Parents of intact boys tend to be very cautious about protecting their sons from forced foreskin retraction, usually from the moment they learn how harmful it can be. Your Whole Baby group and page admins hear daily from parents who report that their child’s foreskin was forcibly retracted at a doctor's visit. Forced retraction comes with risk of physical injury, as it can cause tearing, irritation, and scarring, and it disrupts the protective function of the foreskin. It is infuriating to intact-friendly health care providers such as myself that this harmful, non-evidence-based practice ever occurs in a medical setting.
On the other hand, this understandable panic has led to the erroneous belief that the foreskin should never be touched by anyone besides its owner — as if it will somehow instantly become a problem for the child. (Notice I said “touched” and not “retracted.”) There are a few things I need to clear up for people to calm their anxiety, and these things all center around the difference between the (perhaps very occasionally necessary) manipulation of the mobile, unattached tip of the foreskin versus forcible retraction. To learn more about the do’s and don’ts of preputial care, read on.
Checking Placement of the Urethral Opening
Before we go too far, there are two things to understand about Your Whole Baby’s philosophy on this topic:
It is our organization’s position that it is NOT necessary to check urethral placement in an otherwise healthy baby.
It is also our organization’s position that hypospadias, chordee, and/or penile torsion surgeries should not be performed on babies or children who cannot consent and are still developing, as long as they can urinate freely. [Please note that testicular torsion is different and can be a medical emergency, so it should be investigated promptly.]
Is it possible for a doctor to check urethral placement without breaking the membrane adhering the foreskin to the glans? Sometimes, but we still do not recommend allowing this! Firstly, it is not necessary; secondly, it is very risky because so many doctors are not aware of preputial structure, function, and development. Thus, we err on the side of caution and recommend a hands-off approach when it comes to the foreskin.
Routine visualization of the meatus isn’t necessary, so why subject your newborn to invasive handling when you don’t have to? If your child’s doctor tells you that they need to check the placement of the urethra, ask why. What are they looking for? The conversation may unfold like this:
Informed Parent: “Why do you want to visualize his urethral opening?”
Doctor: “For one thing, we need to make sure that the foreskin isn’t so tight that it would prevent urine flow.”
Informed Parent: “Wouldn’t an issue with urinating already have presented, as babies pee in the womb? We would like to monitor his urine output as we would for a baby girl, and leave it at that. As long as he can urinate, we are not concerned.”
Doctor: “Okay, but we also need to make sure the urethral opening is in the correct place. If he has hypospadias, this condition can cause pain later and possibly affect his ability to reproduce.”
Informed Parent: “Well, significant hypospadias would be evident without having to manipulate his foreskin, and besides, neither of those potential issues you raised are relevant right now. If he has hypospadias, we would wait and allow him to make the decision about surgery. Again, as long as he can urinate, there is nothing to check for at this time.”
Stick to your guns, and remember — if he can pee, leave it be. If the foreskin were so abnormally tight that it prevented a baby from peeing, this would most likely be evident long before birth because babies urinate in utero. If the prepuce isn’t restricting the baby’s urine flow before birth, it isn’t suddenly going to restrict urine flow after birth and require immediate surgery.
When boys need to have a catheter inserted into their urethra, there is no need to forcibly retract the foreskin. The provider may attempt to visualize the meatus to aid in insertion. This can be done as follows:
Gently squeeze the penis just below the glans, forcing the sphincter-like tip to open and allowing visualization without any retraction.
Press gently next to the base of the penis, which will help open the foreskin tip, allowing for visualization.
In cases where the boy’s foreskin is partially or fully retractable, the mobile foreskin can be ever-so-slightly moved for easier catheter placement.
Retraction should only happen if the boy is developed enough to retract himself, and in this case the provider ideally should have the boy retract himself for catheter placement rather than doing it for him.
If the foreskin is retracted at all in the process of inserting a catheter, always be sure to replace it over the glans.
None of the above techniques should be confused with forcible retraction of the foreskin. The provider may need to manipulate the foreskin to some degree to safely insert a catheter. To ensure the provider is knowledgeable about proper catheter insertion, parents should ask them to explain EXACTLY how they will insert the catheter and be ready to intervene during the process if necessary. Prior to age of retractability, there is no clinical justification for visualizing the glans penis. The only portion that may become visible during catheter insertion of an intact pediatric patient whose foreskin is not retractable is the urethral opening, and only if it can easily done through the steps mentioned above.
If none of the above techniques are possible, the provider should use the blind catheter technique, which involves inserting the catheter “by feel” in the same way they would insert an intravenous catheter. The process of catheterization in an intact pediatric patient is also fully explained here by fellow Your Whole Baby Advisory Board members Dr. Adrienne Carmack, MD and Marilyn Milos, RN.
Common Sense Care
As a result of this necessary vigilance when interacting with care providers, we sometimes see parents who are perhaps overly concerned about basic care, to an extent likely not seen in places where the intact penis is the norm. In addition, pro-circumcision culture can combine with postpartum mood disorders (particularly anxiety and/or obsessive-compulsive disorder) and cause a parent to fixate on their son’s foreskin as though it will inevitably cause problems if not constantly monitored.
If a portion of the foreskin is mobile and something small (a piece of hair, a fiber from the child's underwear, a leaf, poop, or anything else that doesn't belong there) enters the opening, it is not harmful to slightly move the already-pliable foreskin to remove it. Penises are not made of porcelain; they will not instantly become injured when touched! Use common sense and clean what you can see without forcibly pulling the foreskin back. Some suggestions:
When wiping base to tip, apply gentle pressure to the mobile portion of the foreskin to work out any visible foreign matter. Manipulating the foreskin forward is not the same as retracting, as the connective membrane is not compromised.
Try using the corner of a wipe to gently clean debris. Do NOT force the wipe into the opening — remember, you are only cleaning what is plainly seen!
We often suggest simply giving your baby a bath if you are concerned, but when that is not feasible, try the above.
If you have any further questions about caring for your intact son, please join our Raising Your Whole Baby group on Facebook.
Published Nov. 6, 2019
Angela Saltalamacchia is an Emergency Department nurse in a level 3 trauma center who is working to change nursing school curricula around the US to reflect the teaching of medical associations in countries where infant circumcision is not routinely performed. She is a mother of three intact children. She is a member of the Your Whole Baby Advisory Board, a nurse administrator for Your Whole Baby: A Community for Learning and Raising Your Whole Baby, and also volunteers with Nurses for the Rights of the Child.