* Approved by CPG Committee; PIC endorsement pending

See also

Acute scrotal pain or swelling

Key points

1. A non-retractable foreskin is a normal variant and needs no intervention. It is different from true phimosis
2. The foreskin should never be forcibly retracted for cleaning
3. Acute surgical interventions are rarely necessary
4. Red flags include urinary retention, a swollen red penis with a fever, and blue or black discolouration to distal penis

Normal anatomy and function

• At birth, the normal foreskin (prepuce) is attached to the glans and has a tight opening (preputial ring) at the distal end. The foreskin is not retractable in most newborns
• Retractability increases with age, with full retraction possible in
  • 10% of boys by 1 year of age
  • 50% of boys by 10 years of age
  • 99% of boys by 17 years of age
• A non-retractable foreskin is a normal variant and needs no intervention. It is different from true phimosis (below)
• The foreskin should never be forcibly retracted for cleaning. Once it becomes freely retractable naturally, the child should retract it as part of routine bathing, ensuring immediate replacement over the glans to prevent paraphimosis (below). See care of the normal uncircumcised penis

Smegma

• Smegma is a collection of desquamated epithelial cells and sebaceous matter that collects between the glans penis and the foreskin
• Before the foreskin becomes separate and retractable, it is common for smegma to collect in small yellow/white lumps which may be visible or palpable through the foreskin. This is normal, and needs no intervention
• Discharge of smegma from the foreskin opening is sometimes mistaken for pus

Foreskin attachments

• Sometimes the normal process of separation is uneven, and the foreskin becomes partially retractable but with residual attachments to the glans. This may lead to a day or two of soreness and dysuria
• These are normal and need no intervention

Foreskin ballooning

• Some children with non-retractable foreskins notice ballooning during urination
• This is usually of no consequence, but may cause minor urine trapping within the foreskin with associated spotting in underpants and increased risk of balanitis
• Treat if problematic:
  • Topical steroid cream can be used sparingly to preputial ring (tightest part of foreskin): use 0.05% betamethasone tds for 6-12 weeks. Note the longer duration than treatment of phimosis
  • Success rate >90%, recurrence rate up to 17%
  • Circumcision is not indicated unless pathological phimosis

Inflammation and infection

Balanitis and inflammation

• Minor redness and/or soreness of the tip of the foreskin is common and can be managed with reassurance and avoidance of chemical and physical triggers
• More extensive inflammation of the glans penis +/- foreskin is termed balanitis
• Causes include
  • Chemical irritation: urine trapping, soiled nappies, soap residue, talc powder
  • Physical trauma: forcible retraction
  • Candida nappy rash in infants
• Treatment
  • Soaking in warm, weak salt water
  • Barrier cream or 1% hydrocortisone cream (see also Nappy rash)
  • Antifungal cream (clotrimazole, miconazole) if candida suspected
  • Oral analgesia may be needed
  • Topical antibiotic ointments and creams are not efficacious or recommended
  • Preputial retraction during acute inflammation is not recommended as this can lead to paraphimosis

Infection and cellulitis

• Secondary bacterial infection can occur, with erythema or lymphangitis tracking proximal to distal along the penile shaft. Associated dysuria is common
• If fever is present, urine culture should be performed to exclude concomitant UTI
• Group A streptococcus (Streptococcus pyogenes) infection can cause a severe genital rash that is weeping and raw
• Treatment:
  • Antimicrobial recommendations may vary according to local antimicrobial susceptibility patterns. Refer to local guidelines
  • Cefalexin 20 mg/kg (max 750 mg) PO tds for 7 days
  • Acute pain management
  • Soaking in warm, weak salt water may ease discomfort
  • Swabs are often contaminated and not routinely recommended. Treat on clinical merit

Other conditions

• Persistent genital rash may be due to a dermatosis, eg psoriasis or eczema. These children may require referral to a paediatrician or paediatric dermatologist
• A genital rash or penile discharge in a sexually active male raises other diagnostic considerations. See Sexually transmitted infections

