Foreskin and penile conditions

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.

Paraphimosis occurs if a tight foreskin is forcibly retracted, and the tight ring of the foreskin gets trapped behind the head of the penis. This makes it difficult for the foreskin to return to its normal position. Paraphimosis is uncomfortable for the child, and the penile and foreskin tissues will start to swell. Prompt medical assistance should be sought for paraphimosis treatment.

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.

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

If hypospadias is detected at birth, early review by the paediatric urologist is recommended within the first three months of life. Depending on the severity, the paediatric urology will advise about the optimal management for hypospadias repair. If required, reconstructive surgery to address function and anatomical variance may be recommended. This will be discussed with parents and planned as appropriate. Reconstructive surgery may need to be planned in stages for severe hypospadias.

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.