In some cases, there may be scarring of the foreskin which may result in a permanent phimosis. The scarring may be caused by infection or inflammation of the foreskin, or forced stretching of the foreskin causing splitting, before it is ready to be stretched. Approximately 10% of boys develop scarring with phimosis.
When should the foreskin be able to retract?
Most boys are able to fully retract their own foreskins by 1-2 years of age. Some boys take longer than 2 years but if there is no evidence of significant scarring, then there should be no harm in waiting a few more years before becoming concerned.
Who needs a circumcision?
Boys who have either tight, normal phimosis or scarring with phimosis are unable to pull their foreskins back completely, and as a result of this there may be ballooning of the foreskin when it fills with urine. Those boys who have particularly tight foreskins, may experience pain when they have erections.
If there is a possibility of scarring causing the phimosis, the boy needs to be seen by a Paediatric Surgeon. If the Paediatric Surgeon believes that the phimosis will not resolve of its own accord, then circumcision will be recommended.
Are there any dangers?
Phimosis with scarring if left untreated, can result in further infections of the foreskin and even urinary infections. Once circumcision has been performed, there are not usually any ongoing problems.
Circumcision is an operation which is performed to remove the foreskin.
Who needs a circumcision?
The medical indications for performing a circumcision include a tight foreskin or phimosis with associated scarring that prevents the foreskin from being completely pulled back, or recurrent, severe infections of the penis and foreskin. Circumcisions may also be performed for social and religious reasons.
When should this be performed?
If possible, circumcision is performed when the child is over one year of age. Circumcision of the newborn should be avoided, as there is a significantly increased risk of complications in this age group. These complications include narrowing of the urinary opening due to scarring.
Circumcision is usually performed as a daycase operation. Under a general anaesthetic, the foreskin is removed using either scissors or a scalpel. The edges of the skin are then stitched together using stitches that dissolve of their own accord after 1-2 weeks. Whilst the child is asleep, the anaesthetist will block the nerves to the penis with an injection of local anaesthetic. After the child has woken, he should not be in significant pain but may be distressed at waking in a strange place, and feeling hungry. The anaesthetic injection tends to last for about 6-8 hours and after this time the boy may require oral pain killers for 1-2 days. If it is comfortable to do so, the boy can bath or shower normally, even on the first day.
Can there be complications after the operation?
The two main side effects of the operation are bleeding and infection. If bleeding from the edges of the cut become a trickle, then the Paediatric Surgeon will need to review the child again and occasionally may need to return the child to the operating theatre to stop the bleeding. If infection occurs, it is usually 2-3 days after the operation and the penis will become more swollen, more red and more painful rather than less so. If this occurs, the boy may require a course of antibiotics. Sometimes the edges of the cut will stick to the head of the penis and will require gentle separation in the clinic some weeks after the operation.
If a child has a slightly abnormal penis and foreskin, a Paediatric Surgeon must exclude the possibility of hypospadias before a circumcision is performed. Hypospadias is a congenital abnormality of the penis in which the opening for the urine is not located at the tip of the penis. There is an associated hooding of the foreskin, there may be curvature of the penis and sometimes the urinary opening is smaller than it should be. As the foreskin is useful in the correction of Hypospadias, it should be preserved in the boys with this abnormality.
It is important that circumcision achieves a cosmetically and functionally appropriate result with the correct amount of foreskin removed during the operation.