Category: Urology

The foreskin is usually fixed in place in young children, but it should begin to loosen during early childhood.

The foreskin will normally be able to retract and then move back into place over the head or glans of the penis. However, sometimes this doesn’t happen till much later in childhood. This is called physiological phimosis. This is normal.

In other cases, a problem develops. A foreskin that was retracting well changes, and no longer retracts as it used to do. This is abnormal i.e. pathological phimosis.

It is important to be aware that the foreskin cannot usually be retracted at a young age. The foreskin usually becomes looser during early childhood. The process usually begins by age two to three, but it can take longer for the foreskin to be able to retract completely.

• Ballooning: One of the most common phimosis symptoms is the bulging or ballooning of the foreskin during urination. This happens because urine builds up inside the foreskin as it makes its way out. If the urine builds up under the foreskin, this can lead to a chemical irritation and balanitis. Teaching your child how to shake off and mop up urine from the foreskin after voiding are essential.

• Discomfort: Severe phimosis may make it harder to pass urine. Children may complain of a burning sensation or pain in the tip of the penis as they pass urine.
• Balanitis: This is where the foreskin is inflamed and can progress to an infection. It is also called balanoposthitis.

You should never try to force the foreskin to retract as this could damage it. If the foreskin becomes scarred then it might not be able to retract properly in the future and phimosis surgery may then be required to correct it.

Phimosis isn’t usually anything to worry about unless it is causing pain or other phimosis symptoms. In most cases, the foreskin will start to retract between the ages of about 2 and 6. Therefore, the problem will often correct itself in time without the need for phimosis surgery. However, if you are concerned that the foreskin is taking longer than expected to retract, it can be reassuring to see a doctor.

By late adolescence, the foreskin can usually be fully pulled back from the glans and is then able to return into place. Medication or phimosis surgery is only required if this doesn’t happen naturally. It is important not to rush the process by trying to move the foreskin back as this could damage it.

Older boys may also feel self-conscious or anxious about phimosis, so it can be important to talk to them about the condition and enable them to speak to a doctor if they wish.

You should also seek medical advice if your son is experiencing any phimosis symptoms or if the foreskin stops being able to retract later on.

Phimosis can return later in childhood / adolescence after the foreskin has already been pulled back. This is when the tissue becomes scarred and fibrous and stops the foreskin from retracting properly. When the condition occurs due to scarring it is sometimes known as true phimosis.

The foreskin can be damaged in different ways, including by attempts to force it to retract when it is still too tight. Phimosis surgery may then be needed.

The foreskin may also be affected by a condition called BXO (balanitis xerotica obliterans). This condition is diagnosed by a specialist and requires phimosis surgery as treatment.

Most children do not require any treatment for phimosis. Seeing a doctor is useful. The doctor will ask about any phimosis symptoms that you or your child have noticed. The doctor will also examine your child. You should remain present for the examination. This examination will help to rule out balanitis xerotica obliterans, a skin condition that can prevent the foreskin from retracting. The doctor will also check for scarring or damage to the foreskin that could be responsible for phimosis symptoms.

If there are no signs of damage and the foreskin has never been able to retract then it can be best to wait and see if it happens naturally as long as your child is still young enough and isn’t experiencing any phimosis symptoms.

Some children will be successfully treated with a treatment of steroid cream e.g. hydrocortisone. This can be useful even if there is no significant scarring or any evidence of BXO. Steroid cream makes the skin looser and more supple.

Phimosis surgery may also be needed if your child is in pain or having issues such as urinary problems. Surgery is only recommended for phimosis treatment when the condition is unlikely to correct itself, the symptoms are severe or it is associated with scarring or damage

There are two options:

• An incision to release the fibrotic scar. This is called a dorsal slit procedure. This retains the foreskin but can have an unsatisfactory cosmetic result.
• Circumcision: The foreskin is surgically removed. Different surgeons achieve using various methods. The key question to ask are:
  • What procedure would they recommend for younger versus older children? Some methods are only suitable for newborn babies and infants.
  • How is pain controlled? Local or general anaesthetic? Syrups and tablets after the procedure? Pain control must be appropriate to the age of the child. The experience may be unecessarily traumatic if these factors are not considered.
  • What infection rates do they have in their practice? how ill infection be prevented?

It is important to be aware that it will change the appearance of the penis and can affect its sensitivity too. You will need to discuss the risks and benefits of circumcision for phimosis treatment with the doctor.

It is also important to talk to your son about the procedure in an age-appropriate way so that he understands what is happening. 

Most children do improve. However, it can take them a very long time. The length of time required to be cured is related to the length of time with the symptoms and the failure of previous medical therapy.

The child can finding ‘waiting’ to grow out of the condition very frustrating and disempowering.

Again, bed wetting is really common. In a class of 30 children who are 8 years old, 6 children will continue to have wet nights.

Bedwetting is due to a combination of factors:

• excess urine production at night
• smaller bladder capacity
• sleep disturbance

40% of children with bed wetting have a strong family history with a parent having had a similar history as a child.

No, most children do not require surgery.

However a very small number of children have a structural problem which requires investigation for better understanding and management. Surgery for this condition is very uncommon.

Rarely in life is there a quick fix for anything and the same applies to bed wetting.

Most children require time. Consultation with a specialist can help them get on the right path.

Once they are ‘fixed’ they are cured forever.

Thinking about the causes, some contributing factors can be improved:

• Excess urine production at night: Behavioural changes to drinking and voiding (passing urine) can reduce the bladder load at night. Sometimes, medications can be useful.

• Sleep disturbance: Many changes can be made to improve sleep patterns and toilet habits around sleep
• Small capacity bladder: Rarely, this is a cause of night time wetting. Investigations by a specialist can help explain the underlying cause.

Our policy is to try and avoid medication and most children not need medication. However medication can be useful. A specialist (paediatrician, paediatric surgeon/ urologist) should be consulted first if you are considering medications for this condition.

• Daytime voiding pattern: Many children have undiagnosed major daytime issues that are often unknown to family and parents. Ensure your child is voiding every 2-3 hours during the day. It is important to establish regular daytime voiding as part of your child’s routine. Alarms, vibrating watches etc, can be useful aids.
• Drinking: Lots of children don’t drink enough fluid in the day and fluid restriction is not the way to go. However, consider the timing of the last drink before bed. Encourage your child to drink plenty , up till an hour before bed. Your child should drink mostly water. Fluids that irritate the bladder include caffeine and fizzy drinks.
• ‘Lifting’ is placing your child on the toilet to void in the middle of the night. This activity does stop the bed getting wet. However unless the child is awake it rarely improves the situation in the long-term.
• Alarms: Bedwetting alarms can function very well in some children and are a very useful treatment modality in primary care.