Development of retractable foreskin

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A human penis before and after retraction of the foreskin.

In the majority of adult men, the foreskin normally retracts to reveal the head of the penis. In newborns, it is common for the foreskin to be fused to the head of the penis by the synechia, thus rendering it non-retractable. The preputial cavity is sealed by the synechia.[1] The foreskin usually separates from the glans and becomes retractable with increasing age. There is much uncertainty among health care workers about when the foreskin of a boy should become retractable.[2] The mistaken belief that the foreskin was supposed to be retractable at the time of birth of the infant has led to a characterization of the genitalia of most infant males as defective at birth. This has led to many false diagnoses of phimosis, followed by unnecessary circumcision, when, in fact, the foreskin is developmentally normal.

Normally, developmental non-retractability does not cause any problems. Non-retractability may be deemed pathological if it causes problems, such as difficulty urinating or performing normal sexual functions, but even then, this is rare, and, if the non-retractability itself is not caused by pathological inflammation, it cannot be called "pathological" or "true phimosis." A foreskin that is so narrow it will retract very little or not at all, but is not the result of a pathological inflammation, is accurately termed preputial stenosis (narrow prepuce), and will respond to treatment including steroid creams, manual stretching, and changing masturbation habits.

History

The first data on development of retractile foreskin were provided in 1949 by the famous British paediatrician, Douglas Gairdner.[3] His data have been incorporated into many textbooks and is still being repeated in the medical literature today. Gairdner said that 80 percent of boys should have a retractable foreskin by the age of two years, and 90 percent of boys should have a retractable prepuce by the age of three years.[3]

Unfortunately, Gairdner’s data are inaccurate,[4] [5] [6] so most healthcare providers have been taught inaccurate data.[5] Retractability usually occurs much later than previously believed.[4] This page provides accurate data, derived from newer and better studies, for healthcare providers.

Current view

Almost all boys are born with the foreskin fused with the underlying glans penis by the synechia. Most also have a narrow foreskin that cannot retract. Non-retractile foreskin is normal at birth and remains common until after puberty (age 18). Some boys develop retractile foreskin earlier, and about 2 percent of males have a non-retractile foreskin throughout life. Non-retractile foreskin is not a disease and does not require treatment.

There are three possible conditions that cause non-retractile foreskin:

  • Tightness of the foreskin orifice
  • Fusion of the foreskin with the glans penis[7]
  • Frenulum breve (which is rare and cannot be diagnosed until the previous two reasons have been eliminated)

The first two reasons are normal in childhood and are not pathological in children. The third can be treated conservatively, retaining the foreskin.

Infants and pre-school

Kayaba et al. (1996) reported that before six months of age, no boy had a retractable prepuce; 16.5 percent of boys aged 3-4 had a fully retractable prepuce.[8] Imamura (1997) examined 4521 infants and young boys. He re-ported that the foreskin is retractile in 3 percent of infants aged one to three months, 19.9 percent of those aged ten to twelve months, and 38.4 percent of three-year-old boys.[9] Ishikawa & Kawakita (2004) reported no retractability at age one, (but increasing to 77 percent at age 11-15).[10] Ko et al. (2007) examined 59 newborn Taiwanese boys. Not one had a retractable foreskin.[11]

Non-retractile foreskin is the normal, expected, and more usual condition in this age group.[12]

School-age and adolescence

Percentage of boys with tight ring totally non-retractile foreskin according to Kayaba et al.


Jakob Øster, a Danish physician who conducted school examinations, reported his findings on the examination of school-boys in Denmark, where circumcision is rare.[13] Øster (1968) found that the incidence of fusion of the foreskin with the glans penis steadily declines with increasing age and foreskin retractability increases with age.[13] Kayaba et al. (1996) also investigated the development of foreskin retraction in boys from age 0 to age 15.5 Kayaba et al. also reported increasing retractability with increasing age. Kayaba et al. reported that about only 42 percent of boys aged 8-10 have fully retractile foreskin, but the percentage increases to 62.9 percent in boys aged 11-15.[8] Imamura (1997) reported that 77 percent of boys aged 11-15 had retractile foreskin.[9] Thorvaldsen & Meyhoff (2005) conducted a survey of 4000 young men in Denmark.9 They report that the mean age of first foreskin retraction is 10.4 years in Denmark.[14] Non-retractile foreskin is the more common condition until about 10-11 years of age.

