Hi everybody! A friend sent me a link to this thread because I have been providing information on this issue for years and have been able to help many Moms with genital problems with their boys. I hope no one minds.
In all of my years in providing this help, so far, none of the boys have been circumcised although many of them had gotten a recommendation for a circumcision and all of them are happy and healthy today. There have been more than a hundred.
Many issues have been brought up here. Please bear with me and I?ll address them one by one
Phimosis: This is also called ?tight foreskin.? The normal condition of the foreskin of young boys is tight. This is by design to keep things out of the foreskin. At some time later in life, this condition (called developmental phimosis) resolves all by itself to allow for retraction. The exact time this happens is not known and there is much disagreement as to when it happens. Of a half dozen studies I have seen, they range from 2/3 being retractile at 3 years old to 70% not being retractile until after puberty. All of the studies state that normal retraction doesn?t come for some boys until late teens. In almost all cases, a diagnosis of tight foreskin or phimosis is a false and erroneous diagnosis.
There is also a rare condition called pathological phimosis. This is a result of injury to the foreskin either by long term untreated infections or as a result of physical trauma. The physical trauma is almost always the result of forcibly retracting the foreskin before the normal time has come. There is a band of tissue surrounding the tip of the foreskin called the preputial sphincter or frenar band that keeps the tip of the foreskin closed. In older boys and men, this band is elastic. In young boys, it is not elastic. In young boys repeatedly retracting the foreskin tears this non-elastic tissue and that can cause tears in the band which are repaired with scar tissue and scar tissue is not elastic and can not be replaced as the time for retraction comes. Long term untreated infections can also cause scar tissue to form but it forms in the skin surface. Although it is very rare, this can require circumcision to correct. Almost all cases of pathological phimosis can be resolved with a steroid cream but this should be reserved for boys in their mid to late teens. In younger boys, it will temporarily loosen the foreskin but it will return to it?s normal tight condition when the medication is ended and it can cause a case of normal developmental phimosis to convert to a case of pathological phimosis.
If a boy can urinate freely, there is no need for worry. The foreskin opening can be so tight that the end can not be viewed or it can be loose enough to easily view the tip of the penis and it can change from day to day from one to the other.
Ballooning: Ballooning of the foreskin is a normal in probably 10% to 15% of boys. The process of the body preparing for retraction of the foreskin requires two steps. The foreskin is bonded to the glans (the head of the penis) just like the finger nails are bonded to the nail beds and the tissue is the same, synechia or the epithelium layer. As the time for retraction approaches, this bond dissolves on it?s own and the non-elastic tissue in the preputial sphincter is replaced with elastic tissue. It can happen in either order. Ballooning is just evidence that the boy is nearing the time for retraction and the normal adhesions have dissolved before the non-elastic tissue has been replaced with elastic tissue. No treatment is required for ballooning, just time. That time may be several years.
Adhesions: Adhesions are completely normal. All boys have them at birth and in time, they will dissolve all on their own. Adhesions should never be forcibly separated!
Infections: Boys will occasionally have infections but girls also have infections. The difference is that girls are never treated with surgery. This is purely because of cultural acceptance of circumcision for boys and a rejection of surgical correction for girls. Boys and girls genital infections are the exact same bacteria or fungals (yeasts) and boys respond equally well to medication as girls. There is simply no reason for boys to be circumcised for genital infections.
The main reason for reports of repeated genital infections in boys is because the infection has not been accurately diagnosed and treated. Many doctors will do a visual examination and make a diagnosis and prescription. Often, the prescription is one that is not effective on the particular bacteria or fungal but does succeed in resolving the symptoms for a few weeks or months but the symptoms eventually return. This appears to be separate infections when in reality it just that the symptoms have returned.
The only way to get an accurate diagnosis is with a culture. The physician will take a sample from the tip of the foreskin with a cotton swab and transfer that sample to a petri dish with a growing medium. The bacteria or fungal will rapidly reproduce in just a couple of days when it can be accurately read. Each bacteria or fungal has distinct characteristics and when they are viewed in quantity, they are easily distinguishable. Once the specific pathogen is identified, a medication can be prescribed that is known to be effective against that pathogen. This almost always results in a quick cure and repeat episodes are rare. Often, the doctor will prescribe a medication on the first visit but you should always call the office in two or three days to find out what the pathogen was and if the prescription is known to be effective against that pathogen. It may be that the prescription needs to be changed. With the proper medication, you should see a noticeable improvement in a day or two and no future flare ups. Always insist on a culture and if there is any resistance, insist on another physician.
Cleaning: It is not any more necessary to clean inside a boy?s foreskin than it is necessary to clean inside a girl?s vagina. Indeed, it can actually cause problems just as cleaning inside a girl?s vagina can be expected to cause problems. You simply clean the outside just like a finger.
This is because of two reasons. First, it can cause physical damage to the foreskin as mentioned above. Second, it can cause tears in the foreskin or glans which is an opening inviting infectious bacteria or fungals to take hold. The third reason is discussed below in ?smegma.?
Smegma: This is a creamy white substance that both boys and girls produce. It is absolutely normal and actually beneficial and necessary. Smegma is the greek word for ?soap? and that is a hint. It contains an enzyme called lysozime that protects the penis from infection. This same enzyme is also found on girl?s vulvas and in the eyes protecting those areas as well. Washing the smegma away also washes the lysozime away and makes infections much more probable.
Smegma also acts as a barrier crème. It isolates the separated areas of the foreskin and glans and keeps them from rebonding with scar tissue. As the separation process is taking place, small tears in the surface of the foreskin or glans can occur. During the healing process, smegma prevents the foreskin and glans from healing to each other permanently. That is certainly something no one wants. The best thing to do is to not try to separate the foreskin or retract it and let the process take place on it?s on. The boy should be the first to retract his foreskin. He is the only one that can feel the pain and know when to stop before damage is done. He?s going to stop before damage is done.
There is one additional problem that occasionally shows up. It is called separation trauma. This happens as the foreskin is separating from the glans. The process is not even in most boys and the foreskin can be loose from the glans in most areas but still firmly adhered in spots. Usually, boys will have an erection on waking and these erections cause pulling at the remaining adhesions causing slight tears in the foreskin inner surfaces or the glans. The foreskin is similarly enervated and vascularized to the lips and any trauma can cause a very noticeable reaction just like a slight blow to the lips can cause a noticeable ?fat lip.? In these cases, sometimes the symptoms can be quite extreme with a badly swollen and red foreskin, sometimes all of the way down the shaft to the base of the penis. However, it also resolves itself quite quickly with most of the symptoms disappearing within a day or so. This is most often diagnosed as an infection when there is no infection at all. Usually, there is a prescription to treat it when there was no infection at all but the prescription is given the credit.
Genital infections are simply minor skin irritations. There is no harm in delaying treatment for a single day to see if the symptoms subside on their own and they do in most cases. The only caveat is that you make sure your son is having no problem urinating. There may be pain or burning with urination but watch for a fine, thin stream or dribling or signs of urinary retention. So far, I have heard of no case of separation trauma where there was urinary retention but it is possible. Urinary retention requires emergency treatment.