Foreskin Problems in Children

In the United States, research shows that while most boys are circumcised after birth, the rate of circumcision has declined by around 10% over the past few decades. An increasing number of parents are electing to forgo circumcision, making it more important than ever to understand the potential problems that can occur with the foreskin. Several foreskin conditions can affect children, including phimosis, paraphimosis, and balanitis. These conditions are fairly common and very treatable, but they can be a medical emergency in some cases.

Foreskin Problems

The foreskin (or prepuce) is the skin that covers the head (glans) of the penis. Circumcision, the surgical removal of the foreskin, is performed in many male infants for religious, medical, or personal reasons, but may also be performed to treat problems with the foreskin. In adult men, the foreskin should move freely, allowing it to be retracted and fully expose the head of the penis. When children are born, the foreskin is attached to the head of the penis and is not moveable. As children grow older, they can retract their foreskin; about 10% of boys can retract their foreskin at 1 year old and 50% can by age 10. Foreskin problems are not uncommon, but serious problems are rare. Most of these conditions can be caused by injury, irritation, or infection. Foreskin conditions that cause inflammation or scarring can increase the risk of penile cancer, but the risk is still very low.

Phimosis

Phimosis occurs when the foreskin becomes tight or cannot be retracted. Most children cannot retract their foreskin before age 10, and it is normal for some older teens as well. Once the foreskin can be retracted, however, it should continue to do so. Phimosis can also occur before the foreskin is retractable. It can cause the opening of the foreskin to narrow, preventing normal urination and leading to repeated urinary tract infections (UTIs). Symptoms of phimosis include inability to retract the foreskin, painful urination, urinary retention, and skin infections. Causes include infection, scarring from chronic inflammation or injury, and swelling or inflammation of the foreskin (posthitis). Treatment for phimosis can include stretching of the foreskin, topical medications, surgery to loosen the foreskin, or circumcision.

Paraphimosis

Paraphimosis occurs when the foreskin gets stuck in the retracted position and cannot be pulled back over the tip of the penis. Paraphimosis is a medical emergency. In addition to causing pain and swelling, paraphimosis can cut off blood flow to the penis. If not treated promptly, this can lead to permanent injury to the penis and can even result in gangrene.

Treatment for paraphimosis involves returning the foreskin to its normal position by reducing swelling or, if needed, surgery, including circumcision. Applying ice and pressure can help relieve swelling and may allow the foreskin to move back into place. In some cases, medication may be injected into the penis to reduce swelling. If the foreskin remains stuck, then it may require surgery to cut and loosen or remove the foreskin.

Balanitis

Balanitis is inflammation of the head of the penis caused by irritation or infection that occurs in adults and children. Balanitis can also involve the foreskin (called balanoposthitis). Balanitis is more common in diabetics and uncircumcised men. Symptoms of balanitis include a rash, itching, pain, swelling, and redness of the head of the penis. It can also cause a foul-smelling discharge from the penis and pain with urination. Balanitis can make it difficult to retract the foreskin in older children and adults.

Poor hygiene can lead to balanitis. Fungi and bacteria can grow under the foreskin where it is warm and moist. Men and older boys who can retract their foreskin need to be sure that they keep their foreskin clean. Chemical irritation or allergies can also cause balanitis. Some soaps and detergents have dyes and perfumes that can cause skin reactions, including balanitis.

If balanitis is caused by infection, antibiotics or antifungal creams may be used to treat it. If chemical irritation is the cause, the irritating chemicals need to be identified and eliminated. Over time, balanitis can cause scarring of the penis, foreskin, and urethra, leading to further problems. In severe cases, circumcision may be required.

Balanitis Xerotica Obliterans

Balanitis xerotica obliterans (BXO) is a rare condition affecting the foreskin and head of the penis. While it is most commonly seen in men in their 40s-60s, it can happen at any age. BXO, also called lichen sclerosus, is an inflammatory skin condition that causes redness and white lesions on the foreskin and head of the penis, including around the urethra. This can cause pain and itching and may lead to infections. Over time, BXO can result in scarring, difficulty urinating, and phimosis. BXO can also increase the risk of penile cancer. BXO can be treated with topical steroid creams that reduce inflammation and help prevent scarring.

Penile Cancer

Penile cancer does not typically affect children, but childhood medical conditions can increase the risk of cancer. Balanitis, phimosis, balanitis xerotica obliterans, and simply having a foreskin are all possible risk factors for penile cancer. Anyone who has a foreskin, especially if they have experienced any of these conditions, needs to be aware of their risk of penile cancer and watch for changes in their penis, including new growths, sores, discharge, or bleeding, that could be symptoms of a serious condition.

The rate of infant circumcisions has declined in recent decades, meaning that more children are growing up with foreskins. Foreskin problems are not uncommon, but they can have serious consequences if not treated. Parents and children need to be aware of these potential problems and how to recognize them. Foreskin problems can be serious medical emergencies and also increase the risk of penile cancer. If you or a child in your care are having swelling, pain, difficulty urinating, or other problems involving the penis, seek medical help.