INFANT CIRCUMCISION - NECESSARY?
You already know that physiological phimosis is a normal condition in children, and that the medical-scientific literature demystifies a number of widespread misconceptions about infant phimosis. Now get to know the recommended lines of action when your child's tight foreskin is really a medical issue.
1 - ADHESIONS BETWEEN THE FORESKIN AND THE GLANS
Balanopreputial adhesions (BPA) are due to a layer of epithelium whose role is to protect the interior of the penis from contamination during the first years of life, and which tends to spontaneously disappear during childhood[1,2].
If this does not happen, and the child has recurrent inflammations such as balanitis, a medical intervention may be necessary for detachment to occur.
But this intervention does not have to be surgical. A simple and painless technique using eutectic mixture of local anesthetics (EMLA), for example, is extremely effective in the elimination of adhesions[2,3].
2 - PHIMOTIC RING
Physiological phimosis due to narrow preputial opening (phimotic ring) also tends to resolve spontaneously until puberty and is usually not a problem[1,2,4]. It is not uncommon, however, that cases such as ballooning of the foreskin when urinating, partial urinary tract blockage (urine "spray"), chronic urinary tract infection, or repetitive balanitis (glans inflammation) may require an acceleration in the process of phimotic ring widening.
For such cases, topical steroids (corticosteroid ointments or creams), such as betamethasone valerate, among others, have been used for more than two decades and presented excellent results[5,6].
In the rare cases in which the patient does not respond to topical steroid treatment, a conservative invasive method (without tissue amputation) such as preputioplasty surgery may be recommended[7,8,9]. Unlike circumcision, preputioplasty preserves the protection, lubrication, and sensitivity functions performed by the foreskin.
By the way, ballooning of the foreskin when urinating is not as worrying as it may seem, and its manifestation is a sign that the skin is still healthily elastic as it should. When not associated with any recurrent inflammation or infection, it can be considered as part of the normal developmental process, that is, a transient condition that tends to disappear over time.
Depending on its etiology and stage of manifestation, pathological phimosis may not necessarily require surgical intervention.
Most cases of foreskin inflammation (posthides and balanoposthides) are of infectious nature and respond well to antibiotic or fungicide treatments. On the other hand, pathological phimosis due to lichen sclerosus (LS) can in some cases be reversed with ultrapotent topical corticosteroids, which should be the first-line treatment for this condition.
It is important to try to reverse the pathology with non-invasive and conservative methods for the following reasons:
- the foreskin is not a useless piece of skin. It serves to keep the glans protected, lubricated and sensitive to tactile stimuli. In addition, its internal mucosa is intensively innervated and erogenous, and its removal will deprive your child, later on, of a series of sensory stimuli;
- studies demonstrate that even circumcision performed shortly after birth is traumatic and can leave profound psychological sequelae[14,15]. And if the boy is in the so-called phallic stage (between 3 and 6 years old, stage of psychosexual development in which the child discovers his own genitalia and the difference between the sexes), amputation of the foreskin may be unconsciously perceived as an act of aggression and even of castration, and cause, among others, family and social adaptation problems and disfunctions.
When the skin disease that causes pathological phimosis cannot be cured by medical treatment or is in a very advanced stage of manifestation, circumcision (surgical removal of the foreskin) is the recommended course of action. In that case, try to talk to your child and explain exactly what it is and why it will be done.
Sometimes it's hard not to be influenced by surrounding social or cultural pressures. But you, father or mother, have the moral obligation to inform yourself and reflect according to the weight of the burden you may carry if your decision is not the best for your child. And if you got here it means you're already doing your part: congratulations.
- Oster J (1968). Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Archives of Disease in Childhood, 43(228):200-203.
- Wright JE (1994). Further to "the further fate of the foreskin". Medical J of Australia, 160:134-5.
- MacKinlay GA (1988). Save the Prepuce. Painless separation of preputial adhesions in the outpatient clinic. British Medical J, 297:590-1.
- Thorvaldsen MA, Meyhoff H (2005). Phimosis: pathological or physiological? Ugeskr Læger, 167(17):1858-62.
- Kikiros C, Beasley S, Woodward A (1993). The response of phimosis to local steroid application. Pediatric Surgery International, 8(4):329-332.
- Yilmaz E, Batislam E, Basar M, Basar H (2003). Psychological trauma of circumcision in the phallic period could be avoided by using topical steroids. International J of Urology, 10(12):651-656.
- Shahid SK (2012). Phimosis in Children. ISRN Urology, 2012:707329.
- Cuckow PM, Rix G, Mouriquand PDE (1994). Preputial plasty: a good alternative to circumcision. J of Pediatric Surgery, 29(4):561-3.
- Verma K, Hathila N, Bhimani S, Rajan S, Rupani P (2014). A Comparative Study of Circumcision and Preputioplasty in Pediatric Cases of Phimosis: A Prospective Study in a Tertiary Care Hospital. National J of Medical Research, 4(4):326-329.
- Edwards S, Bunker C, Ziller F, Meijden W (2014). 2013 European guideline for the management of balanoposthitis. International J of STD & AIDS, 25(9):615-626.
- Neill SM, Tatnall FM, Cox NH (2002). Guidelines for the management of lichen sclerosus. British J. of Dermatology, 147:640-9.
- Taylor JR, Lockwood AP, Taylor AJ (1996). The prepuce: specialized mucosa of the penis and its loss to circumcision. British J of Urology, 77:291-5.
- Goldman R (2002). The psychological impact of circumcision. British J of Urology International, 83(S1):93-102.
- Frisch M, Simonsen J (2015). Ritual circumcision and risk of autism spectrum disorder in 0- to 9-year-old boys: National cohort study in Denmark. J of the Royal Society of Medicine, 108(7):266-279.
- Cansever G (1965). Psychological effects of circumcision. British J of Medical Psychology, 38:321-31.