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The foreskin or the prepuce is the thin skin that covers the glans penis. Glans penis is the ‘head’ of the penis which is continuous with the shaft at the level of a groove called coronal sulcus.

Phimosis and paraphimosis

The foreskin serves the function of protecting the delicate and very sensitive glans penis. If not present, it can lead to irritation, inflammation and infection of the glans penis due to wet diapers in babies. Foreskin is also related to many surgical conditions like phimosis and paraphimosis. For these conditions circumcision is done. Preservation of foreskin is important in certain surgical conditions. Proper foreskin care is hence very essential.

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What is phimosis?

Phimosis refers to the inability to retract the foreskin back. At birth it is physiological. The foreskin cannot be retracted at birth and it is absolutely normal. This is because there will be adhesions between the foreskin and the glans penis which prevents retraction. These adhesions get broken and loosened up gradually. By 3 years of age, in 90% of those who are uncircumcised the foreskin can be retracted.

What is paraphimosis?

Paraphimosis is a condition in which the foreskin which is pulled behind the glans penis cannot be brought back to its original position. It is also called as capistration. It is a urological emergency. Forceful retraction of the foreskin most often results in paraphimosis.

What is circumcision?

Circumcision is an operation in which the foreskin is removed. Mostly it is done as a ritual in certain religions like Islam and Judaism. Ritual circumcision is usually done within the first 10 days of life. Medical reasons for circumcision are very limited. These include phimosis in older children and adults, paraphimosis and recurrent balanitis (infection of the glans penis). Circumcision during childhood may sometimes prevent cancer of penis. But cancer of penis can occur even in circumcised penis. The American Academy of Pediatrics and the American Academy of Family Physicians do not recommend routine circumcision to prevent the medical conditions affecting the foreskin and penis.

Sometimes circumcision is avoided to preserve the foreskin. This is especially so in a surgical condition called hypospadias. Hypospadias is a birth defect in which the urethral opening is not found at the tip of the penis but at the lower surface of it. It may be associated with bending of the penis during erection which is called chordee. Hypospadias are to be corrected surgically as it can affect urination and later in the adult life the sexual function.  During surgery for hypospadias, the foreskin is used to correct the abnormal opening of the urethra. So any baby with hypospadias should not get circumcised and the foreskin has to be preserved to be used later for surgery.

Before doing circumcision for phimosis the doctor may consider using medical treatment to make the foreskin retractable. He may prescribe a steroid cream to be applied for about a month. Sometimes this makes the foreskin retractable. When it is not retractable in spite of applying steroid cream, circumcision is done.

Care of the foreskin

The following are some of the important things with regards to foreskin that a mother should be aware of while taking care of the baby:

  • The foreskin should never be forcefully retracted. If the foreskin in a baby is forcefully retracted it can injure the foreskin and glans penis causing pain and bleeding. The injured tissue may heal with scarring which worsens phimosis and the foreskin may not be retractable at all (called pathological phimosis).
  • During bathing the baby, the foreskin should be retracted gently only as much as possible and is washed with a mixture of mild soap and warm water. Do not apply soap directly to baby's genitals. A whitish substance called smegma may be seen beneath the foreskin which has to be cleaned. 
  • After retracting and cleaning, the foreskin has to be brought back to the usual position covering the glans penis.
  • If the foreskin cannot be retracted there is no need to worry about washing under the foreskin and only the surface of the penis is washed.
  • In most cases, a complete retraction is never possible during the fist few years and should never be attempted.
  • As the boy gets older and starts bathing on his own, he should be taught about how to gently retract the foreskin and clean it. He should also be advised and cautioned about the harmful effects of forceful retraction.
  • When the foreskin is tight, the doctor may prescribe steroid cream as mentioned above. This has to be applied by gently retracting the foreskin as much as possible. After applying the cream, the foreskin is moved over it again to its normal position so that cream gets beneath the foreskin. This has to be done 3-4 times a day for about a month to get good response.

Read More: Circumcision: Pros and Cons

When to get medical advice?

The mother should take her baby to the Pediatrician for examination and treatment in the following circumstances:

  • When the foreskin is reddened and painful it may indicate infection. It has to be treated with antibiotics. This usually occurs due to the irritating substances present in the urine. Promptly changing wet diapers may prevent this. When there is recurrent infection, it may result in scarring and circumcision may have to be done.
  • When there is ballooning of the foreskin during urination, it may indicate a significant phimosis requiring circumcision.
  • When the front margin of the foreskin shows a whitish ring like discoloration, it may indicate scar formation between the foreskin and the glans penis. In these circumstances the phimosis is considered pathological and may not be retractable at all even after the baby grows older.
  • If retraction of the foreskin is not possible even after 5 years then a visiting his doctor is necessary. He may examine the foreskin and see for himself whether it is retractable. If it is not retractable he will plan for circumcision. 
  • Many doctors consider circumcising a boy with phimosis who develops recurrent urinary tract infection when all the other factors causing urinary tract infection are ruled out.
  • www.cua.org/documents/patient_information/15e-fore0609r.pdf
  • emedicine.medscape.com/article/442883-overview
  • www.baby-medical-questions-and-answers.com/baby-foreskin.html
  • kidshealth.org/parent/system/surgical/circumcision.html
  • www.ncbi.nlm.nih.gov/pubmed/15825185
  • www.cua.org/documents/patient_information/15e-fore0609r.pdf

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