Written by Professor Paddy Dewan, Paediatric Urologist, PhD MD MS MMedSc FRCS FRACS
Tragically, a boy died after circumcision in Perth recently, and his brother was reported to have become seriously unwell after a similar procedure. Any death of a child is tragic; death as an outcome of elective surgery is a disaster.
Not surprisingly, the death has sparked further debate about parents choosing to have their son circumcised for non-medical reasons. It should also sharpen our focus on what constitutes good medical care and what is considered proper foreskin care, to ensure any bad outcomes are avoided.
The role of circumcision
With 200 deaths reported in 2018 in USA from 9,883,110 circumcisions over a 10 year period, appropriate discussion about the role of circumcision should occur. But like for the COVID debate, we need to know who died because of the illness or intervention, not just COVID was present or a circumcision had occurred.
As tragic as the death of the boy is, unfortunately, the discussion after such an event is focused entirely on the rights of and wrongs of circumcision, with very little discussion on the hidden problem of disease of the foreskin.
Sadly, so many boys have a problem with their foreskin is due to the lack of discussion about appropriate care, and a lack of education of families. We are here to help change this.
Quite frankly, there is so little appropriate education of parents of young babies because of the “taboo” nature of the discussion. It’s a tendency to the “politically correct” prejudice that touching a baby’s penis for cleaning is inappropriate, and the misinformation that proactive treatment of the foreskin will cause damage.
No one would discourage a parent from thoroughly cleaning their boy’s bottom. Why is the boy’s penis any different?
And, the reason for teaching good care of the infant foreskin, is because of problems that can occur.
In Australia, in 2019, there were 14,361 boys with the need for the treatment of their foreskin.
Not all problems with due to a lack of foreskin care. However, careful management can identify and minimise the harm from congenital abnormalities.
So, what should a family know about their boy’s foreskin?
- Most boys do not have a fully retractable foreskin at birth – because the hole at the end is not yet big enough.
- The infant foreskin is usually adherent to the head of the penis (glans penis), similar to the skin of a banana; thus it may not retract even with a wide opening at the end of the foreskin – these adhesions are normal.
- As the baby grows, smega collects between the foreskin and the head of the penis – it looks like a yellow lump – one that goes away as the foreskin separates – it is not a problem.
When to be concerned:
- The foreskin should pout like a budding rose, thus opening with gentle retraction – if unretractable this is called physiological phimosis.
- If, when passing urine, ballooning of the foreskin persists after voiding, there is possibly pathological phimosis.
- A narrow, non-retractable foreskin can increase the risk of balanitis (infection and inflammation of the tip of the penis and foreskin).
- If the foreskin is gently unfolded and the appearance is that of a dome with a pinhole, the diagnosis is pathological phimosis … without gentle retraction, the foreskin can look normal.
- When the pinhole opening is white and thickened, the inflammatory condition is known as BXO (Balanitis Xerotica Obliterans).
Foreskin care for uncircumcised boys
Most importantly, be gentle, but be thorough.
When bathing, and at the time of nappy changes, the foreskin should be unrolled with the same care that is needed for removal of faeces from between the scrotum and thigh, and with the same thoroughness that the boy’s bottom is cleaned.
Leaving the fold of the foreskin with bowel motion will increase the chance of infection, and the family cleaning the foreskin will lead into the toddler years of the boy learning to self-care. It’s appropriate to ensure the school boy knows to clean his teeth, wipe his bottom and roll his foreskin back when he passes urine.
Foreskin care begins at home
Hopefully, this article on foreskin care help families be better trained in how to care for their uncircumcised boy so that fewer require the “circumcision for medical reasons”, and fewer families feel compelled to elect for circumcision because of the horror stories of recurrent penile infections because of phimosis.
Parents need to feel supported, not potentially criticised; and discussion on the subject of genital hygiene should be viewed as important parent education.
As a parent, learn to care for all of your boy; with gentle, loving, respectful care … and thoroughness.