Poliklinika Arcadia

The foreskin, or prepuce, protects the glans (head of the penis) against urine, feces and other types of irritation agents. It also protects against infection and scarring of the urinary opening (meatus) and protects the sensitivity of the glans.
At birth, it is unusual for the foreskin to be retractable because of the incomplete separation between the skin layers and also the conical shape of the foreskin. Only about a 4% of the newborns have a fully retractable foreskin and in 54% the tip of the glans may be revealed by very gentle traction.

Normally, after the age of 3 years the prepuce can be normally retracted to uncover the glans of the penis in 90% of the boys.
The word phimosis is used to describe the narrow, nonretractable foreskin of childhood.

Phimosis can be:

Primary, referred also as physiologic, where the foreskin is narrow since birth and in most cases will cease (90%).
Secondary, a pathologic process resulting from scarring after forceful retraction of the foreskin or as a result of a scarring process called balanitis xerotica obliterans (BXO).

In the first years of life, keratin is produced between the foreskin and the gland, and because the space is very narrow, balls or “pearls” of keratin (also called smegma) can accumulate and be visible under the foreskin. This is a normal process and sometimes parents get worried when watching these keratin pearls. This situation ends when occurs the complete separation between the glans and the foreskin around 3-4 years of age.

Phimosis: This is a condition in which the foreskin is tightly covering the head of the penis and it cannot be retracted (pushed down exposing head of penis). Phimosis is uncommon and an attempt can be made to treat with a topical medication.   In general, true pathologic phimosis is resolved through surgery. These cases that require surgery usually have a very narrow foreskin with a small opening, or scarring after forced retractions.   Sometimes the skin is possible to retract with difficulty and it’s observed a compressive ring of skin, which can result in an episode of paraphimosis if the foreskin is not put back to its original position.

In some cases of phimosis the opening of the foreskin is so narrow that the parents notice that when the child is urinating the foreskin inflates like a balloon and after finishing keeps dripping for the time this “balloon” needs to deflate. These anatomical conditions rarely resolve without surgery so they always should be evaluated by a pediatric surgeon to decide whether or not the patient needs a circumcision (Complete or partial resection of the foreskin).

Paraphimosis: Occurs when the narrow tip of the foreskin (prepuce) is withdrawn behind the glans and constricts the penile shaft, leading to swelling of the glans. Complications of this include urinary retention, ulceration of the glans and even ischemia and necrosis of the skin of the glans.
This condition is very painful and is an emergency, the foreskin must be repositioned by a pediatric surgeon as soon as possible and sometimes is necessary to resolve this with surgery and then the patient is programmed for a circumcision once the swelling disappeared after a couple of days (Doing a circumcision in the same moment is difficult and often leads to unaesthetic results).

Balanoposthitis: This is the term to describe the inflammation of the glans and foreskin seen in small boys. This occurs in around 4% of uncircumcised boys, mostly between 2 and 5 years of age. The cause can be an infection, irritation due to long exposure to urine and allergy to some component of the diaper. Symptoms are pain, dysuria (pain when urinating, bleeding from the foreskin and others). The treatment is an antibiotic cream, warm baths and proper local hygiene. In the case of associated narrow foreskin the pediatric surgeon will recommend a circumcision in some patients with repetitive balanoposthitis without other associated causes but phimosis.

Webbed Penis (Buried penis): This is the condition where the scrotum, instead of being attached in the base of the penis, is attached closer to the prepuce, giving the impression of a small or “buried” penis. Careful examination by the specialist will reveal the presence of a normal sized penis for the age of the boy and the anatomic characteristics particular to this pathology. Normal circumcision does not give good results and a more complex procedure is performed with the objective of giving a more normal appearance and functionality.

Balanitis Xerotica Obliterans (BXO): BXO is the cause of a secondary or true phimosis, and a recognizable lesion at the tip of the prepuce can be observed, usually in children from 5 years until adolescence. The resulting phimosis is severe and often is not possible to visualize any part of the glan. In some cases the scarring process can involve the glans and the meatus as well (external opening of the urethra in the glans, where the urine goes out). The cause of BXO is unknown and the treatment is essentially surgical with a circumcision that resects all the fibrotic tissue involved, though the healing process can be longer and a higher rate of complications are seen.