Forcible retraction of the foreskin
Encyclopedia
Forcible retraction of the foreskin, sometimes called premature retraction, in infants or young children can damage the glans
and mucous inner tissue of the foreskin
. Doctors or parents who may be unfamiliar with the foreskin can often forcibly retract it, unaware that it can be damaging.
At birth, the foreskin is fused to the glans. Over time, separation occurs naturally. Infants are sometimes diagnosed as having pathological phimosis
, which some authors consider to be erroneous. In order to perform circumcision
the foreskin must be retracted by force.
of the glans
. The foreskin cannot be retracted without tearing the fusion which exists between the inner foreskin and the glans penis. According to McGregor et al (2005), many physicians have difficulties distinguishing between this normal physiological non-retractile foreskin and pathological phimosis.
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 (2005) reported that average age of first foreskin retraction is 10.4 years. Marques et al (2005) reported that 99% of boys can retract their foreskins by age 14.
About 2% of males have a non-retractable 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.
, 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 bridge
s. The Canadian Pediatric Society poses the question of whether increased urinary tract infection
and balanitis
rates in uncircumcised male infants may be caused by forced premature retraction.
Forcible retraction happens in a variety of occasions. Most well known is the forcible retraction by doctors. Spilsbury et al (2003) suggest that doctors may be likely to confuse congenital (and normal) infant phimosis and the fused glans and foreskin with pathological phimosis. Forcible retraction may also be done by carers. Osborn et al (1981) reported that mothers are often advised by their doctors to retract the child's foreskin.
Camille et al (2002), in their guidance for parents, state that "[t]he foreskin should never be forcibly retracted, as this can cause pain and bleeding and may result in scarring and trouble with natural retraction."
Cooper et al (1983) urged therapeutic retraction as an "alternative to circumcision" and reported resolution of a number of problems, including balanoposthitis, dysuria, and phimosis through retraction under anaesthesia. Griffiths & Freeman (1984) reported the use of topical anaesthetic for forcible retraction, reporting:
MacKinlay (1988) reported on breaking the adhesions between foreskin and glans, which rendered the foreskin non-retractile, with topical anaesthetic, thus achieving full retractibility "without the necessity of circumcision". Iwamuro et al (1997) have reported similar results in treating older children "without further operation."
Osborn et al (1981), however, say "[t]he office practice of freeing adhesions and subsequent retraction of the foreskin is unnecessary." Simpson & Barraclough (1998) state that "[n]o attempt should be made to retract a foreskin in a child unless significant separation of the subpreputial adhesions has occurred. Failure to observe this basic rule may result in tearing with subsequent fibrosis and consequent true phimosis. ..."
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 Paediatric Society
emphasize that the infant foreskin should be left alone and requires no special care.
Glans penis
The glans penis is the sensitive bulbous structure at the distal end of the penis. The glans penis is anatomically homologous to the clitoral glans of the female...
and mucous inner tissue of the foreskin
Foreskin
In male human anatomy, the foreskin is a generally retractable double-layered fold of skin and mucous membrane that covers the glans penis and protects the urinary meatus when the penis is not erect...
. Doctors or parents who may be unfamiliar with the foreskin can often forcibly retract it, unaware that it can be damaging.
At birth, the foreskin is fused to the glans. Over time, separation occurs naturally. Infants are sometimes diagnosed as having pathological phimosis
Phimosis
Phimosis , from the Greek phimos ), is a condition where, in men, the foreskin cannot be fully retracted over the glans penis...
, which some authors consider to be erroneous. In order to perform circumcision
Circumcision
Male circumcision is the surgical removal of some or all of the foreskin from the penis. The word "circumcision" comes from Latin and ....
the foreskin must be retracted by force.
Biology of the infant 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 epitheliumEpithelium
Epithelium is one of the four basic types of animal tissue, along with connective tissue, muscle tissue and nervous tissue. Epithelial tissues line the cavities and surfaces of structures throughout the body, and also form many glands. Functions of epithelial cells include secretion, selective...
of the glans
Glans penis
The glans penis is the sensitive bulbous structure at the distal end of the penis. The glans penis is anatomically homologous to the clitoral glans of the female...
. The foreskin cannot be retracted without tearing the fusion which exists between the inner foreskin and the glans penis. According to McGregor et al (2005), many physicians have difficulties distinguishing between this normal physiological non-retractile foreskin and pathological phimosis.
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 (2005) reported that average age of first foreskin retraction is 10.4 years. Marques et al (2005) reported that 99% of boys can retract their foreskins by age 14.
About 2% of males have a non-retractable 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.
Prevalence and consequences
Forcible retraction may lead to bleedingBleeding
Bleeding, technically known as hemorrhaging or haemorrhaging is the loss of blood or blood escape from the circulatory system...
, scarring
Scar
Scars are areas of fibrous tissue that replace normal skin after injury. A scar results from the biological process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound results in...
, pathological phimosis
Phimosis
Phimosis , from the Greek phimos ), is a condition where, in men, the foreskin cannot be fully retracted over the glans penis...
or paraphimosis
Paraphimosis
Paraphimosis is an uncommon medical condition where the foreskin becomes trapped behind the glans penis, and cannot be reduced...
