Forcible retraction of the foreskin

The Forcible retraction of the foreskin, sometimes called "premature retraction", in infants or young adults can damage the glans and mucous inner tissue of the foreskin. Doctors or parents who may be unfamiliar with the uncircumcised penis can often do this not knowing that it can be damaging. At birth, the foreskin is fused to the glans. Overtime, separation occurs naturally. Infants are sometimes diagnosed as having pathological phimosis, which some authors consider to be erroneous. In order to perform circumcision the foreskin must be retracted by force.

Biology of the infant foreskin

"Also see Phimosis and Foreskin"

It has been widely recognized by the medical profession for most of the 20th century that normal male infants have foreskins which are incompletely separated from the epithelium of the glans penis. They cannot be easily retracted. McGregor reports that many physicians have difficulties distinguishing between this and pathological phimosis. [http://www.emedicine.com/emerg/topic423.htm] [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15877942&query_hl=6&itool=pubmed_docsum]

At birth, the foreskin is usually still fused with the glans. As childhood progresses the foreskin and the glans gradually separate, a process that may not be complete until the age of 17. A Danish survey reported that average age of first foreskin retraction in Denmark is 10.4 years. Marques reported that 99% of boys can retract their foreskins by age 14. [http://www.cirp.org/library/anatomy/deibert/] [http://www.cirp.org/library/general/oster/] [http://www.brazjurol.com.br/july_august_2005/Marques_ing_370_374.htm] [http://www.cirp.org/library/normal/thorvaldsen1/]

In children, the foreskin covers the glans completely but in adults this need not be so. In a German study, [http://www.male-initiation.net/library/medicus/schoeberlein.html#start Schoeberlein] found that about 50% of young men had full coverage of the glans, 42% had partial coverage, and in the remaining 8%, the glans was uncovered. After adjusting for circumcision, he stated that in 4% of the young men the foreskin had spontaneously atrophied (shrunk).

About 2% of males have a non-retractile foreskin throughout life, although this does not necessarily mean it is a pathological phimosis. Wright emphasizes that the first person to retract the boy’s foreskin should be the boy himself. [http://www.cirp.org/library/normal/wright2/]

Prevalence and consequences

Forcible retraction may lead to bleeding, scarring, pathological phimosis or paraphimosis, and often pain. Adhesions after forcible retraction, especially in infants, can fuse the foreskin with itself or the glans, leading to skin bridges. The Canadian Pediatric Society poses the question of whether increased UTI and balanitis rates in uncircumcised male infants may be caused by forced premature retraction. [http://www.cps.ca/english/statements/FN/fn96-01.htm] [http://www.cps.ca/english/statements/FN/fn96-01.htm] [http://www.emedicine.com/emerg/topic423.htm] [http://www.racp.edu.au/hpu/paed/circumcision/anatomy.htm] [http://www.racp.edu.au/hpu/paed/circumcision/indications.htm]

Forcible retraction happens in a variety of occasions. Most well known is the forcible retraction by doctors . Spilsbury suggests that doctors may be likely to confuse congenital (and normal) infant phimosis and the fused glans and foreskin with pathological phimosis. [http://www.mja.com.au/public/issues/178_04_170203/spi10278_fm.html] Cooper reported resolution of a number of problems, including balanoposthitis, dysuria, and phimosis through retraction under anaesthesia. [http://www.cirp.org/library/treatment/phimosis/cooper/] Others have reported similar results in treating older children. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9038050&dopt=Citation] [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16291369&query_hl=2&itool=pubmed_docsum] [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=97155165&dopt=Citation] MacKinlay reported on breaking the adhesions between foreskin and glans with topical anaesthetic, thus achieving full retractibility. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=3139222&query_hl=6&itool=pubmed_docsum]

Griffiths reported::"Between March, 1973 and November, 1980 we treated 161 patients in this way, achieving complete separation in 150 and partial separations in 11. Complications were severe trauma in 9 and slight discomfort in 15. 2 mothers fainted. Apart from the 4 failures, the procedure had to be repeated in 4 children and paraphimosis was recorded in 1." [http://www.cirp.org/library/treatment/phimosis/griffiths/]

Forcible retraction may also be done by caretakers. Osborn reported that mothers are often advised by their doctors to retract the child's foreskin. Griffiths reported that children may be advised to gently retract the foreskin themselves. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7243473&query_hl=6&itool=pubmed_docsum] [http://www.cirp.org/library/procedure/griffiths-frank/]

The American Academy of Pediatrics caution parents not to retract their son's foreskin, but suggest that once he reaches puberty, he should retract and gently wash with soap and water. The Royal Australasian College of Physicians as well as the Canadian Pediatric Society emphasize that the infant foreskin should be left alone and requires no special care. [http://www.racp.edu.au/hpu/paed/circumcision/anatomy.htm]

ee also

*Balanitis
*Bioethics of neonatal circumcision
*Circumcision
*Foreskin
*Phimosis
*Posthitis

References

* [http://www.racp.edu.au/hpu/paed/circumcision/anatomy.htm Royal Australasian College of Physicians: Anatomy of the foreskin]
* [http://www.cps.ca/english/statements/FN/fn96-01.htm Canadian Pediatric Society: Circumcision statement]
* [http://www.medem.com/search/article_display.cfm?path=\TANQUERAYM_ContentItem&mstr=/M_ContentItem/ZZZRNBDTODD.html&soc=AAP&srch_typ=NAV_SERCH American Academy of Pediatrics: Care of the uncircumcised penis]

External links

* [http://www.mothersagainstcirc.org/care.htm Mothers Against Circ: Intact care agreement]
* [http://www.nocircoftx.org/care/pamphlet6.html NOCIRC of Texas: About premature retraction]
* [http://www.doctorsopposingcircumcision.org/info/retraction12-16-05.html Doctors Opposing Circumcision: Development of Retractile Foreskin]