In her otherwise excellent article on paraphimosis (EMN 2005;27:16), Lisa Filippone, MD, implies an erroneous view of the normal development of the penis and foreskin. The corollary to the statement, “In the newborn and infant, phimosis is often physiological,” is that if phimosis persists beyond infancy, it is pathologic. Due to a lack of published information, many medical professionals throughout the United States, including emergency physicians, primary care physicians, nurses, and even pediatric urologists, have long taught parents that the foreskin on an uncircumcised child should be forcibly peeled back until it has been completely peeled away from the glans.
I would like to take this opportunity to publicize to the emergency medicine community the natural development of the penis. The inner tissue of the foreskin at the level of the glans is composed of secretory glandular mucosa. By sexual maturity, the glandular tissue of the inner foreskin begins to secrete mucus, and it slides easily off the glans. Phimosis is the normal developmental stage of the foreskin until sexual maturity.
If the foreskin is left unmolested, the distal tube of squamous epithelium provides a shelter for the urethral orifice in case of fecal contamination. Bacteria adhere poorly to the squamous epithelium of the undamaged foreskin, and if the mucosa remains adherent to the glans, bacteria are flushed away with each urination. Fecal contamination of the genitalia is very common in infants under age 3.
The urethra of the female infant is similarly protected from fecal contact. In adult females, the urethra is usually located in the anterior portion of the introit. In the female infant, however, the urethra is minimally anterior to the vagina, and is protected from direct contact with feces by a flap of hymeneal tissue. Most students who observe me catheterize a female infant believe that I am headed for an intravaginal catheterization until clear urine is recovered. In infant girls, urinary catheterization is not difficult as long as the practitioner realizes that the urethra in female infants is more posterior than in adults, and is almost invariably obscured by a flap of hymeneal tissue.
When the immature foreskin is forced back, some of the glandular mucosa is destroyed, leaving granulomatous tissue which readily readheres to the glans. With repeated trauma, this granulomatous tissue eventually becomes a band of fibrous scar tissue in the distal foreskin. This inelastic ring is frequently what causes entrapment of the erect penis when young adults experience paraphimosis. With forced retraction, glandular tissue that is not destroyed is unnecessarily exposed.
E. coli and other fecal bacteria that reach the level of the urethral orifice then have a naturally hospitable tissue to cling to. These resident bacteria can begin to attack the urethra as soon as urination is terminated. It has been reported that the increased incidence of UTIs in uncircumcised males may in part be due to the ability of bacteria to cling to the mucous membrane that lines the inner foreskin.
The American Academy of Pediatrics has published a number of position papers about the uncircumcised penis. One that I keep at the office is entitled, “Newborns: Care of the Uncircumcised Penis, A Guideline for Parents.” This pamphlet admonishes that “no attempt should be made to forcefully retract the foreskin. Eventually, sometimes as long as five, 10, or more years after birth, “full separation of the foreskin occurs, and it may then be pushed back away from the glans.” If the foreskin does not seem to retract easily early in life, it is important to realize that this is not abnormal and that it should eventually do so.
Clinical Guidelines for Phimosis (www.norm-UK.org/phimosis), complete with copious footnotes, notes, “The development of the prepuce is incomplete in the newborn male child. Separation from the glans, rendering it retractable, does not usually occur until sometime between 9 months and 3 years. It is common, however, for preputial adhesion to persist into later years and may not be concluded until the age of 17.” Nonretractability of the foreskin in childhood does not constitute phimosis.
The web site, www.medindia.net/patients/paediatrics/Phimosis.asp, states, “If parents resort to the practice of retraction exercises, they might overdo and can cause soreness and bleeding. Also excessive retraction with damage heals with scarring, leading to real phimosis.” The scarring associated with real phimosis eventually leads to real paraphimosis.
In most of Europe, the foreskin is not considered to be a disease, and very few males are circumcised. As I come across European parents in my practice, I have questioned them on the care of the uncircumcised penis. Most of these parents do not understand what strange tradition I am trying to unmask. To quote a German father, “You wash it like you wash your face.”
Unfortunately, so many Americans think of the foreskin as a disease that many uncircumcised children become physically scarred and painfully injured by well meaning physicians, nurses, or parents, the ultimate result being adhesions and finally paraphimosis in the teenage years. To quote the AAP, “‘Leave it alone’ is the best advice.”
I ask that those of you who read this missive to reconsider before you recommend that a normal child have his foreskin forcefully retracted. If you cannot agree with this letter, ask the opinion of a colleague who was raised and trained in a country where circumcision is not the custom. If you would like to conduct research to confirm or disprove my thesis or if you can show research that is contrary, please contact me at Lakeped@mpinet.net.
E. Thomas Carlson, MD
Ft. Lauderdale, FL