Foreskin and penile conditions
What is tight foreskin?
Almost all newborn males have a ‘tight foreskin’, which is a foreskin that cannot retract to reveal the head of the penis. Tightness in the foreskin is termed ‘phimosis’. In over 96% of newborn males, it is completely normal for the foreskin not to retract. In this age group the phimosis is normal or ‘physiological’.
Over time, the tightness gradually becomes supple as the infant grows. The inner layer of foreskin is also stuck or attached to the head of the penis at birth, and this slowly separates naturally as the child grows.
For infants and toddlers, parents do not need to retract the foreskin. Boys around the age of 6 or 7 years can be taught to retract their foreskins in the bath or shower for hygiene. By adolescence and throughout adult life, the foreskin should be freely and easily retracting.
It is not normal to have pain, discomfort, redness, swelling, or discharge from the foreskin at any age.
Tight foreskin problems
Phimosis is the term for a tight foreskin that cannot be retracted. This may be normal for an infant or child who has no symptoms.
Phimosis treatment, involving paediatric surgery and urology review, is recommended in these cases:
- If the tightness is associated with pain, swelling, discharge, infections, or if there is difficulty passing urine, ballooning with urination, or spraying urinary stream
- If the child is over age 6 or 7 and cannot retract the foreskin, even though there are no symptoms
- If the foreskin used to be easy to retract but has tightened and now cannot be retracted. In this group, the suspicion is raised of a progressive scarring condition of the foreskin and penis, known as “balanitis xerotica obliterans” or BXO. The tight tip of the foreskin often has a rim of waxy, white, and brittle appearing skin which is characteristic of BXO. A circumcision is the recommended treatment for BXO.
Problems with phimosis or tight foreskin may run in families.
Posthitis and Balanitis
Posthitis and balanitis may occur secondary to phimosis. Posthitis is the medical term for infection of the foreskin. Balanitis is the medical term for infection of the head of the penis or glans. Usually, the infection affects both regions, and this is termed “balanoposthitis”. The foreskin and penile tissues swell, become red and painful, and there may be a pus-like discharge from under the foreskin.
Sometimes children with phimosis will only experience pain and irritation at the foreskin tip, burning with urination, and mild swelling. This is recurrent mild posthitis, and may be secondary to trapped urine in the space under the foreskin and low-grade inflammation.
The inability to retract the foreskin is normal for most infants and young boys, and resolves with age.
Phimosis only becomes a problem when there are associated conditions, such as pain, infection, swelling, or difficulties with urinating. These problems may run in families.
Forcible retraction causing a trapped foreskin, or any infection of the foreskin, penis, or glands, will all require medical assistance.
How do we treat tight foreskin?
Babies, infants toddlers and young children with tight foreskin and no symptoms have a “physiological phimosis” and do not need any treatment. If they have mild symptoms such as redness or pain, a course of topical steroid may be trialled under the guidance of the paediatric surgeon or urologist.
For older children around age 6 or 7 who still cannot retract their foreskins, and who may or may not have mild symptoms, treatment can also be trialled with a course of topical steroid cream. As children get older and near adolescence, the success rate of topical steroid in resolving the phimosis diminishes.
Circumcision may be required for various medical indications, including:
- Children with recurrent foreskin infections
- Children with recurrent urine infections
- Suspicion of BXO
- Failure of topical steroid cream to resolve phimosis
- Persistent phimosis at adolescence
What is hypospadias?
Hypospadias is a term used to describe a broad spectrum of variances or anomalies in the development of the penis. It has been shown to occur in around 1 in 150 male births. Cases will vary from individual to individual, and so, each person born with hypospadias should be carefully assessed and managed by a specialist paediatric urologist.
Hypospadias commonly affects where the urine channel (urethra) opens on the penis. With this condition, the urine channel may open low on the shaft of the penis. In severe hypospadias, the opening of the urethra may be low on the penile shaft, in the scrotum or even at the base of the scrotum.
Often the penis affected by hypospadias has a bend or curve tethering it forward. This is known as chordee. The chordee is often accentuated during erection and may impair future sexual function. In addition, the foreskin is often incompletely formed in hypospadias, with the appearance of a ‘hood’ at the back of the penis, and foreskin missing over the front of the penis.
How do we treat hypospadias?
What is buried penis?
Buried penis in children is a spectrum of penile anomalies where the ‘stem’ of the penis does not protrude as expected beyond the body wall. Only a small cone of seemingly empty foreskin seems to be visible.
The penis itself is usually normal in shape and size but does not appear to be so, because it is in a ‘sunken’ or ‘hidden’ position under the tissues of the lower tummy.
A variant of buried penis is known as ‘congenital megaprepuce’. This occurs when the inner layer of foreskin is excessive, and fills with urine when the child voids. Parents often describe needing to express the urine out of the foreskin space for the baby.
The degree of severity of buried penis and congenital megaprepuce varies vastly.
Occasionally, the penis may also be small in size for age.
How do we treat buried penis?
An early review with the specialist paediatric urologist is recommended, so a careful assessment of the problem can be undertaken. We will give you appropriate advice for your child, and a management plan for the treatment of buried penis. If reconstructive surgery is required, this will be discussed and scheduled as appropriate.
If there is a concern about penile size, appropriate investigations and review by the paediatric hormone specialists will be arranged.
We strive to deliver the highest level of paediatric surgical service to families. All children, whether they are newborn, toddlers, young children or teenagers, deserve excellent support and care. As surgeons we believe that it is essential to address paediatric urology and surgical problems in accordance with world’s best practice.
If children require surgery, our role encompasses building a reassuring environment to prepare your family for the surgery, and of course to provide expert surgical care and follow-up. At WA Paediatric Surgery and Urology, both our surgeons and our team will be here to assist you with kindness and support.
Tongue tie surgery
Lip tie surgery
Groin & scrotum conditions
Contact our paediatric surgeons and urologists
Dr Andrew Barker
Dr Naeem Samnakay
85 Monash Avenue, Nedlands, WA 6009