Retractile foreskin complications

Phimosis

• Pathological phimosis results from scarring of the preputial ring preventing retraction. This is distinct from normal non-retractable foreskin described above
• Features
  • Obvious ring of scar tissue, visible at foreskin opening
  • Foreskin not retractable at the conclusion of puberty
  • Previously retractable foreskin no longer retractable
  • Persistent ballooning of foreskin on urination in older children, with pinhole foreskin opening, narrow urinary stream and no response to topical steroid creams
• Causes
  • Most commonly due to repeated attempts to forcibly retract the foreskin before it has become naturally retractable
  • Balanitis Xerotica Obliterans (BXO), an aggressive scarring condition (very rare <8 years)
• Treatment
  • Application of topical steroid cream (0.05% betamethasone cream 2-3 times daily) should be trialled for 2-4 weeks
  • If good response to steroids, continue for total of 6-12 weeks
  • If no or poor response to steroids, pathologic phimosis is likely. Refer to Paediatric Surgery
• Red flag
  •  Urgent surgical referral is required if the child is unable to pass urine

Paraphimosis

• Paraphimosis is a urological emergency with a risk of preputial necrosis
• Paraphimosis occurs when the foreskin is left in the retracted position. The foreskin distal to the tight area becomes oedematous which makes it difficult to reduce the foreskin back over the glans
• Paraphimosis can usually be corrected without surgery
  • Give oral analgesia and reassurance
  • Wrap a firm compression bandage, ideally 1 inch, over the oedematous area, starting at the penile tip. eg Coban™ pictured
  • Leave bandage on for 10-15 minutes (use a timer)
  • Remove bandage and attempt to reduce foreskin over the glans. If unsuccessful, repeat bandaging for further 15 minutes and re-attempt
  • If manual reduction fails, obtain an urgent surgical consult
• Post reduction care
  • Circumcision is not indicated, and follow-up is not necessary
  • To avoid recurrence, advise the child and parents as follows
    • No retraction for a few days
    • Only retract foreskin for cleaning
    • Ensure immediate complete replacement of foreskin over glans following retraction
  • Children with evidence of ischaemia (dusky or dark tissue) require urgent review by a paediatric surgeon

Zipper injuries

• The tip of the foreskin or scotal skin may become entrapped in the teeth of a zipper
• Treatment
  • Give oral analgesia +/- sedation
  • Cut median bar of zip slider with wire cutters - #1 (see picture)
  • Cut across zipper with wire cutters - #2 (see picture)
  • Separate zip teeth
• Always check for injury to the glans and, if present, refer to paediatric surgery

Hair tourniquet

• In infants, hair or fine clothing fibres can wind around the penile shaft forming a tourniquet
• Presents as redness and swelling of the distal part of the penis with a demarcation line
• Treatment: divide fibre or hair ring and check skin for integrity. Discuss with a senior doctor if unsure

Circumcision

• Circumcision involves removal of the foreskin and exposure of the glans
• Medical indications for circumcision include pathologic phimosis or recurrent UTIs
• If not medically indicated, parents should make an informed decision after carefully understanding and considering the facts about the benefits and risks for their child
• Circumcision should be done in a safe, child-friendly environment by properly trained and qualified staff who are available to manage any post-operative complications. The child should receive appropriate analgesia. Click here for the RACP Circumcision Guide for Parents

Post-circumcision problems

• It is common for the glans penis to be inflamed and crusted following circumcision. This is due to the forcible separation of normal tissue layers
• Liberal application of petroleum jelly to the nappy or a panty liner for a few days may help
• Infection is uncommon but can be serious. See inflammation and infection above
• Bleeding is uncommon but if significant
  • Apply compression and obtain urgent surgical advice
  • Consider coagulopathy if there is significant bleeding after a circumcision
• PlastiBell circumcision: a ring is placed around the tip of the penis following separation and removal of the distal foreskin. This should fall off within days following the procedure. Any post-circumcision complications should be discussed with a paediatric surgeon

Priapism

• Priapism is a prolonged penile erection (>4 hours) and is a rare condition in childhood
• The commonest causes in children are sickle cell disease (65%), leukaemia (10%) and trauma (10%)
• Priapism can result in ischaemia and is a surgical emergency
• In older children, possible management options are
  • Running up stairs
  • Urination
  • Cold bath
  • Cold packs. NB: NOT to be used if child could have sickle cell disease
• Counsel the child and parents about seeking medical attention early if the above measures do not resolve priapism in <2 hours. Otherwise, refer to paediatric surgery for follow up and Doppler ultrasonography to assess blood flow

Consider consultation with local paediatric or paediatric surgery team when

• Child is unable to pass urine for any reason
• Paraphimosis with evidence of ischaemia
• Priapism
• Zipper injury that involves the penile glans

Consider transfer when

Children requiring care above the level of comfort of the local hospital or their treating medical team

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Parent information

Penis and foreskin care

Last updated September 2025