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
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
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.
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
Hydrocortisone 1% cream or ointment may help.
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
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.
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.
The tip of the foreskin or
other skin (eg scrotum) may become entrapped in the teeth of a
zipper. This is painful.
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
If trapped between slider and teeth of
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
Indicators of true phimosis (rather than simple
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
Routine circumcision has been a controversial issue. It has
become much less frequent in recent years (now<10%). The
Paediatrics & Child Health section of The Royal Australasian
College of Physicians and the Australasian Association of
Paediatric Surgeons recommend against the practice and certainly
not in infants <6 months of age.
See here for RACP Policy
Medical indications for circumcision have become less frequent,
and include significant phimosis resistant to steroid
Some religious groups still require circumcision.
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.
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