Caring for the uncircumcised penis: what parents (and you) need to know
A declining circumcision rate means more and more parents need to be educated about care of their son's foreskin and more pediatricians need to be prepared to manage problems associated with an uncircumcised penis.
Although still very common, routine neonatal circumcision has been declining in prevalence in the United States in recent years. (1) Pediatricians are seeing more uncircumcised boys among their patients and, in turn, encountering more parents asking for advice on care of the prepuce. Many parents--and many physicians--are unfamiliar with normal development of the penis and foreskin.
In this article, we do not address in depth the pros and cons of neonatal circumcision. Rather, we focus on the development and routine care of the normal, uncircumcised penis, as well as management of common associated problems.
A change in thinking and in practice
Circumcision has been a controversial topic in both professional and lay circles for a number of years. The procedure has historically been performed for cultural, religious, and medical reasons. Opposition to routine neonatal circumcision has been vocal, and medical indications have been revisited over the past three decades. The American Academy of Pediatrics (AAP) has issued several policy statements during this period, the most recent in 1999. Current AAP recommendations state that while there are potential medical benefits of newborn male circumcision, the data are not sufficient to recommend routine neonatal circumcision. (2)
Although accurate data on the prevalence of routine circumcision are lacking, it is known that approximately 80% of males born in the US in the years after World War II were circumcised; that percentage increased with the percentage of hospital births. (1) The number declined slightly when some voices in the medical establishment began to question the value of the procedure. Most recent estimates of the rate of neonatal circumcision are in the range of 60% to 65%, with a noted difference across racial and ethnic groups. (2) When other variables are controlled, data from the National Health and Social Life Survey for the years 1933 to 1974 show that the rate of circumcision for whites was 81%; for blacks, 65%; and for Hispanics, 54%. (1) Despite some convergence in the circumcision rate for the three groups across cohorts, differences among racial and ethnic groups persist. (1) With the Hispanic population in the US growing, uncircumcised males are being seen even more often in pediatric practice.
At eight weeks' gestation, the skin of the body of the penis begins growing forward over the developing glans penis, initially as a ridge of thickened epidermis. The prepuce grows more quickly dorsally than ventrally, where full development depends on final formation of the glanular urethra. This explains why the foreskin is usually deficient ventrally in cases of hypospadias.
If all proceeds normally, the prepuce is complete by 16 weeks' gestation. The squamous epithelial lining of the inner prepuce is contiguous with the glans at this stage, so that preputial adhesions are a normal part of development, not a pathologic state. (2,3) Desquamated skin...