Care and complications of the uncircumcised penis in infants and children

INTRODUCTION — The care and complications of the uncircumcised penis in infants and children will be reviewed here. The procedures, risks, benefits, and complications of circumcision are discussed separately. (See "Neonatal circumcision: Techniques" and "Neonatal circumcision: Risks and benefits" and "Complications of circumcision".)

NORMAL ANATOMY AND DEVELOPMENT OF THE FORESKIN — The foreskin (prepuce) is the excess skin that typically extends approximately 1 cm beyond the glans (picture 1 and figure 1). It provides protection to the urethral meatus and glans penis.

The normal foreskin begins to develop as an epithelial fold that grows inward from the base of the glans penis at eight to nine weeks gestation with normal completion by 4 to 4.5 months gestation. The squamous epithelial lining of the inner prepuce is contiguous with the glans penis, resulting in the normal initially circumferential adhesions between the inner layer of the prepuce and the glabrous epithelium of the glans penis.

ROUTINE CARE

History and physical examination — The history and physical examination of an uncircumcised child focuses on identifying symptoms of potential pathologic conditions.

●History – History concentrates on evaluating the urinary stream and any symptoms related to voiding with the following questions:

•Is the urinary stream strong?

•Is the urinary stream straight? If the answer is no, is there any dribbling or spraying noted?

•Does the foreskin balloon out when voiding?

•Does the infant/child appear comfortable while voiding?

If this reveals any issues with the urinary stream (other than simple ballooning), a more in-depth assessment should be performed. If possible, direct observation of the urinary stream can provide information about complications or potential pathologic conditions of the foreskin. In particular, if the child has to strain to void, that may reflect flow obstruction. Although ballooning can be associated with increased risk of infection, it also reflects separation of the foreskin from the glans, which may be a sign of imminent full retraction. Similarly, spraying may also reflect foreskin separation. (See 'Distinguishing pathologic phimosis' below and 'Associated pathologic conditions' below.)

●Physical examination – The uncircumcised penis is examined during the newborn visit and at each well-child visit.

•During the newborn examination, the penis and foreskin (picture 1) are assessed for any anatomic abnormalities (ie, hypospadias, penile chordee). It may be possible to visualize the urethral meatus with very gentle retraction (ie, retracting until one feels any resistance) of the tip of the foreskin. Physical examination reveals a pliant unscarred preputial orifice [1] (picture 2).

•During well-child checks, the penis and foreskin are assessed for anatomic abnormalities (ie, hypospadias) or signs of pathologic conditions (ie, balanoposthitis). While some degree of phimosis is normal during much of childhood and does not require any intervention, paraphimosis (when the foreskin is retracted behind the glans penis and cannot be returned to its normal position (picture 3)) requires emergency intervention. (See 'Paraphimosis' below and "Paraphimosis: Clinical manifestations, diagnosis, and treatment".)

Well-child checks are also a good time to educate parents/caregivers and growing boys about proper care and hygiene of the uncircumcised penis.

Hygiene — Expert opinions vary on the best practices for preputial care and evidence-based guidelines do not exist [2]. Our approach to routine infant prepuce care is based on expert opinion and observational studies [1,3,4]:

●Wash the penis when a bath is given, either with water alone or with soap, provided it is nonirritating and safe for the child's age.

●Wash the penis the same way that a finger would be washed, without retracting the foreskin.

●Change diapers frequently to prevent diaper rash and decrease skin irritation.

The foreskin should never be forcibly retracted (see 'Counseling on retraction' below) during bathing. However, as the foreskin naturally becomes more retractable, the foreskin and the area underneath it can be cleaned and dried. After bathing, the retracted foreskin should always be pulled down to its normal position covering the glans penis. Uncircumcised boys should be instructed on retraction of the foreskin, regular cleaning and drying of the glans, and returning the foreskin to its normal position, since they will be performing their own care as they grow. Failure to replace the foreskin may result in paraphimosis which results in venous and lymphatic congestion of the glans (picture 3). (See "Paraphimosis: Clinical manifestations, diagnosis, and treatment".)

Educating boys and their caregivers about proper care and hygiene of the uncircumcised penis is an essential part of clinical care [5]. Optimal education reduces anxiety and unnecessary referrals to subspecialists and, perhaps, lowers the risk of pathologic phimosis [6]. However, it seems that this is not routinely done; in one study of pediatric urologists, only 66 percent of those surveyed reported routinely advising parents on routine foreskin care [2].

