Rates of neonatal circumcision are declining in Canada
Knowledge of foreskin care is important for both practitioners and parents. Physiologic phimosis (nonretractable foreskin) is normal in childhood. At birth, the inner foreskin is fused to the glans penis; this is termed “physiologic” and rarely requires treatment. Pathologic phimosis occurs in less than 2% of boys and presents as a sclerotic white ring at the foreskin tip on clinical examination.1 Lichen sclerosus, a form of pathologic phimosis related to chronic skin inflammation, is rarely seen in the first few years of life and results in substantial, progressive scarring that can involve the urethra.2
Physiologic phimosis decreases with age
Adhesions between the inner and outer foreskin release over time from repeated reflex erections and smegma collection.1 Physiologic phimosis exists in about 50% of 7-year-old boys and decreases to less than 10% by age 13.3
Retraction of physiologic phimosis should not be forced
When performed by parents or practitioners, retraction of physiologic phimosis can cause unnecessary discomfort, microscopic tearing and scarring. Ballooning of the foreskin with urination is benign and is not associated with obstruction. 4 The best treatment of physiologic phimosis is watchful waiting.1
Routine foreskin care can prevent problems
Along with testicular self-examination, boys should be taught foreskin care to prevent infections. This involves gentle retraction during voiding to prevent urine pooling, and cleaning during bathing with soap and water.1 Avoiding paraphimosis (foreskin pushed above the glans penis, resulting in edema) is critical; if paraphimosis occurs, it requires urgent medical attention.
Physiologic phimosis with complications or pathologic phimosis should prompt treatment
Physiologic phimosis with recurrent urinary tract infections, balanoposthitis (inflammation of the entire foreskin and glans penis) or persistence of phimosis beyond age 10 years should prompt medical therapy and possible urologic referral.1 Treatment involves a topical steroid cream (0.1% betamethasone) applied to the distal foreskin with gentle retraction for up to 8 weeks (70%–80% success rate, with similar efficacy from less potent steroids).1,5 Pathologic phimosis may be treated medically initially and closely monitored by a urologist. The efficacy of medical treatment is lower for pathologic phimosis than for physiologic phimosis, and patients who do not respond to medical treatment require circumcision.1 Lichen sclerosus may be treated with a short course of steroids but often requires circumcision.2
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Footnotes
CMAJ Podcasts: author interview at https://soundcloud.com/cmajpodcasts/180875-five
Competing interests: None declared.
This article has been peer reviewed.
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