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The Penis & Foreskin

• Normal
• Attachments
• Smegma
• Minor inflammation
• Balanitis
• Bacterial infection
• Zipper Injury
• Phimosis
• Paraphimosis
• Circumcision
• Hair Tourniquet

Normal

The normal foreskin is attached to the glans and is non-retractile in most newborns. Over time the foreskin separates and becomes retractile. The proportion of boys with retractile foreskins is: 40% at 1 year, 90% at 4 years and 99% at 15 years.

• Non-retractile foreskin is a normal variant and needs no intervention. It is different from true phimosis (see below).
• The foreskin should never be forcibly retracted for cleaning. Once it becomes freely retractile naturally then the boy should retract it as part of routine bathing.
• See parent leaflet on care of the normal uncircumcised penis.

Attachments

Sometimes the normal process of separation is uneven and the foreskin becomes partially retractile but with a residual attachment to the glans. This is normal and needs no intervention. It will resolve spontaneously by the time of puberty.

Sometimes the normal separation of an attachment between the foreskin and glans will lead to a day or two of soreness and dysuria.

Smegma

Before the foreskin becomes separate and retractile, it is common for smegma to collect in small yellow / white lumps which may be visible or palpable through the foreskin. These are normal, and need no intervention.

• Discharge of smegma from the foreskin opening is sometimes mistaken for pus.

Minor inflammation

Minor redness / soreness of the tip of the foreskin is very common. A number of factors may contribute, including: irritation from wet / soiled nappies, inappropriate attempts at retracting the foreskin for cleansing, bubble bath, soap residue etc. Avoiding these factors, reassurance, and application of a napkin barrier cream to the tip of the foreskin will help. See also napkin rash guidelines.

Hydrocortisone 1% cream or ointment may help.

Balanitis

More severe inflammation of the glans penis +/- foreskin is often due to infection and is usually termed balanitis. It is common, affecting around 6% of uncircumcised and 3% of circumcised males.

Soaking in a warm bath with the foreskin retracted (if retractile and not too painful) will help with cleaning and urination may be easier in the bath. Topical hydrocortisone 1% cream or ointment may help in mild cases. Topical antibiotics creams are sometimes used but are of unproven efficacy.

Candida infection may be responsible in some infants. It is usually associated with more generalised napkin candidiasis and the presence of satellite lesions. Topical anti yeast creams (eg nystatin, clotrimazole, miconazole) will be helpful. See also napkin rash guidelines.

Bacterial infection

If there is significant cellulitis of the whole of the foreskin or the skin of the penile shaft then bacterial infection is likely and antibiotics should be given. Pain and swelling sometimes produce marked dysuria.

• Streptococci (including Group A), staphylococci, and gram negative organism are most often responsible.
• Swabbing the discharge is unhelpful because the normal foreskin is usually colonised with multiple organisms.
• Most cases respond to oral antibiotics (eg Co-trimoxazole 4/20 mg/kg (max 160/800) 12 hourly or Amoxycillin 15 mg/kg (max 500 mg) 8hourly).
• Analgesia is important, and sitting in a warm bath may ease dysuria.
• Occasional cases require admission for parenteral antibiotics, and rarely urgent surgery (eg dorsal slit / circumcision) is indicated.Significant recurrent balanitis may be an indication for circumcision. Also, true phimosis may lead to recurrent balanitis and should be treated (see below).

Zipper Injury

The tip of the foreskin or other skin (eg scrotum) may become entrapped in the teeth of a zipper. This is painful.

Treatment options include:

Prior to these procedures, adequate analgesia +/- sedation should be given. See sedation Guidelines Liberal application of topical anaesthetic cream may work or local infiltration may be necessary (never use local agents with adrenaline on the penis).

If trapped between teeth below the slider (see figure):

1. Cutting the median bar of the zipper with wire cutters. The median bar is the part at the top of the slider which joins the front and back plates of the slider. Once cut, the slider falls off and the zipper can be separated (see figure).
2. Cutting through the material either side of the zipper below the entrapped skin and then cutting across the zipper with wire cutters / strong scissors. Then the zipper can then be separated from below (see figure).

If trapped between slider and teeth of zipper:

1. Liberal application of topical anaesthetic cream, then ease slider down. 
   Always check for injury to urethral meatus.

Phimosis

Non-retractile foreskin is a normal variation (see above). (Confusingly some refer to this as "physiologic phimosis").

True phimosis is when scar tissue is present in the distal foreskin and this prevents retraction. It may result from attempts to forcibly retract the foreskin before it has become naturally retractile.

Indicators of true phimosis (rather than simple non-retractile foreskin):

• Foreskin not retractile by the time of established puberty.
• Previously retractile foreskin becomes non-retractile.
• Obvious ring of scar tissue visible at foreskin opening
• Inability to visualise urethral meatus when foreskin opening is lifted away from glans.
• Ballooning of foreskin on micturition, with pinhole foreskin opening, and very narrow urinary stream. (Note: minor ballooning may occur in normal non-retractile foreskin).

Treatment options:

• Application of topical steroid creams: 0.05% betamethasone cream should be used twice daily for 2 to 4 weeks.
  Gently retract foreskin without causing any discomfort and apply a thick layer of cream to the tightest part of the foreskin.
  Steroid creams ofhigher potency may be tried if this fails.
  
  
• Circumcision (if significant phimosis and steroid creams fail)

Paraphimosis

This occurs when the foreskin is left in the retracted position. The the glans and the foreskin distal to the tight area become oedematous and swollen. Pain and swelling make it difficult to return the foreskin to the non-retracted position.

Paraphimosis can usually be corrected without surgery:

• Adequate analgesia +/- sedation should be given. Liberally covering the entire foreskin and glans in topical anaesthetic cream & Gladwrap for 1 hour may be effective. Local infiltration of anaesthetic is best avoided as it increases the swelling.
• The swollen area is gently but firmly compressed within one hand, for a few minutes, to squeeze out the oedema fluid. The glans may then be pushed back and the foreskin returned to the normal position.
• If manual reduction fails, consult surgical registrar immediately. Surgical options include needle puncture to release oedema fluid or incision of the tight band of the foreskin.Once reduced, a single episode of paraphimosis is not an indication for circumcision. If the child has significant phimosis then it should be treated as above.

Circumcision

Routine circumcision has been a controversial issue. It has become much less frequent in recent years (now<10%). The Australian College of Paediatrics and the Australasian Association of Paediatric Surgeons recommend against the practice and certainly not in infants <6 months of age.

See http://www.cirp.org/library/statements/acp1996/

Medical indications for circumcision have become less frequent, and include significant phimosis resistant to steroid therapy. Some religious groups still require circumcision.

Post-circumcision problems

• It is common for the glans penis to be inflammed and crusted following circumcision. This is due to the forcible separation of normal tissue layers.
• Bleeding and infection are the sometimes a problem.
• Bleeding circumcision site in a neonate can be the presentation of coagulopathy. FBE and coagulation tests should be checked.
• Treat infection with oral / parenteral antibiotics as for cellulitis elsewhere. Infants under 1 month of age should be admitted to hospital.

Hair Tourniquet

If an infant presents with redness and swelling if the distal part of the penis with a demarcation line - look carefully for hair (or clothing fibre) which may have become wound around the penis and forming a tourniquet.