Percentage of boys with fused foreskin by age according to Øster


Ko et al. (2007) examined 1145 Taiwanese boys aged 7 to 13. Ko et al. reported:

Our findings indicate that the degree of preputial retractability increases with age, while the prevalence of unretractable prepuce decreases with age. By the age of 13 years, very few boys (some 0.3%) still had an unretractable prepuce (i.e. type 1 prepuce).[11]

The findings reported by Ko et al."' are consistent with the findings reported by Øster (1968), by Kayaba et al. (1996), and by Thorvaldsen & Meyhoff (2005)

Discussion

Boys usually are born with a non-retractile foreskin. The foreskin gradually becomes retractable over a variable period of time ranging from birth to 18 years or more.[13][14] There is no “right” age for the foreskin to become retractable. Non-retractile foreskin does not threaten health in childhood and no intervention is necessary. Many boys only develop a retractable foreskin after puberty. Education of concerned parents usually is the only action required.[15]

Avoidance of premature retraction

Care-givers and healthcare providers must be careful to avoid premature retraction of the foreskin, which is contrary to medical recommendations, painful, traumatic, tears the attachment points (synechiae), may cause infection, is likely to generate medico-legal problems, and may cause paraphimosis, with the tight foreskin acting like a tourniquet. The first person to retract the boy’s foreskin should be the boy himself.[4] [16]

Making the foreskin retractable

Teen boys who still have a non-retractable foreskin (about 10 percent of boys) should start stretching exercises to make the foreskin retractable in preparation for adult life.

Occasionally a male reaches adulthood with a non-retractile foreskin. Some men with a non-retractile foreskin happily go through life and father children. Other men, however, may want to make their foreskin retractile.

The foreskin can be made retractable by:

Male circumcision is outmoded as a treatment for non-retractile foreskin, but it is still recommended by many urologists because of lack of adequate information, and perhaps because of the profit to the doctor associated with circumcision. Nevertheless, circumcision should be avoided because of pain, trauma, cost,[21][22] complications,[21] difficult recovery, permanent injury to the appearance of the penis, loss of pleasurable erogenous sensation,[23] impairment of erectile and ejaculatory functions,[24][25] and adverse sexual and psychological effects.

