NOCIRC Information Series: Premature Retraction

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NOCIRC Information Series: Premature RetractionAnswers To Your Questions About Premature (Forcible) Retraction of Your Young Son'sForeskinfrom theNational Organization of Circumcision Information Resource CentersEducating A New Generation For The Well-Being Of All Children.www.nocirc.orgNow that more males are growing up with their foreskins intact, NOCIRC is gettingan increasing number of calls from parents whose son's foreskin was retracted prematurelyby a healthcare professional, the child's caregiver, or even the child himself.This pamphlet is to help parents protect their child from premature foreskin retractionand to help them know what to do if forced retraction occurs.What do I need to know about the foreskin?Almost all males are born with a fold of specialized skin - a foreskin (also knownas the prepuce) - that covers their glans (head of the penis) and, in many males,extends beyond it.In infancy and usually during childhood, the inner surface of a male's foreskin andthe surface of his glans are one continuous structure.The cells that connect these two surfaces dissolve naturally over time - a processthat should never be hurried.The narrow opening of the non-retractable (normal) foreskin protects the urinaryopening (meatus) from ammonia, feces, foreign matter, friction, irritation, ulceration,and infection.What is foreskin retraction?The foreskin is retracted when it is behind the glans instead of covering it.The foreskin becomes retractable when its inside fold separates from the glans andits opening widens. This usually happens between early childhood and sometime afterpuberty. Even if the glans and foreskin separate by themselves in infancy or earlychildhood, the foreskin may still not be retractable because its opening may stillbe just large enough to allow for the passage of urine. This is normal.After the foreskin separates from the glans and its opening widens, a boy can retracthis own foreskin, without pain or injury.Who should be the first person to retract the child's foreskin?The first person to retract a child's foreskin should be the child himself.A boy should not be coaxed or urged to retract his foreskin. In early childhood,a boy will pull his foreskin out, away from his body, assisting the separation ofthe foreskin and glans. As he gets older he will begin to pull it towards his body,too, and one day he will discover that he can pull it all the way back behind hisglans.Many boys do not develop fully retractable foreskins until after puberty. This isnormal.How can I protect my son?Parents of an intact boy often know more about the structure, functions, development,and care of the normal penis than their son's physician. Most medical doctors inthe U.S. today have little or no knowledge about the foreskin because they were nottaught about it in medical school. Many still do not know that a child's foreskinand glans begin as one structure, separate in time naturally on their own, and shouldbe allowed to do so.Tell your son's doctor — before his newborn examination and before every examination thereafter — that your son is intact and that you do not wanthis penis touched or his foreskin retracted. Then, watch carefully to make sure thedoctor respects your wishes. NOCIRC continually receives calls from parents who toldthe doctor not to retract their child's foreskin, only to have the doctor retractit anyway."The foreskin therefore can be likened to a rosebud which remains closed and muzzled.Like a rosebud, it will only blossom when the time is right. No one opens a rosebudto make it blossom."H. L. Tan, MDWould my son's foreskin need to be retracted if he were catheterized for a urinalysisor medical treatment?No. A catheter can be inserted when the foreskin is retracted just enough to seethe meatus (urinary opening). if the foreskin's opening is too small to retract farenough to see the meatus, a catheter can be inserted through the foreskin's openingand into the meatus "by feel." The foreskin should never be retracted by force forany reason.What happens if my son's foreskin is retracted by force?Forced retraction of the foreskin causes pain and trauma because it rips the child'sforeskin from his glans and/or tears his foreskin's opening. Creating raw surfaceson the foreskin and glans can cause the following problems:Infection. There is now an opening through which bacteria can enter the body.Adhesions. The two raw surfaces grow together as they heal, often requiring surgeryto make foreskin retraction possible later.Acquired Phimosis. The foreskin's narrow opening sometimes tears when the glans is forced through it,forming scar tissue that may prevent it from widening later on its own.Paraphimosis. When a child's foreskin is retracted by force, its (narrow) opening may "get caught"behind his glans, and, like a tourniquet, trap blood in the glans and make it swell.Many physicians recommend circumcision to "correct" this, but the foreskin can bebrought forward without cutting by holding the shaft of the penis and gently pushingthe glans into the foreskin. If this doesn't work, squeezing the glans to reduceswelling should help slip it back inside the foreskin. If these techniques fail,putting ice on the glans or injecting the swollen foreskin with hyaluronidase usuallyallows the foreskin to be returned to its normal forward position.What should I do if my son's foreskin is forcibly retracted?Regardless of your son's age, first explain that you didn't know anyone would dothat to him, apologize, and tell him you will do your best to make sure no one everdoes that to him again.If your son's penis is swollen, sitz baths will help relieve the swelling and discomfort.If it hurts your son to urinate, put him in the bath several times a day so thathis urine will be diluted by the bath water, then rinse him off. Do not use soapon his penis.Even if you have been told to retract your son's foreskin, don't. He has been hurtand traumatized and his penis needs to be left alone to heal.Watch for infection.Your son may develop adhesions when his foreskin and glans heal but you might notknow whether these have separated by themselves or will need to be separated surgicallyuntil he has completed puberty.No one except your son should manipulate his penis to check for adhesions or to seehow far his foreskin will retract. A narrow foreskin deserves the same respect asa tight hymen. Both openings will enlarge with sexual maturity.What legal and/or regulatory action can I take?David J. Llewellyn, J.D., of Atlanta, Georgia, states:"Generally the law does not permit a physician to carry out a non-emergency invasiveor damaging procedure on a child without the parent's permission. If an infant'sforeskin is forcibly retracted, resulting in tearing and pain, and the parents havenot given their permission for the procedure, the law of most states provides thatthe parents may bring a suit on behalf of the child for assault and battery againstthe physician. Parents should be aware of these facts and should consult competentcounsel if their child has been forced to suffer unnecessary pain without their permission."Parents of boys whose foreskins have been forcibly retracted may want to consultcompetent, knowledgeable legal counsel about initiating litigation to recover moneydamages on behalf of their son.Parents can also file a complaint against the doctor with their state medical licensingboard (www.fsmb.org/members.htm). Information about reporting physicians is available at Circumcision: Legal Issues(www.cirp.org/library/legal/).The Federation of State Medical Licensing Boards (www.fsmb.org) advises that filing complaints against errant physicians improves the quality ofpatient care and is a service to the public.Please report all incidences of premature retraction to NOCIRC.More information can be found at:www.nocirc.org andwww.cirp.org.