If you have an intact son or will have, please read.
The Phony Phimosis Diagnosis
By Jennifer Coias
I'm writing this article because this is probably one of the most frequent misconceptions that I encounter. It seems that everyone knows of a child or man who 'had' to be circumcised due to a tight foreskin, also known as phimosis. When people hear these stories, most of them do not question the validity of the diagnosis and treatment and simply accept it as, "What had to be done". Could it really be that so many men were designed with such a flaw or is this really just an epidemic of misdiagnosis courtesy of widely foreskin-ignorant medical professionals?
In this article, I will give an overview of the development of the intact male and explain why the diagnosis of phimosis in children and teens is entirely phony. Additionally, I will outline what is true phimosis, its proper treatment, and why our doctors are so confused.
Development of the Prepuce ('foreskin' in males/'hood' in females):
During infancy the prepuce is tightly fused to the glans (head) of the penis. The tissue itself is fibrous and dense at this age, as it is composed of a whorl of muscle fibers. The opening of the prepuce acts like a sphincter and only releases to allow urine to pass. This design serves very important functions:
-It protects the developing penis from feces, bacteria and other harmful pathogens. This is especially important during the diaper-wearing years when a baby is continually exposed to his/her own feces (e-coli and other harmful bacteria/viruses).
-It protects the developing glans and keeps them from becoming desensitized and keratinized.
-It protects against urinary tract infections.
As a child grows, the foreskin will separate from the glans. This can take many years for some boys and for other boys, it seems to happen all at once. During or after the separation process, there may be some shedding of dead skin cells in the form of smegma (please note that women and girls also have smegma). This shedding of dead cells aids in separation since it helps the foreskin differentiate itself from the glans. There is no need to try to clean smegma from underneath a child's foreskin. It will slowly work itself out via the narrow opening. Once a child's foreskin is completely differentiated from the glans this is not an indication that retraction is possible.
Retraction is a separate function that is designed specifically for intercourse and masturbation. Retraction enables the foreskin to glide smoothly over the glans of the penis. This gliding stimulates nerve endings in both the foreskin and the glans. In order for retraction to occur, the foreskin must have separated from the glans and the opening of the foreskin must have widened to allow it to slip back over the glans. How does the foreskin opening widen? Throughout childhood and adolescence, there is a release of hormones. As hormone levels rise, the fiber-dense tissue of the prepuce is replaced with a more elastic tissue. A boy will begin to explore his genitals as he grows and as time passes, the elastic tissue will allow the opening of the foreskin to widen. This can happen at any age but it is not common in young boys. In fact, only 50% of boys are retractable by age ten. The other 50% usually become retractable between age ten and the completion of puberty.
So why all the fuss about retraction? Well, many parents fear that if a boy can not retract, he will get infections. This fear probably stems primarily from misinformation given to them by their doctors and their own fears about lack of hygiene. First, parents must know that there is absolutely no need to clean under a boy's foreskin. As mentioned above, the smegma produced by a boy is merely a shedding of dead skin cells. It is not harmful will not harbor bacteria. Trying to clean under a prepubescent boy's foreskin is the equivalent to trying to wash out a girl's vagina. It is entirely unnecessary and, in fact, harmful. Premature retraction introduces harmful pathogens, disturbs the natural flora, creates scar tissue, damages the intricate structures and can lead to long-term complications. Second, parents must know that retraction of the foreskin is not a necessary function in boyhood. Retraction is specifically designed for sexual relations. The only function a boy's penis needs to perform during childhood is urination. In other words, if a boy can urinate, then his penis is doing exactly what it needs to do.
The Phony Diagnosis:
When a doctor diagnoses a boy with phimosis it is because he/she does not understand the normal development of the prepuce. First, in order to diagnose this condition, the doctor would have had to either try to retract the foreskin or encourage the boy to try to retract his foreskin. This is a huge "no, no" for the reasons described above. Second, there is no expiration date on developing a retractable foreskin. Each boy is individual as to when the separation and widening processes have completed. Just as each girl will begin menstruation in her own time, each boy will experience retraction in his own time. Since hormones play an important role in changing the composition of the tissue of the prepuce, it is not abnormal if the process isn't complete until the finish of puberty. Once an adolescent's foreskin is retractable he can easily retract his foreskin in the shower, rinse with water, and replace his foreskin over the glans. Most men do this naturally during normal manipulation of their genitals while showering. In the case that a boy becomes retractable before puberty, there is no need for him to rinse under his foreskin, unless he so chooses. In the case that an adolescent is not retractable, there is still no need to worry about cleaning under the foreskin. Remember, it is not abnormal for retraction to take until the end of puberty.
True phimosis is when a post-pubescent man is unable to retract his foreskin or becomes unable to retract his foreskin and he feels discomfort during sexual activity. A small percentage of men (and women) have prepuces that never retract. This can be a normal variation, so long as it does not impede sexual activity. If it does impede sexual activity then a man should seek conservative treatment. 90% of men with this rare condition can correct the problem with the application of a steroidal cream and stretching exercises. The steroidal cream mimics the effects of puberty hormones and allows the skin to become more elastic. A man usually applies the cream several times a day and uses manual stretching exercises while he showers. Men should be wary of any doctor who recommends circumcision prior to trying a more conservative treatment.
So why are most our nations doctors confused or ignorant as to the normal development of the prepuce? This question has a few answers. First, if we look at the AAP (American Academy of Pediatrics) recommendations, it wasn't until the 1990s that the AAP finally warned against the harms of forcible retraction and outlined the development of the foreskin in the intact boy. Prior to this AAP's warning, it was widely believed that parents needed to retract their intact sons for 'cleaning'. As you can imagine, this lead to many complications for intact boys and resulted in many otherwise unnecessary circumcisions. Second, there was a preliminary study of about 300 boys to determine the average age of the development of a retractable foreskin. This study concluded that most boys will become retractable by age three. This out-dated study set an expiration date in the minds of the medical professionals. A follow up study of thousands of boys concluded that, in fact, only 50% of boys are retractable by age ten. Many doctors, unaware of the most recent study, still operate under the misinformation of the preliminary study. Third, the development of the prepuce is not taught in medical schools. There is no discussion of how the prepuce is structured, how it changes throughout childhood and its protective and sensory functions. Essentially, the only thing medical students learn is how to amputate the foreskin. Some medical students may learn about the condition of phimosis but they are not informed that this only applies to adult men, as children's foreskins are designed to be tight. Fact is, the US medical profession has cut off so many foreskins over the past century that the doctors rarely if ever saw an intact boy and have lost the base of knowledge of diagnosis and treatment. Now, professionals are operating in a vacuum of information or even worse, in an environment of false information. As the nation's circumcision rates have fallen dramatically, intact boys everywhere are suffering the consequences of a widely foreskin-ignorant medical profession. Each year thousands of intact boys between ages two and up are circumcised unnecessarily at the hands of misinformed care providers. Educating parents, doctors and future doctors is an essential step to correcting this problem.