Forcible retraction of the foreskin

Forcible retraction of the foreskin, sometimes called premature retraction, refers to the retraction of the foreskin (prepuce) in infants or young adults, where the penis and the prepuce have not yet sufficiently developed to allow for full or partial retraction. This may be painful, and can sometimes damage to the glans and mucous inner tissue of the foreskin. It is sometimes performed by doctors who may be unfamiliar with the uncircumcised penis in general, and is a necessary step in infant circumcision. The unretractible infant foreskin is often misdiagnosed as pathological phimosis.

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Biology of the infant foreskin

Also see Phimosis and Foreskin

It has been widely recognized by the medical profession for most of the 20th century that normal male infants have foreskins which are incompletely separated from the epithelium of the glans penis. They cannot be easily retracted. McGregor reports that many physicians have difficulties distinguishing between this and pathological phimosis.[1] [2]

At birth, the foreskin is usually still fused with the glans. As childhood progresses the foreskin and the glans gradually separate, a process that may not be complete until the age of 17. A Danish survey reported that average age of first foreskin retraction in Denmark is 10.4 years. Marques reported that 1% of boys cannot retract their foreskins by age 14.[3] [4] [5] [6]

In children, the foreskin covers the glans completely but in adults this need not be so. In a German study, Schoeberlein found that about 50% of young men had full coverage of the glans, 42% had partial coverage, and in the remaining 8%, the glans was uncovered. After adjusting for circumcision, he stated that in 4% of the young men the foreskin had spontaneously atrophied (shrunk).

About 2% of males have a non-retractile foreskin throughout life, although this does not necessarily mean it is a pathological phimosis. Wright emphasizes that the first person to retract the boy’s foreskin should be the boy himself.[7]

Prevalence and consequences

Forcible retraction may lead to bleeding, scarring, pathological phimosis or paraphimosis, and often pain. Adhesions after forcible retraction, especially in infants, can fuse the foreskin with itself or the glans, leading to skin bridges. The Canadian Pediatric Society poses the question of whether increased UTI and balanitis rates in uncircumcised male infants may be caused by forced premature retraction.[8] [9] [10] [11] [12]

Forcible retraction happens in a variety of occasions. Most well known is the forcible retraction by doctors. Spilsbury suggests that doctors may be likely to confuse congenital (and normal) infant phimosis and the fused glans and foreskin with pathological phimosis.[13] Cooper reported resolution of a number of problems, including balanoposthitis, dysuria, and phimosis through retraction under anaesthesia.[14] Others have reported similar results in treating older children.[15] [16] [17] MacKinlay reported on breaking the adhesions between foreskin and glans with topical anaesthetic, thus achieving full retractibility.[18]

Griffiths reported:

Between March, 1973 and November, 1980 we treated 161 patients in this way, achieving complete separation in 150 and partial separations in 11. Complications were severe trauma in 9 and slight discomfort in 15. 2 mothers fainted. Apart from the 4 failures, the procedure had to be repeated in 4 children and paraphimosis was recorded in 1.[19]

Forcible retraction may also be done by caretakers. Osborn reported that mothers are often advised by their doctors to retract the child's foreskin. Griffiths reported that children may be advised to gently retract the foreskin themselves.[20] [21]

The American Academy of Pediatrics caution parents not to retract their son's foreskin, but suggest that once he reaches puberty, he should retract and gently wash with soap and water. The Royal Australasian College of Physicians as well as the Canadian Pediatric Society emphasize that the infant foreskin should be left alone and requires no special care.[22]

See also

• Balanitis
• Bioethics of neonatal circumcision
• Circumcision
• Foreskin
• Phimosis
• Posthitis

References

• Royal Australasian College of Physicians: Anatomy of the foreskin
• Canadian Pediatric Society: Circumcision statement
• American Academy of Pediatrics: Care of the uncircumcised penis