Pediatric Urology: Circumcisions, Phimosis, Paraphimosis

The prepuce, or foreskin, is a normal part of the external genitalia, forming a natural covering over the tip of the penis (glans). At birth the foreskin typically is un-retractable, or does not easily glide back and forth over the glans. This is a normal condition and the foreskin will become fully retractable as the child grows. At birth up to 95% of boys have un-retractable foreskins compared to the forth year of life when only 10% of boys have un-retractable foreskins. Medical intervention is usually unnecessary. Medical or surgical intervention is necessary when a child has difficulties with urination (for example, the urine pools in the foreskin) or problems with infections.

Circumcision

Circumcision involves the removal of the foreskin from the tip of the glans to the ridge of the glans. Circumcision is often a hotly debated issue in terms of when it should be done and if it should be done. The latest recommendations put out by the American Academy of Pediatrics state that there are no medical indications for routine newborn circumcisions. In The United States it is frequently done within 1-2 days after birth for various reasons, including religious and/or cultural beliefs. Circumcision should never be done if there is a question as to whether or not the possibility of hypospadias exists.

Phimosis

This is a condition whereby the foreskin is tight and narrow, thus making it impossible or painful to retract. This may cause extreme pain when your child experiences stronger erections. In addition it may cause problems with infections as stated above. Although this is a normal condition in infancy, medical or surgical intervention may be indicated if this persists beyond 4-5 years of age. At this point in time your child should be evaluated by a pediatric urologist who can make the decision whether the need for a circumcision is indicated.

Paraphimosis

This is a condition somewhat opposite of phimosis. Paraphimosis occurs when the foreskin is fully retracted behind the ridge of the glans and is unable to be pulled back over the glans. As the foreskin remains behind the ridge of the glans, it may cause irritation and swelling making it impossible for the foreskin to be pulled back over the glans. This condition requires urgent medical attention.

Medical Treatment ( Non-surgical)

Some families prefer to try other options before immediately having their child circumcised. If the pediatric urologist believes the child will not be at risk for further problems, it may be appropriate to try a low potency steroid cream. The parents or child (if old enough) will be instructed to apply the cream 2-3 times a day, with a Q-tip, to the tip of the penis in order to help the foreskin naturally and easily retract. This is typically tried for one full month after which the child is re-evaluated.

Surgical Treatment-Circumcision

As stated earlier, circumcision is the removal of the foreskin. If this is not done within the first few days of life, the earliest it can be done is at 6 months of age. The reason for this delay is the need for general anesthesia. By 6 months of age infants are healthy and strong, able to tolerate general anesthesia, and in fact able to tolerate it better than an adult. By this age they have also had some time to bond with their parents and have not reached the Separation/Anxiety Stage of Development.

The procedure itself will take approximately 30 minutes and will be done in the Outpatient Surgical Unit. This means your child will go home as soon as he is stable and tolerating fluids, and can be as early as two hours after the circumcision.

Postoperative Care for Circumcision

Post-op care is minimal. A combination antibiotic/pain ointment called Spectrocin is applied to the penis to help the healing process and to prevent the penis from sticking to the diaper. You may bathe your child within 24 hours.