose a urinary tract infection with certainty. Uncircumcised boys have a higher incidence of urinary tract infection compared with circumcised boys younger than 5 years.12 The reason is thought to be enhanced preputial bacterial adherence to the inner prepuce, along with a higher rate of colonization in the periurethral area of uncircumcised boys.12
Balanitis and balanoposthitis are infrequent problems in children and rarely lead to bacterial ascent in the urethra to initiate a true urinary tract infection.13 These conditions usually respond to an antibiotic with broad coverage, such as a first-generation cephalosporin; the high antibiotic concentration in the urine leads to rapid resolution of the infection, and a topical antibiotic is usually not needed. Only in the most severe cases of infection accompanied by urinary retention is acute surgical intervention (a dorsal slit) required.
An unrelated condition, balanitis xerotica obliterans (BXO), also known as lichen sclerosus et atrophicus, is a chronic atrophic mucocutaneous disorder with no known cause. Fortunately, it is rare in children.14 BXO may affect the glans and the meatus. In its most severe form, involvement of the prepuce obliterates the preputial sac with dense adhesions, and the urethra may be affected.3 Surgery, in the form of circumcision, meatotomy, or, in severe cases, urethroplasty, may be required.
Penile lymphedema is a rare problem, affecting the prepuce and sometimes involving the shaft to varying degrees. Inflammatory erythema can make it difficult to distinguish lymphedema from balanoposthitis in the initial acute phase. Surgical intervention (a dorsal slit) in the acute phase may be needed in patients with urinary difficulty. More definitive therapy with circumcision is best postponed for at least six months.3
Parental concerns about care of their uncircumcised son can often be addressed with education and reassurance (a Guide for Parents appears below). With older circumcised boys, review penile hygiene during health supervision visits. With pubertal males, also include education on testicular self-examination.
Topical steroid therapy is a cost-effective, safe, and frequently efficacious treatment for phimosis. Referral for urologic consultation is indicated for true phimosis that is unresponsive to topical steroid therapy, difficulty urinating, or balanoposthitis not responsive to an antibiotic.
When betamethasone dipropionate 0.05% cream is prescribed for phimosis, it is generally applied twice a day for four weeks. One 15 g tube is usually sufficient. You can provide parents with the following instructions.
Apply the betamethasone dipropionate cream once after your son urinates in the morning and once after he urinates in the evening, following these guidelines:
The parent guide on care of the uncircumcised penis may be photocopied and distributed to families in your practice without permission of the publisher.
Many parents who have chosen not to have their son circumcised have questions about how to care for the penis. They also want to know what is "normal" for a penis that has foreskin—the skin that covers the head of the penis.
When a boy is born, the foreskin is not usually retractable. This means that it can't be pulled back over the head of the penis (called the glans). A normal process occurs that gradually separates the foreskin from the glans. The penis sheds skin cells, which may look like whitish pearls, lumps, or bumps under the foreskin. These cells, called smegma, are part of the separation process. Erections aid in this process, causing the foreskin to retract or loosen up a little at a time.
The foreskin separates from the glans bit by bit until it can be retracted (pulled back) without difficulty. This occurs in most boys by the time they are 5 years old, but the age varies for each child; in some boys, the foreskin may stay partially stuck to the head of the penis until puberty. The foreskin should never be forcibly retracted, as this can cause pain and bleeding and may result in scarring and trouble with natural retraction.
The foreskin of an infant's penis needs no special care. The most important thing to remember is not to force the foreskin to retract. Wash the penis regularly when you give your son a bath. Avoid most soaps or cleansing agents because they can irritate the penis; water is usually sufficient for cleansing.
Frequent diaper changes to keep urine and feces away from the skin decrease skin irritation, helping to prevent diaper rash, which can occur on just the penis or scrotum or on any part of the diaper area. Diaper creams containing zinc oxide are useful if a rash does develop, as they create a protective barrier.
Once the foreskin separates easily from the glans, gently retract and clean underneath the foreskin with a washcloth and water at least once a week. After cleansing, always pull the foreskin forward to its normal position. Retract the foreskin again after the bath so you can dry the head of the penis with a towel; then again pull it back to the normal position to cover the head.
Teach your son to retract the foreskin and clean on a regular basis as he takes more responsibility for his own bathing, usually during the preschool years. As he gets older and bathes alone, verbally remind him about proper penile hygiene; the foreskin should be cleaned with each bath or shower.
The advice to see one's pediatrician if the head of the penis cannot be seen by the time the boys is five years old apparently is based on the now outmoded and erroneous belief that 92 percent of boys should have a retractile foreskin by age 5. Most wrongful diagnoses of alleged "pathologic phimosis" in childhood are based on outdated beliefs about when the foreskin should become retractile. For current correct information on the development of retractability, see Normal.
This guide may be photocopied and distributed without permission to give to the parents of your patients. Reproduction for any other purpose requires express permission of the publisher. Copyright © 2002 ThomsonMedical Economics
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