Premature, forcible retraction of the foreskin is an extremely painful, serious, and potentially permanent injury that happens in infants or young children, due to ignorance of normal penile development. It tends to happen in English-language medicine due to an absence of proper knowledge of the foreskin and its development in the medical curriculum.
Premature, forcible retraction of the foreskin can damage the glans and mucous inner tissue of the foreskin. Doctors or parents who may be unfamiliar with the normal development of the foreskin can often forcibly retract it, unaware that it can be damaging.
The foreskin is fused to the glans at birth, separating naturally over time. Infants are sometimes diagnosed as having pathological phimosis, which is in most cases, erroneous.
Forcible, premature retraction of the foreskin is a necessary step in performing circumcision in infants and under-age children.
Biology of the infant foreskin
It has been widely recognized by the medical profession for most of the 20th century that normal male infants have foreskins which are incompletely separated from the epithelium of the glans. The foreskin cannot be retracted without tearing the fusion which exists between the inner foreskin and the glans penis. According to McGregor et al (2005), physicians often have difficulties distinguishing between this normal, natural state of the penis in neonates and pre-pubecent boys and pathological phimosis.
At birth, the foreskin is usually still fused with the glans. As childhood progresses the foreskin and the glans gradually separate, a process that may not be complete until the age of 17. A Danish survey (2005) reported that average age of first foreskin retraction is 10.4 years. Marques et al (2005) reported that 99% of boys can retract their foreskins by age 14.
About 2% of males have a non-retractable foreskin throughout life, although this does not necessarily mean it is a pathological phimosis. Wright emphasizes that the first person to retract the boy's foreskin should be the boy himself.
Prevalence and consequences
Forcible retraction may lead to bleeding, scarring, pathological phimosis or paraphimosis, and often pain. Adhesions after forcible retraction, especially in infants, can fuse the foreskin with itself or the glans, leading to skin bridges. 
Forcible retraction happens in a variety of occasions. Most well known is the forcible retraction by doctors, who, unaware of the harmless nature of the normal, natural state of the penis in neonates (AKA physiological phimosis) and adhesions in infants and pre-pubecent boys, sometimes forcibly retract the foreskin just to see if it retracts. Spilsbury et al (2003) suggest that doctors may be likely to confuse the aforementioned conditions with pathological phimosis. Forcible retraction may also be done by naive caretakers. Osborn et al (1981) reported that mothers are often erroneously advised by their doctors to retract the child's foreskin.
Camille et al (2002), in their guidance for parents, state that "[t]he foreskin should never be forcibly retracted, as this can cause pain and bleeding and may result in scarring and trouble with natural retraction."
Therapeutic forcible retraction
Several doctors have proposed forcible retraction as treatment for a number of penile problems.
Cooper et al (1983) urged therapeutic retraction as an "alternative to circumcision" and reported resolution of a number of problems, including balanoposthitis, dysuria, and phimosis through retraction under anaesthesia. Griffiths & Freeman (1984) reported the use of topical anaesthetic for forcible retraction, reporting:
- "The procedure we describe is safe, simple, relatively atraumatic, cheap, and easily repeated if adhesions recur. Only 4 boys (2.5%) came to circumcision and can be regarded as failures. Between March, 1973 and November, 1980 we treated 161 patients in this way, achieving complete separation in 150 and partial separations in 11. Complications were severe trauma in 9 and slight discomfort in 15. 2 mothers fainted. Apart from the 4 failures, the procedure had to be repeated in 4 children and paraphimosis was recorded in 1."
MacKinlay (1988) reported on breaking the adhesions between foreskin and glans, which rendered the foreskin non-retractile, with topical anaesthetic, thus achieving full retractibility "without the necessity of circumcision". Iwamuro et al (1997) have reported similar results in treating older children "without further operation."
Osborn et al (1981), however, say "[t]he office practice of freeing adhesions and subsequent retraction of the foreskin is unnecessary." Simpson & Barraclough (1998) state that "[n]o attempt should be made to retract a foreskin in a child unless significant separation of the subpreputial adhesions has occurred. Failure to observe this basic rule may result in tearing with subsequent fibrosis and consequent true phimosis. ..."
Recommendations of paediatric societies
The American Academy of Pediatrics cautions parents not to retract their son's foreskin, but suggest that once he reaches puberty, he should retract and gently wash with soap and water. The Royal Australasian College of Physician as well as the Canadian Paediatric Society emphasize that the infant foreskin should be left alone and requires no special care.
- ↑ 1.0 1.1 Phimosis and Paraphimosis at eMedicine
- ↑ McGregor TB, Pike JG, Leonard MP (April 2005). "Phimosis—a diagnostic dilemma?". Can J Urol 12 (2): 2598–602. PMID 15877942.
- ↑ Metcalfe PD, Elyas R. Foreskin management. Survey of Canadian pediatric urologists. Can Fam Physician 2010;56:e290-5.
- ↑ Deibert GA. The separation of the prepuce in the human penis. Anat Rec 1933;57:387-399.
- ↑ Øster J. Further fate of the foreskin: incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child 1968;43:200-3.
- ↑ Thorvaldsen MA, Meyhoff H. Patologisk eller fysiologisk fimose? Ugeskr Læger 2005;167(17):1858-62.
- ↑ Marques TC, Sampaio FJ, Favorito LA (2005). "Treatment of phimosis with topical steroids and foreskin anatomy". Int Braz J Urol 31 (4): 370–4; discussion 374. doi:10.1590/S1677-55382005000400012. PMID 16137407. http://www.brazjurol.com.br/july_august_2005/Marques_ing_370_374.htm.
- ↑ Wright JE. (1994) Further to the "Further Fate of the Foreskin." Med J Aust 1994; 160: 134-5.
- ↑ Spilsbury K, Semmens JB, Wisniewski ZS, Holman CD (February 2003). "Circumcision for phimosis and other medical indications in Western Australian boys". Med. J. Aust. 178 (4): 155–8. PMID 12580740. http://www.mja.com.au/public/issues/178_04_170203/spi10278_fm.html.
- ↑ 10.0 10.1 Osborn LM, Metcalf TJ, Mariani EM. Hygienic care in uncircumcised infants. Pediatrics 1981;67:365-7.
- ↑ Camille CJ, Kuo RL, Wiener JS. Caring for the uncircumcised penis: What parents (and you) need to know. Contemp Pediatr 2002;11:61.
- ↑ Cooper GC, Thompson GJL, Raine PAM. Therapeutic retraction of the foreskin in childhood. Br Med J 1983;286:186-7.
- ↑ Griffiths DM, Freeman NV. Non-surgical separation of preputial adhesions. Lancet 1984;8398(2):344.
- ↑ MacKinlay GA (September 1988). "Save the prepuce. Painless separation of preputial adhesions in the outpatient clinic". BMJ 297 (6648): 590–1. doi:10.1136/bmj.297.6648.590. PMID 3139222.
- ↑ Iwamuro S, Furuta A, Iwanaga S, et al. (January 1997). "[Foreskin retraction for phimosis of the newborn]" (in Japanese). Nippon Hinyokika Gakkai Zasshi 88 (1): 35–9. PMID 9038050.
- ↑ Simpson ET, Barraclough P. The management of the paediatric foreskin. Aust Fam Physician 1998;27(5):381-3.
- ↑ American Academy of Pediatrics: Care of the uncircumcised penis, 2007
- ↑ Cite error: Invalid
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- ↑ Royal Australasian College of Physicians. (2010) Circumcision of Infant Males.