Counseling on retraction — Forcible retraction should be avoided, as it can cause tearing of the preputial skin, leading to bleeding, fibrosis, and potentially pathologic phimosis. For uncircumcised children for whom there is concern that the foreskin is not retracting, who have had frequent infections associated with un-retracted foreskin, or who are older than five years old, we suggest gentle retraction (ie, retracting until one feels any resistance) of the foreskin while bathing. Children and families should be advised that once the foreskin can be retracted past the glans, it is important to return it to its original position. Gentle retraction facilitates the breakdown of adhesions between the inner preputial skin and the glans penis. As the adhesions are broken down, the foreskin becomes progressively more retractile.

Although age and toilet training status are often used as guidelines for when to start gentle retraction, expert opinions vary. One study of 204 pediatric urologists reported that approximately half (48 percent) used age of the child as a guide for when to start gentle retraction, 19 percent used toilet training status, 8 percent advised retraction when the foreskin was easily reducible, and 5 percent advised starting retraction at birth [2]. Opinions varied even among those who based their advice on the age of the child. Most respondents (61 percent) advise starting retraction between two and five years of age, but 16 percent advise starting by 6 to 11 years, 13 percent advise starting at less than two years, and 10 percent advise starting at 12 years or older.

Benign conditions — Benign conditions that do not usually require intervention, but only reassurance, include smegma, preputial cysts, and foreskin ballooning.

Smegma and preputial cysts — Desquamated epithelial cells that are trapped under the foreskin are referred to as smegma [1]. Smegma aids in the process of separation between the foreskin and the glans penis. It appears as a yellow-white cheese-like substance under the foreskin. In boys without a fully retractable foreskin, smegma may form white lumps under the foreskin, often referred to as preputial cysts or pearls. Preputial cysts are benign and usually are located around the corona. They are extruded once the foreskin becomes more retractable.

Foreskin ballooning — Transient ballooning of the foreskin during voiding is usually benign [1]. Parents/caregivers can be assured this is a benign condition that will resolve over time as there is increasing retractability of the foreskin. However, if urinary retention can only be resolved after applying manual pressure, the parent or caregiver should seek medical attention.

PHIMOSIS

Definition and natural history — Phimosis is defined as an inability to retract the foreskin. It is present in almost all newborn males due to adhesions between the inner layer of the prepuce and the glans penis. Progressive foreskin retraction becomes possible over time as the adhesions break down.

Separation of the foreskin from the glans penis occurs by desquamation and begins late in gestation, but separation remains incomplete in most male infants at birth. Only approximately 4 percent of males have a completely retractable foreskin at birth, and in more than half of newborn males the foreskin cannot be retracted far enough to visualize the urethral meatus [3]. After birth, penile growth and physiologic erection aid in the desquamation process and the formation of keratinized pearls (smegma) between the layers, which loosens the adhesions and allows retraction of the preputial skin.

Although the rate of spontaneous resolution is high, the timing is highly variable, so there is no definite age when the foreskin should be completely retractile [7-9]. In general, over 60 percent of boys in fourth grade are able to either fully or partially retract their foreskin so that part of the glans penis is visible [7]. Approximately 95 percent retract by puberty. School-age boys without a fully retractable foreskin and their parents/caregivers should be counseled that there is normally a wide range of retractability rate, and over time, there is a very high likelihood physiologic phimosis will spontaneously resolve. The clinician should also reinforce proper preputial hygiene.

The incidence of a fully retractable foreskin increases with age as the rate of phimosis decreases [7,8,10]. This was illustrated in a study of 2149 Taiwanese school boys, which reported the incidence of the following five categories of preputial anatomy for three different age groups based on grade level; first, fourth, and seventh grade [7]:

●Fully retractable: 8, 21, and 58 percent, respectively

●Partial retraction with part of the glans penis visible: 40, 41, and 29 percent, respectively

●Partial phimosis with only the urethral meatus visible and none of the glans penis: 33, 25, and 7 percent, respectively

●Phimosis with nonvisualization of the meatus and glans: 17, 10, and 1 percent, respectively

Management of physiologic phimosis — Physiologic phimosis does not typically need specific treatment given the high rate of spontaneous resolution, as above. However, for boys or caregivers who are concerned about how long it is taking to achieve full retraction or who have had frequent infections we suggest the following approach:

•Stretching exercises (retraction as far back as the appearance of stricture for one minute) performed several times a day. (See 'Counseling on retraction' above.)

•Betamethasone cream (0.05%) applied twice a day directly on and around the phimotic ring for four to eight weeks to speed up the natural process of foreskin retractility. Other effective topical corticosteroids include 0.25, 0.1, and 0.5% triamcinolone and 0.05% fluticasone propionate [1,6,11-15].

This approach is supported by randomized trial and observational data [11-15]. In a meta-analysis of 12 studies that included 1385 individuals with phimosis, topical corticosteroids increased the rate of complete or partial resolution within four to six weeks compared with placebo (84 versus 34 percent, RR 2.45, 95% CI 1.84-3.26) [6]. Adverse effects were not well reported, and risk of bias was deemed uncertain because of incomplete reporting on study design.

