The normal foreskin (prepuce) surrounds the glans of the penis as an infolded layer of skin. In early childhood it is normal for the foreskin to be nonretractile. In many boys this remains the state until puberty. The skin is adherent to the glans by congenital adhesions which gradually break down throughout childhood. It may be several years before the glans becomes visible and this is normal.

When a young child urinates the stream can generate a very high pressure and this may cause the foreskin to expand or balloon. Provided there is no skin inflammation (balanitis), dysuria (painful urination) or scarring there is no need to treat ballooning. Occasionally collections of shedded skin may form under the foreskin trapped by the congenital adhesions. These are known as smegma deposits and can appear as palpable white nodules under the foreskin. These deposits can usually be released with a steroid cream applied to the congenital adhesions. Phimosis is a condition whereby the foreskin is unable to be retracted due to scarring and contraction of the foreskin at its very tip. When the opening becomes very small then symptoms occur. The foreskin may become inflamed and red. The child usually has difficulty passing a strong forceful stream of urine and a little trapped urine often dribbles out when the child has left the toilet. Sometimes the foreskin will be seen to swell or balloon when the child urinates. Ballooning is often seen however in children with a normal degree of tightness to their foreskin and its presence alone in a young boy does not mean that there is a phimosis. Furthermore it is normal for the foreskin not to be fully retractile in many boys until they are close to puberty. The process that seems to result in phimosis is a small tear in the skin at the very end of the foreskin that heals with scarring and contraction. Treatment involves release of the scar tissue. This can be successfully achieved in 80% by the application of a local steroid cream to the foreskin. This requires 4 weeks of treatment. Failure of this method will dictate a need for surgery including circumcision in many.

Circumcision is the operation to remove the foreskin. The main indications for this include:

¨1 Phimosis resistant to treatment with steroid cream.

¨2 Recurrent foreskin infections (balanitis).

The operation is carried out under full general anaesthesia preferably when the child is 6 months or older. Under general an additional local anaesthetic is applied to provide pain relief for well up to 12 hours after surgery. The operation takes 10 minutes. The whole proceedure is completed as a day stay patient. The sutures used automatically dissolve and are usually completely gone by 4 weeks after surgery. Postoperatively vasoline or occasionally an antibiotic cream needs to be applied to the head of the penis and suture line for 5 days following surgery. Paracetamol can be given also but is is seldom required. A dressing is not applied to the wound as this is unnecessary and often sticks to the wound and can be difficult to remove. Your child can bathe a day after surgery. A review in outpatients 2 weeks following surgery is suggested. Complications are uncommon (less than 2%) and include bleeding and infection. More commonly a crust or scab may be noticed on the exposed head of the penis called the glans. This occurs particularly when there has been significant prior scar tissue. This crust or scab which does not represent infection may deflect the urinary stream. It is treated and easily removed by daily application of vasoline. Rarely following circumcision the exposed opening of urinary tube (urethra) onto the head of the penis may narrow down. This condition is called meatal stenosis and requires treatment.