Understanding foreskin concerns in children

In his latest online article, Mr Andrew Robb gives us an insight into phimosis and balanitis, he expains what these conditions are, the most common concerns, when to seek medical attention and the different types of treatment.

Normal development of the foreskin

When boys are born, the foreskin normally cannot retract. The foreskin and the tip of the penis are stuck together with adhesions, which is a type of scar tissue, and over the course of childhood they need to separate apart.

This is achieved in a number of ways. The most important is that the opening of the foreskin is narrower than the opening of the urethra so some of the urine is forced down each side. That means whenever they separate apart the tip of the penis or the tip of the foreskin can balloon up and that's a normal part of development.  That leaves children without a retractable foreskin but over the course of childhood that foreskin will tend to get wider. During puberty over 95% of boys will have a fully retractable foreskin. This is why it is normal in childhood for boys to not have a fully retractable foreskin.

What are the most common concerns and conditions related to foreskins in children, such as phimosis and balanitis?

The most common problem that parents are concerned about is that the foreskin doesn't retract. This can be normal or it can be due to disease, and the challenge is working out if this is just a normal part of development or if the child actually needs treatment.

Another condition parents may be concerned about is Balanitis and this is where there is inflammation on the foreskin. This can be caused by an infection and typical symptoms of this can be discharge as well as the tip of the penis becoming red, swollen and hot. It can also be caused by irritation by urine being trapped behind the foreskin. However, this will settle down with good hygiene.

Another condition they could be concerned about is balanitis xerotics obliterans (BXO) which is a benign scarring that affects the foreskin and can also affect the glands and the urethra. The tip of the penis will become swollen and the opening of the foreskin becomes progressively narrower and, in some cases, it can be difficult to urinate.

When is medical intervention necessary?

For balanitis, if a young person has a yellow or green discharge coming from behind the foreskin due to a bad infection, or they are systemically unwell with high temperatures and being lethargic, then they need to seek attention.

The treatment can include giving topical antibiotics underneath and behind the foreskin, they may need antibiotics by mouth, and in very severe conditions they may need IV antibiotics.

For the foreskin that doesn't retract, they only need treatment if they have a diseased foreskin.  If they've got a normal non-retractable foreskin, they don't need any treatment for that if they haven't reached puberty yet. If they've got a diseased foreskin, Balanitis Xerotics Obliterans (BXO), then they need to have treatment, but sometimes telling the difference needs an expert to have a look at it.

What are the available surgical and non-surgical treatments for problems of foreskin related in children?

If it's recurrent episodes where the tip of the penis becomes red and inflamed, then good personal hygiene is the best course. Start by teaching the young person to gently retract the foreskin so there's no laxity or space behind it and then just dabbing the tip of the foreskin or the penis with tissue to draw urine out so nothing builds up behind the foreskin. Having a bath can also help wash everything out.

If they have balanitis xerotics obliterans or they've got scarring, which means that things aren't going to improve. The most common thing that we will do is a circumcision to remove the foreskin and they may need some steroid ointment following that depending on the findings at the time of the surgery.

For boys who have gone through puberty, or who are going through puberty and have a non-retractile foreskin, they have the option of doing nothing and seeing if it improves by itself, or using a long course of steroid ointment along with stretching exercises a couple of times a day. The surgical options include, a circumcision to remove the foreskin or an operation called a preputioplasty which widens the foreskin up, but that's not suitable for everybody.

Mr Andrew Robb is a highly esteemed paediatric urologist with over 20 years of experience in his field. You can schedule an appointment with him on Top Doctors today.