Observational studies have supported combining stretching exercises with topical corticosteroids. In two observational studies, treatment with 0.05% betamethasone cream twice daily application of cream for at least four weeks plus stretching exercises, was associated with complete resolution of phimosis in over 90 percent of patients [11,12]. In both studies, therapeutic response rates were similar regardless of the initial severity of phimosis. Observational data also suggest that stretching exercises alone are less effective than stretching exercises plus topical corticosteroids [11-15]

Distinguishing pathologic phimosis — Although phimosis in infants and children is typically benign and reflects normal development of congenital adhesions between the foreskin and glans, pathologic phimosis can occur, predominantly in older children. Pathologic phimosis is defined as a foreskin that is truly nonretractable due to distal scarring of the prepuce. It may occur after preputial fibrosis due to trauma (ie, forcible retraction), infection, and/or inflammation. The reported incidence of pathologic phimosis ranges from 0 to 16 percent [16]. It is important for primary care clinicians to be able to distinguish between benign, physiologic and pathologic phimosis so that unnecessary referrals to pediatric urologists can be avoided for the patient and his family.

Pathologic phimosis should be suspected when patients who were previously able to retract the foreskin can no longer do so. Other symptoms of pathologic phimosis may include:

●Irritation or bleeding from the preputial orifice

●Dysuria

●Painful erection

●Recurrent balanoposthitis

●Chronic urinary retention with ballooning that is only resolved with manual compression

Examination of the phimotic penis may reveal a fibrotic preputial ring (cicatrix) that appears as a contracted white fibrous ring around the preputial orifice (picture 4) [1]. A cicatrix can form from scarring due to forcible retraction or following episodes of balanoposthitis, or it may occur from scarring after circumcision. (See "Complications of circumcision", section on 'Cicatrix'.)

Foreskin entrapment behind the coronal sulcus suggests paraphimosis (picture 3), which is distinct from phimosis and is a medical emergency. (See "Paraphimosis: Clinical manifestations, diagnosis, and treatment".)

Patients who have none of these findings likely have physiologic phimosis. (See 'Definition and natural history' above.)

Management of pathologic phimosis — Pediatric urology consultation is needed in patients with pathologic phimosis, regardless of whether symptoms are present, since it increases the risk of other foreskin complications (ie, paraphimosis, recurrent urinary tract infections, recurrent/severe balanoposthitis, BXO) [17].

Although initial therapy with topical corticosteroids and stretching, as used for physiologic phimosis (see 'Management of physiologic phimosis' above), can be attempted, we inform patients and parents that it is unlikely to be successful once the foreskin has fibrotic scarring.

We determine the best alternative treatment based on the clinical findings and the patient/family/caregiver’s preference. Surgical options include preputioplasty (surgical release of the scarred tissue), preputial balloon dilation, and various prepuce preserving plastic surgical procedures designed to widen the preputial ring. Among males requiring surgical intervention for foreskin complications, phimosis is the most common cause, reported in 95 percent in one review [17].

Circumcision is a procedure of last resort for the treatment of pathologic phimosis. We never counsel families that their child "needs" a circumcision without first considering more conservative interventions. It is discussed in detail separately. (See "Neonatal circumcision: Techniques" and "Neonatal circumcision: Risks and benefits".)

ASSOCIATED PATHOLOGIC CONDITIONS

Paraphimosis — Paraphimosis is caused by foreskin entrapment behind the coronal sulcus, which may result in venous and lymphatic congestion of the glans, and ultimately arterial compromise (picture 3). Paraphimosis is a medical emergency requiring immediate care. Its clinical features and management are discussed separately. (See "Paraphimosis: Clinical manifestations, diagnosis, and treatment".)

Recurrent urinary infection — There is a 4- to 10-fold increased risk of urinary tract infection (UTI) in uncircumcised versus circumcised male infants. In boys with recurrent UTI or who have UTI and/or evidence of genitourinary abnormality (eg, renal scarring and vesicoureteral reflux), circumcision may be considered as a potential intervention to decrease the risk of future UTI [18-23]. (See "Urinary tract infections in children: Epidemiology and risk factors", section on 'Lack of circumcision'.)

Balanoposthitis — Balanoposthitis is an inflammatory condition of the glans penis and the foreskin (picture 5). Balanitis is inflammation of only the glans. Although the etiology is multifactorial in children, balanoposthitis typically results from poor hygiene that is sometimes complicated by secondary infection. In patients with recurrent balanoposthitis, pathologic phimosis may be an underlying contributing factor, which should be corrected. (See 'Distinguishing pathologic phimosis' above.)