, and often pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
. Adhesions after forcible retraction, especially in infants, can fuse the foreskin with itself or the glans, leading to skin bridge
Skin bridge
A skin bridge is a penile skin adhesion. It most commonly occurs as a consequence of an improperly healed circumcision, being formed when the inner lining of the remaining foreskin attaches to another part of the penis as the cut heals. While less common, skin bridges can also occur in...
s. The Canadian Pediatric Society poses the question of whether increased urinary tract infection
Urinary tract infection
A urinary tract infection is a bacterial infection that affects any part of the urinary tract. Symptoms include frequent feeling and/or need to urinate, pain during urination, and cloudy urine. The main causal agent is Escherichia coli...
and balanitis
Balanitis
Balanitis is inflammation of the glans penis . When the foreskin is also affected, it is termed balanoposthitis....
rates in uncircumcised male infants may be caused by forced premature retraction.
Forcible retraction happens in a variety of occasions. Most well known is the forcible retraction by doctors. Spilsbury et al (2003) suggest that doctors may be likely to confuse congenital (and normal) infant phimosis and the fused glans and foreskin with pathological phimosis. Forcible retraction may also be done by carers. Osborn et al (1981) reported that mothers are often advised by their doctors to retract the child's foreskin.
Camille et al (2002), in their guidance for parents, state that "[t]he foreskin should never be forcibly retracted, as this can cause pain and bleeding and may result in scarring and trouble with natural retraction."
Therapeutic forcible retraction
Several doctors have proposed forcible retraction as treatment for a number of penile problems.Cooper et al (1983) urged therapeutic retraction as an "alternative to circumcision" and reported resolution of a number of problems, including balanoposthitis, dysuria, and phimosis through retraction under anaesthesia. Griffiths & Freeman (1984) reported the use of topical anaesthetic for forcible retraction, reporting:
- "The procedure we describe is safe, simple, relatively atraumatic, cheap, and easily repeated if adhesions recur. Only 4 boys (2.5%) came to circumcision and can be regarded as failures. 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."
MacKinlay (1988) reported on breaking the adhesions between foreskin and glans, which rendered the foreskin non-retractile, with topical anaesthetic, thus achieving full retractibility "without the necessity of circumcision". Iwamuro et al (1997) have reported similar results in treating older children "without further operation."
Osborn et al (1981), however, say "[t]he office practice of freeing adhesions and subsequent retraction of the foreskin is unnecessary." Simpson & Barraclough (1998) state that "[n]o attempt should be made to retract a foreskin in a child unless significant separation of the subpreputial adhesions has occurred. Failure to observe this basic rule may result in tearing with subsequent fibrosis and consequent true phimosis. ..."
Recommendations of paediatric societies
The American Academy of PediatricsAmerican Academy of Pediatrics
The American Academy of Pediatrics is the major professional association of pediatricians in the United States. The AAP was founded in 1930 by 35 pediatricians to address pediatric healthcare standards. It currently has 60,000 members in primary care and sub-specialist areas...
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
Royal Australasian College of Physicians
The Royal Australasian College of Physicians, or RACP, is the organisation responsible for training, educating, and representing over 9,000 physicians and paediatricians in Australia and New Zealand. It was founded in 1938....
as well as the Canadian Paediatric Society
Canadian Paediatric Society
The Canadian Paediatric Society is a national association of paediatricians, committed to working together to advance the health of children and youth by nurturing excellence in health care, advocacy, education, research and support of its membership....
emphasize that the infant foreskin should be left alone and requires no special care.
See also
- BalanitisBalanitisBalanitis is inflammation of the glans penis . When the foreskin is also affected, it is termed balanoposthitis....
- Bioethics of neonatal circumcisionBioethics of neonatal circumcisionMale circumcision involves the excision of genital tissue from the human body, so the ethics of circumcision are sometimes controversial.Some studies indicate that the foreskin and frenulum perform certain physiological functions among the men tested, which would be destroyed by excision...
- CircumcisionCircumcisionMale circumcision is the surgical removal of some or all of the foreskin from the penis. The word "circumcision" comes from Latin and ....
- ForeskinForeskinIn male human anatomy, the foreskin is a generally retractable double-layered fold of skin and mucous membrane that covers the glans penis and protects the urinary meatus when the penis is not erect...
- PhimosisPhimosisPhimosis , from the Greek phimos ), is a condition where, in men, the foreskin cannot be fully retracted over the glans penis...
- PosthitisPosthitisPosthitis is inflammation of the foreskin of the human penis .The term "posthitis" comes from the Greek "posthe" meaning foreskin + "-itis" meaning inflammation = inflammation of the foreskin.-Signs and Symptoms:...
External links
- Mothers Against Circ: Intact care agreement
- NOCIRC: Premature (Forcible) Retraction
- Doctors Opposing Circumcision: Development of Retractile Foreskin
- Geisheker, John V. Forcible Retraction of the Foreskin — An Epidemic.
- Travis, John W., Geisheker, John V. Only Clean What Is Seen - Reversing the epidemic of forcible foreskin retractions. Kindred, Santa Fe, 30 May 2008.