Fellow’s Corner: Some Foresight on Foreskin

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Children's Doctor

As I’ve started my second year of fellowship, now seeing patients in the clinic, a topic that seems to cause a lot of confusion in the genitourinary region is: “What to do with the foreskin?”

In the last 30 years or so, US circumcision rates have slightly declined, so this topic may become more prevalent in primary care offices. Unfortunately, available resources are often vague, potentially conflicting, and subject to national and cultural variability. Currently, no evidence-based guidelines regarding preputial care exist. The American Urologic Association has no guidelines on routine care of the foreskin. The American Academy of Pediatrics’ (AAP) online information gives general advice and focuses on avoiding forceful retraction of the foreskin with primary, or physiologic, phimosis.

Why? At birth, a physiologic phimosis (inability to retract the prepuce) exists owing to natural adhesions between the glans and inner preputial skin. Later in life, the prepuce separates from the glans primarily due to accumulation of epithelial debris, referred to as smegma, and intermittent penile erections. Preputial retractability increases with age, with less than 1% by 17 years of age with phimosis. Therefore primary phimosis is almost always resolvable during childhood without intervention.

Secondary, or pathologic, phimosis, however, denotes a problematic tightening of the foreskin. It results from several causes, including forceful retraction and balanitis xerotica obliterans (BXO, or lichen sclerosis). AAP notes the importance of educating parents on the maintenance of good genital hygiene, the natural history of physiologic phimosis, and the avoidance of forceful foreskin retraction in order to prevent complications such as balanoposthitis and the development of pathologic phimosis.

Which begs the question: Do you ever need to intervene for physiologic phimosis? AAP advises to begin retraction in a child with no genitourinary issues when the foreskin separates on its own. However physiologic phimosis will still be present in a small number of older teens, potentially leading to confusion for both families and providers as to when to begin retraction.

When a child does develop problems and retraction is necessary, the most common treatment is a topical corticosteroid cream (eg, betamethasone cream), which softens the skin and allows retraction, usually using a regimen of twice daily for 4 to 8 weeks. Indications to enhance preputial retractability include pathologic phimosis, balanitis, posthitis (inflammation of the prepuce), BXO, and UTIs.

As recommended by the AAP’s Task Force on Circumcision, parental education on care of the penis is an important obligation for pediatricians. It should also be an obligation of our specialty to provide best-practice guidelines, based on expert opinion in the absence of better data, to enhance the knowledge base, and to create recommendations for providers on the front lines.

References and suggested readings

Morris BJ, Bailis, SA, Wiswell TE. Circumcision rates in the United States: rising or falling? What effect might the new affirmative pediatric policy statement have? Mayo Clin Proc. 2014;89(5):677-686.

American Academy of Pediatrics. Care of the uncircumcised penis. [parent’s version]. Published 2007. Updated June 19, 2017. Accessed September 5, 2017.

Oster, J. Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child. 1968;43(228):200-203.

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