See also

External links

References

  1. ↑ REFjournal Taylor, J.R., Lockwood, A.P., Taylor, A.J.. The prepuce: specialized mucosa of the penis and its loss to circumcision. Brit J Urol. 1996; 77: 291-5. PMID. DOI. Retrieved 2 December 2019.
  2. ↑ REFjournal Simpson, E.T., Barraclough, P.. The management of the paediatric foreskin. Aust Fam Physician. May 1998; 27(4): 381-383. PMID. Retrieved 17 October 2019.
  3. ↑ a b REFjournal Gairdner, D.. The fate of the foreskin: a study of circumcision. Br Med J. 1949; 2: 1433-7. PMID. PMC. DOI.
  4. ↑ a b c REFjournal Wright, J.E.. Further to the "Further Fate of the Foreskin". Med J Aust. 7 February 1994; 160: 134-135. PMID. Retrieved 17 October 2019.
  5. ↑ a b REFjournal Hill, G.. Circumcision for phimosis and other medical indications in Western Australian boys. Med J Aust. 2 June 2003; 178(11): 587. PMID. Retrieved 17 October 2019.
  6. ↑ REFjournal Denniston, George C., Hill, George. Gairdner was wrong. Can Fam Physician. 1 October 2010; 56(10): 986-7. PMID. PMC. Retrieved 17 October 2019.
  7. ↑ REFjournal Deibart, G.A.. The separation of the prepuce in the human penis. Anat Rec. 1933; 57: 387-99. DOI. Retrieved 7 October 2019.
  8. ↑ a b REFjournal Kayaba, H., Tamura, H., Kitajima, S., et al. Analysis of shape and retractability of the prepuce in 603 Japanese boys. J Urol. 1 November 1996; 156(5): 1813-1815. PMID. Retrieved 19 October 2019.
  9. ↑ a b REFjournal Imamura, E.. Phimosis of infants and young children in Japan. Acta Paediatr Jpn. 1997; 39(3): 403-405. PMID.
  10. ↑ REFjournal Ishikawa, E., Kawakita, M.. Preputial development in Japanese boys. Hinyokika Kiyo. 2004; 50(5): 305-308. Retrieved 8 November 2019.
  11. ↑ a b REFjournal Ko, Ming-Chung, Liu, Chih-Kuang, Lee, Wen-Kai, Jeng, Huey-Sheng, Chiang, Han-Sun, Li, Chung-Yi. Age-specific Prevalence Rates of Phimosis and Circumcision in Taiwanese Boys. Journal of the Formosan Medical Association. April 2007; 106(4): 302-7. PMID. DOI. Retrieved 8 November 2019.
  12. ↑ REFjournal Agawal, Abhnav, Mohta, Anup, Anand, Ritesh K.. Preputial retraction in children. Journal of Indian Association of Pediatric Surgeons. 2005; 10(2): 89-91. DOI. Retrieved 9 December 2019.
  13. ↑ a b c Template:Jakob Øster 1968
  14. ↑ a b REFjournal Thorvaldsen, M.A., Meyhoff, H.. Patologisk eller fysiologisk fimose? [Pathological or physiological phimosis?] (Danish). Ugeskr Læger. 2005; 167(17): 1858-1862. Retrieved 17 October 2019.
  15. ↑ REFjournal Spilsbury, K., Semmens, J.B., Wisniewski, Z.S., et al. Circumcision for phimosis and other medical indications in Western Australian boys. Med J Aust. 17 February 2003; 178(4): 155-158. PMID. Retrieved 17 October 2019.
  16. ↑ REFweb (2019). Doctors Opposing Forcible Retraction, Doctors Opposing Forcible retraction. Retrieved 2 October 2019.
  17. ↑ REFjournal Dunn, H.P.. Non-surgical management of phimosis. Aust N Z J Surg. 1989; 59(12): 963. PMID. DOI.
  18. ↑ REFjournal Beaugé, M.. The causes of adolescent phimosis. Br J Sex Med. 1997; (Sept/Oct): 26. Retrieved 18 October 2019.
  19. ↑ REFjournal Orsola, A., Caffaratti, J., Garat, J.M.. Conservative treatment of phimosis in children using a topical steroid. Urology. 2000; 56(2): 307-310. PMID. DOI. Retrieved 18 October 2019.
  20. ↑ REFjournal Ashfield, J.E., Nickel, K.R., Siemens, D.R., et al. Treatment of phimosis with topical steroids in 194 children. J Urol. March 2003; 169(3): 1106-1108. PMID. DOI. Retrieved 18 October 2019.
  21. ↑ a b REFjournal Van Howe, RS. Cost-effective treatment of phimosis. Pediatrics. October 1998; 102(4): e43. PMID. Retrieved 17 October 2019.
  22. ↑ REFjournal Berdeu, D., Sauze, L., Ha-Vinh, P., Blum-Boisgard, C.. Cost-effectiveness analysis of treatments for phimosis: a comparison of surgical and medicinal approaches and their economic effect.. BJU Int. 1 February 2001; 87(3): 239-244. PMID. DOI. Retrieved 17 October 2019.
  23. ↑ REFjournal Williams, N., Kapila, L.. Complications of circumcision. Brit J Surg. 1993; 80: 1231-1236. PMID. DOI. Retrieved 17 October 2019.
  24. ↑ REFjournal Shen, Z., Chen, S., Zhu, C., et al. Erectile function evaluation after adult circumcision. Zhonghua Nan Ke Xue. 1 January 2004; 10(1): 18-19. PMID. Retrieved 17 October 2019.
  25. ↑ REFjournal Masood, S., Patel, H.R.H., Himpson, R.C., et al. Penile sensitivity and sexual satisfaction after circumcision: Are we informing men correctly?. Urol Int. 2005; 75(1): 62-65. PMID. DOI. Retrieved 17 October 2019.
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