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. See Consider consultation when, below
4. Red flags include urinary retention, swollen red penis with a fever and blue/black 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.  It is not retractable in most newborns.
• Retractability increases with age, with full retraction possible in
• 10% of boys at 1 year
• 50% of boys at 10 years
• 99% of boys at 17 years
• A non-retractable foreskin is a normal variant and needs no intervention. It is different from true phimosis
• The foreskin should never be forcibly retracted for cleaning. Once it becomes freely retractable naturally, then the child should retract it as part of routine bathing, ensuring immediate replacement over the glans to prevent paraphimosis. See care of the normal uncircumcised penis patient information 

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. These are normal, and need no intervention
• Discharge of smegma from the foreskin opening is sometimes mistaken for pus

Attachments

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

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 of underpants and increased risk of balanitis 
• Treat if problematic:
  • Topical steroid cream sparingly to preputial ring (tightest part of foreskin): 0.05% betamethasone tds for 6-12 weeks (NB: longer duration compared to phimosis treatment)
  • Success rate >90%, recurrence rate up to 17%.
  • Circumcision is not indicated unless pathologic 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/physical triggers
• More extensive inflammation of the glans penis +/- foreskin is termed balanitis
• Causes include:
• Chemical irritation: urine trapping, soiled nappies, soap residue
• Physical trauma: forcible retraction
• Candida nappy rash in infants
• Treatment:
• Soaking in warm salt water settles swelling and discomfort
• Barrier 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
• Preputial retraction during acute inflammation should not be recommended as this can lead to paraphimosis

Infection and cellulitis

• Secondary bacterial infection can occur, with erythema or lymphangitis tracking proximally down the penile shaft.  Associated dysuria is common
• If fever is present, urine culture should be performed to exclude concomitant UTI
• Streptococcus pyogenes (group A streptococcus) infection can cause a severe genital rash that is weeping and raw
• Treatment:
  • Oral antibiotics – flucloxacillin 25 mg/kg (max 500 mg) po, 6 hourly for 7 days or cephalexin 25 mg/kg po, 6 hourly for 7 days
  • Acute pain management
  • Soaking in warm salt water may ease discomfort.
  • Swabs are often contaminated. Treat on clinical merit.

Other conditions

• Persistent genital rash may be due to a dermatosis (psoriasis, 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

Foreskin retractable problems

Phimosis

• Pathologic 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 becomes non-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 yo)
• 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 / poor response to steroids, pathologic phimosis is likely. Refer to Urology services
• Red flag: urgent surgical referral is required is the child is unable to pass urine 

Paraphimosis

• Paraphimosis is a urological emergency and brings 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 over the glans
• Paraphimosis can usually be corrected without surgery:
• Give oral analgesia and reassurance
• Wrap a firm compression bandage (ideally 1 inch, for example Coban, pictured) over the oedematous area, starting at penile tip 
• Leave bandage for 10-15 minutes (use a timer)
• Remove bandage and attempt to reduce foreskin over the glans. If unsuccessful, repeat bandage for further 15 minutes and re-attempt 
• If manual reduction fails, obtain urgent surgical consult
• Post reduction care:
• Circumcision is not indicated and follow-up is not necessary
• Advise the child and parents to avoid a repeat event:
  • No retraction for a few days
  • Only the child to retract foreskin for cleaning
  • Ensure immediate complete replacement of foreskin over glans
• Children with evidence of ischaemia (dusky or dark tissue) require urgent review by a urologist

Zipper injuries

• The tip of the foreskin or other skin (e.g. scrotum) may become entrapped in the teeth of a zipper
• Treatment:
• Give oral analgesia +/- sedation
• Cut median bar of zip slider with wire cutters - #1
• Cut across zipper with wire cutters - #2
• Separate zip teeth
• Always check for injury to the glans and refer to urology if present

Hair tourniquet

• In infants, hair or 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 is an operation to remove the foreskin and expose the glans 
• Medical indications for circumcision include pathologic phimosis or recurrent UTIs
• Non-medically indicated circumcisions are performed by private practitioners. Parents need to make an informed decision after carefully looking at all 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 Vaseline to the nappy or a panty liner for a few days helps
• Infection is uncommon, but can be serious. See inflammation and infection section above
• Bleeding is uncommon but if significant:
  • Apply compression and obtain urgent surgical advice
  • Consider coagulopathy in significant bleeding after a circumcision 
• PlastiBell circumcision: any post-circumcision complications should be discussed with a urologist for management advice

Priapism

• Priapism is a prolonged penile erection lasting longer than 4 hours and is a rare condition in childhood
• The commonest causes of priapism in children are sickle cell disease (65%), leukaemia (10%) and trauma (10%)
• Priapism lasting more than 4 hours can result in ischaemia and is a urological 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 above measures don’t resolve priapism in <2 hours. Otherwise arrange urology outpatient follow up and Doppler ultrasonography to assess blood flow

Consider consultation with local paediatric or paediatric urology team when

• The child is unable to pass urine for any reason
• Paraphimosis: Children with evidence of ischaemia (dusky or dark tissue) 
• Priapism (constant erection >4 hours)
• Zipper injury that involves the 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, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650

Parent information

Penis and foreskin care

Last revised July, 2018