The prepuce and glans are fused in utero, and separation of prepuce and glans occurs at different rates after birth, which may be influenced by inflammation and smegma
At 12 months, retraction of foreskin possible in 50 % of boys.
At 3 years, retraction of foreskin possible in 90 % of boys.
Incidence of phimosis in 6 – 7 years old is about 8 %.
Incidence at 16 years old is 1 %.
Ballooning of the foreskin during voiding is very common during 2 – 4 years of age, and is usually transient and self-limiting, requiring no treatment.
Classification of non retractile foreskin / phimosis
Primary – physiological, no scarring, adhesions – expected to resolve as boys grow up
Secondary – pathological, e.g. scarring due to BXO (BXO is rare in boys under 5, with peak incidence 9 – 11 years old)
Balanoposthitis
- Infection of the prepuce – erythema and oedema of the prepuce with or without spread to the underlying glans and surrounding penile skin
- May have minor bleeding and cracking, and purulent discharge
- In fully retractile foreskins in older boys, consider diabetes
- Use oral antibiotic and topical antifungal treatment for acute episodes
- Recurrent episodes may be treated with preputioplasty, circumcision or continue topical steroid
Paraphimosis
- Typically isolated episode
- Treat with manual reduction (other techniques include multiple needle puncture or rarely dorsal slit)
- Circumcision only indicated for recurrent multiple episodes
Penile cysts
- Usually benign
- Occasionally may be trapped smegma under adhesions (“preputial pearls”) – can manage conservatively
Congenital megaprepuce
Enormously capacious preputial sac – urine trapping within requiring compression to expel it.
Other penile lesions
Epidermal inclusion cysts
Vascular malformations
Penile neurofibromas
Primary lymphoedema (rarely indicative of Crohn’s)
Absolute indications for circumcision
BXO (steroids won’t work, preputioplasty will lead to recurrence)
Relative indications for circumcision
Recurrent balanoposthitis
Recurrent paraphimosis
UTIs in boys with urological abnormalities
Trauma i.e. zipper injury
Parental preference, or religious reasons
HIV or STI risk reduction in high prevalence countries
Contraindications for circumcision in newborns and infants
Hypospadias, epispadias or chordee
Buried penis
Sick or unstable infants, including neonatal jaundice
Bleeding diathesis
Alternatives to circumcision
Topical steroid – 0.05 % betamethasone BD for 4 – 12 weeks
- Best for physiological phimosis in an older boy, as an attempt to avoid surgery
Frenuloplasty
Preputioplasty