Following on from the first post in Paediatric Surgery 101 we come to the tricky topic of foreskins. Management of foreskins is best summed up by the phrase shouted by many a parent at their boy, “Just leave it alone!” This topic bedevilled by firmly held opinions handed on from generation to generation often with little basis in evidence. Rather than a blow by blow discourse of every paper ever printed this is simply a distillation of my personal practice as a specialist paediatric surgeon. Which seems to have worked pretty well over the years.
Editorial note – Circumcisions and foreskins clearly have a cultural and religious significance to many. Here at St.Emlyn’s we make no judgement on this. The post and images are designed to help PED clinicians treat their patients better.
My old boss said to me, “ffolliet, (because he was the one who called me ffolliet) there is nothing wrong with the foreskin of a boy under the age of five.” As an aphorism this is helpful. There is nothing that does or can or cannot happen to the foreskin of a boy under 5 that needs anything done to it. Lots of folks worry about the foreskin of a boy under the age of 5 and espouse weird and wonderful and sometimes deeply unpleasant things for these boys and their foreskins but referring back to the original comment and doing as much nothing as possible will see most boys happy. Just leave it alone
Foreskins get sore and red. This is due to irritation. It is an inflammatory response, hence the redness, not an infection. Nor is it due to the retractability or otherwise of the foreskin. It just happens. There is no need to swab the area, culture the urine, retract the foreskin, stretch it or force creams and lotions under the foreskin in an attempt to alter this. It will get better, on its own. Even the most severe cases, which look as though the poor wee man has been hit with a hammer, just get better. They end up having antibiotics prescribed but this is principally to treat the physician, not any proven infection. They do not need a circumcision. Just leave it alone.
The acute onset of the gross redness and severe swelling will occasion referral for assessment of child abuse in most departments at least once every year as “the story as told does not fit” with the understanding of the physician. In reality, severe balanoposthitis can and does occur without obvious causation in a very short period of time. The only caveat would be to look for hair tie tourniquet at the base of the penis, a rare but real enough phenomenon, where long hair of the carer becomes accidentally entwined around the shaft and a forms a ligature. The astute ED department has hair removal cream1,2 (not a knife) for dealing with this.
With the exception of this redness, the majority of other issues that bring families to the department are related to physics and in particular Poiseuille’s Law, the rate of flow of fluids through a tube. The flow from the urethra may be greater than the prepuce will allow and thus spraying and or ballooning. Somewhat counter-intuitively this is an acquired rather than congenital problem and its new occurrence is what causes concern in families. It is “acquired” as the foreskin separates gradually from the glans penis and a much large space within the foreskin develops. The foreskin then balloons, which it previously had not, and the urine often sprays rather than being a single stream. This is not indicative of pathology. It is indicative of physics. Just leave it alone.
Which brings the discussion nicely to the the retractability of the foreskin. A foreskin may retract at any age between the first few months of life and puberty. The average age of retraction is 10.4 years3. Precisely when that happens in an individual is neither here nor there. It affects nothing in a pre-pubertal boy either positively or negatively except the desire of the uneducated to “do something rather than wait until he is older.” It is not a hygiene issue. It does not cause urinary tract infections. It does not lead to balanitis. It won’t “affect him in later life.” There is consequently no need to assess if the foreskin retracts. Glans adhesions noted on retracting a foreskin are not pathological in their existence merely indicative of the evolving process and need no intervention as they do not cause problems. There is no value in encouraging anyone to “stretch the foreskin in the bath”, give creams, give steroids or remove it. Just leave it alone.
There is only one exception to this, the exotic condition called balanitis xerotica obliterans4. As the name suggests this is a dry, scarring condition of the foreskin that frequently extends onto the underlying prepuce. It literally obliterates the meatus of the foreskin. This is phimosis, “to be muzzled.” It presents with recurrent balanitis, ballooning, spraying and clearly, a non retractile foreskin. All of the conditions that a normal child may experience. How does one make the diagnosis? Simply look at the foreskin. Ask the little boy himself, to retract the foreskin. If it looks white and shiny and scarred and nasty, then it’s probably BXO. If it doesn’t, whatever else it looks like, then it is normal. Forget “early”, “suggestive of”, “possible” and any other loose phrases, trust me, the first time you see a small boy with BXO you will know. These guys, need to see a paediatric surgeon in the next few weeks as the only effective treatment is circumcision. The wise amongst you will have figured out the age below which BXO does not happen.
A foreskin that is retracted behind the glans and left in that position for a significant period of time may lead to paraphimosis. This is marked oedema of the glans penis that prevents the foreskin from being replaced. It is important to return the foreskin to its anatomical position. How this is achieved is due to a combination of pressure and force and most EDs have their own special techniques, lotions and manoeuvres. My best advice involves squeezing the glans for an extended period of time to reduce the oedema before attempting anything else. Despite old fashioned teaching, these boys do not require a circumcision if reduction can be achieved. The oedema will settle and they won’t repeat the problem that got it there in the first place. Failure to reduce a paraphimosis is virtually always due to lack of persistence.
The only other reason foreskins should bother an ED physician is when there is a problem with the procedure to remove it. There are two basic techniques; cutting and strangling, with multiple variations of both5. Ask the parents what was done. In the cutting types the foreskin and inner preputial layer are removed by some form of blade. In the strangling variation, some form of ligature or crushing leads to the slow ischaemia of the layers. The risk of complications from these procedures carried out in the community is actually lower than the risk from hospital procedures due to the huge denominator of these groups.
The common complications that are seen are bleeding or swelling with retained devices. Bleeding is never due to a significant vessel leaking and consequently simple haemostatic techniques will work. Direct pressure really is all that is required (Ed – there are rare case reports of shock/transfusion being required if simple measures not done or a bizarre technique has been used but these are very rare). Add topical tranexamic acid if available or even adrenaline soaked swabs but the fact of the matter is pressure stops all bleeding. Find a foreign language you don’t speak and count to one thousand in it whilst you press. And don’t look. The bleeding will stop. “Satu, dua, tiga…” For crush techniques the commonest problems are akin to paraphimosis; the retained device, usually some form of ring, is too tight, causing constriction proximal to the glans penis. Ring cutters work well. Think finger with deformed wedding band. Bizarrely, penises virtually never get infected after such interventions. They make look horrid, particularly after circumcision for BXO but the real numbers of actual wound infection is very very low indeed.
Foreskins cause a whole lot of trouble, usually not in and of themselves but because of who they are attached to. For the majority of problems of the foreskin itself, the best advice is just leave it alone. And no, they don’t need a circumcision.
As a footnote I apologise here and now for the three million, two hundred and forty seven thousand, five hundred and nine regional variations you will hear of this opinion. Sorry, make that five hundred and ten. Eleven! No, twelve…The reality is, for that many variations, no one is right. Just leave it alone.
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