The epidemiology, clinical features, diagnosis, and acute management of balanoposthitis are discussed separately. (See "Balanitis and balanoposthitis in children and adolescents: Clinical manifestations, evaluation, and diagnosis" and "Balanitis and balanoposthitis in children and adolescents: Management".)

Balanitis xerotica obliterans — Balanitis xerotica obliterans (BXO) is a chronic atrophic dermatitis of the foreskin and glans penis of unknown etiology. It is the genital analog of lichen sclerosus et atrophicus and is characterized by white atrophic plaques on the glans penis and foreskin [24]. These plaques eventually enlarge and coalesce into a sclerotic mass with resultant adhesions, phimosis, and meatal stenosis. Because it is uncommon in children, BXO disorder is rarely diagnosed by pediatricians (picture 6).

Although topical corticosteroids have been used to treat BXO, the results are poor except in mild cases [25]. In patients with pathologic phimosis and/or meatal involvement, circumcision is the preferred intervention as it is curative in most patients. However, if after circumcision BXO is persistent, then meatal reconstruction and/or a dermatology consult may be necessary.

In one case series from Children's Hospital Boston over a 10-year period from 1992 to 2002, none of the 41 patients (mean age 10.6 years) with pathologically confirmed BXO were diagnosed prior to referral [26]. In this cohort of patients, 19 patients underwent curative or repeat circumcision, 11 with BXO involvement of the urethral meatus underwent circumcision with meatotomy or meatoplasty, and 9 patients required extensive plastic surgery, including two who received buccal mucosa grafts.

Frenulum breve — The frenulum of the penis is an elastic band of tissue under the glans penis that connects to the foreskin and helps contract it over the glans. Frenulum breve is a congenital condition in which the frenulum is too short, and thus restricts the movement of the foreskin. This condition is typically more symptomatic during an erection as the short frenulum pulls the glans ventrally with erection, leading to pain. In severe cases, during sexual stimulation the frenulum can rupture, leading to discomfort and bleeding [17]. Surgical correction may be necessary if symptoms become severe or if rupture occurs.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Uncircumcised penis".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Should I have my baby circumcised? (The Basics)" and "Patient education: Care of the uncircumcised penis in babies and children (The Basics)")

●Beyond the Basics topics (see "Patient education: Circumcision in baby boys (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Routine care – The foreskin (prepuce) is excess skin that extends beyond and protects the glans penis and urethral meatus (picture 1 and figure 1). Care of an infant’s uncircumcised penis includes washing with water and nonirritating soap. The foreskin should never be forcibly retracted. However, as the child grows and the foreskin naturally becomes more retractable, the foreskin and the area underneath it can be cleaned and dried. (See 'Normal anatomy and development of the foreskin' above and 'Routine care' above.)

●Physiologic versus pathologic phimosis – Phimosis is the inability to retract the foreskin. Phimosis in infants and children is typically benign (ie, physiologic) and reflects normal development of congenital adhesions between the foreskin and glans. Progressive foreskin retraction becomes possible over time as the adhesions break down. Pathologic phimosis is defined as a foreskin that is truly nonretractable due to distal scarring of the prepuce. It typically occurs in older children, who often present with inability to retract the foreskin after previously being able to do so (picture 4). (See 'Phimosis' above.)

•Management of physiologic phimosis – Physiologic phimosis does not typically need specific treatment given the high rate of spontaneous resolution. However, for boys or caregivers who are concerned about not yet having achieved retraction or who have had frequent infections, we suggest treatment with topical corticosteroids and stretching exercises (Grade 2C). Stretching exercises entail gently retracting the foreskin to resistance for one minute several times a day; whenever the foreskin is retracted, it should always be replaced to its normal position covering the glans penis. (See 'Management of pathologic phimosis' above.)

•Management of pathologic phimosis – Although conservative measures can be attempted, pathologic phimosis characterized by a cicatrix or scarring typically requires surgical intervention. (See 'Management of pathologic phimosis' above.)

●Benign conditions – Conditions that do not usually require intervention, but only reassurance, include smegma, preputial cysts, and foreskin ballooning. (See 'Benign conditions' above.)

●Associated pathologic conditions – Pathologic conditions associated with the uncircumcised penis include paraphimosis, recurrent urinary tract infection, balanoposthitis (picture 5), balanitis xerotica obliterans (picture 6), and frenulum breve. (See 'Associated pathologic conditions' above.)

●Paraphimosis is a medical emergency – Paraphimosis is caused by foreskin entrapment behind the coronal sulcus, which may result in venous and lymphatic congestion of the glans, and ultimately arterial compromise (picture 3). It is a medical emergency requiring immediate care. (See 'Paraphimosis' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledge Jason Wilson, MD, who contributed to an earlier version of this topic review.