Monday, August 30, 2010

Intact Penis Information

I have many friends who have intact sons, so I've been inundated with information about the proper care and expectations of intact penises, despite not having a son (yet?) of my own. However, despite the abundance of information available, many doctors in the US are poorly educated and give out bad information because they just haven't seen that many intact penises. The overall US circumcision rate is around 75%1 or so, though the latest statistic for new infants being circumcised is 33%2 (average--the south and midwest having the highest number, varying from 50% upward and the west having the lowest percentage) down from 57% in 1999. If these numbers are true, then doctors need to update their information for dealing with intact boys coming through their practices to properly answer the following questions.

So, let's start with the basics. How do you clean an intact penis?

Mis-educated doctors will answer with, "You gently retract the foreskin and wash with soap and water."

Except for the first part, that's right. You do NOT retract the foreskin--that is the boy's job when he is older, under his own initiative. However, simple soap and water, just like with a girl, is all it takes to clean it.

Next, is "ballooning" a cause for concern?

No. It's caused by the natural separation of the foreskin leaving pockets behind in which urine pools. It does come out eventually and in the meantime, urine is sterile. Apparently, some boys like to play a game that causes ballooning (which is messy but harmless). The biggest concern is that there is an obstruction to voiding, but under study, this was shown not to be so. 3 As long as there is no pain or infection, this is a normal process, particularly around the age of 3 and should go away as he gets older.

When should the skin retract?

This is the most common source of concern for parents of intact boys. The first study done on this subject only followed boys for 5 years who were forcibly retracted from infancy and thus, states that 90% of boys will retract by age 5. This study was refuted over and over and the current advice is that it will retract by puberty. Now, the misunderstanding comes with "by puberty." In fact, it is by late puberty that one should expect retraction (age 15-17, though 5% of men remain non-retractile until the early 20s when, anecdote suggests that most of the remaining men gain the ability to retract, but no studies have been done). At age 12-13 (early puberty), 40% of boys remain non-retractile.4

So, the answer is, it should retract by age 17, but a very small number of men don't retract until age 20 or later. Only the boy should retract his foreskin and he should be advised not to do so where he experiences pain. Forced retraction can cause iatrogenic phimosis,5 which causes the foreskin to be too tight to be retracted or scarring from torn adhesions that can cause the foreskin not to retract properly later and can cause severe pain when retraction occurs.

My son has been diagnosed with phimosis and I've heard that circumcision is the only treatment. Is this true?

First, there are two different kinds of phimosis. Phimosis is a condition where the foreskin either cannot retract or when it does, it chokes or creates a "waist" on the penile shaft, resulting in damage or pain. Pysiological phimosis is the natural period in which the foreskin is non-retractile. Pathological phimosis is problematic and typically caused by Lichen sclerosus, scarring caused by forcible retraction or Balanitis.

Pathological phimosis can be treated with steroid creams (4-6 weeks) 6 (note, in this study, it's stated that circumcision is mandatory following failure, but this is not so, three other, yet still surgical in two cases, options remain), balloon stretching7, dorsal slit8, preputioplasty9 and finally, circumcision, but pathological phimosis is an adult condition, typically. If the boy is experiencing issues with pain, inability to urinate or frequent infections and phimosis is diagnosed, it may be in his best interest to look begin non-surgical treatments first and if the condition persists, consider corrective surgery with circumcision as a last resort (unless he is mature enough to decide that circumcision is preferable).

So, those are the most common questions about care of the intact penis. You can do more reading here:
and here: DAC faq sheet on intact penile care

In regards to circumcised penises, US doctors are well versed and are capable of answering parent's questions and concerns about penile care. Caution needs be exercised when cleaning until it's healed and then normal washing, the same as an intact penis, is all that's needed.10

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