Avoiding Retraction Injuries: Correct Pediatric Foreskin Care
Forced retraction — pulling back a child’s foreskin (prepuce) to any degree — is an ongoing problem in the U.S.A. Forced retraction can happen at the hands of, or the advice of, medical professionals. The nonprofit organizations Doctors Opposing Circumcision and Your Whole Baby receive hundreds of forced retraction complaints annually from parents of boys with intact (uncircumcised) penises, and many of these incidents happen at baby well-checks. It is likely that far more incidents go unreported, as some parents are unaware that the practice is harmful and not evidence-based. We send out educational materials on normal preputial development and penis care to healthcare providers to help prevent patient injuries.
The natural state of pediatric non-retractability is often erroneously termed “physiologic phimosis,” but it is not a condition requiring treatment. “The majority of referrals to pediatric urologists for circumcision constitute developmentally nonretractile foreskin rather than true [pathological] phimosis,” (5) a condition that can actually result from forced retraction of the foreskin. Paraphimosis, a rare, often iatrogenic emergency condition where the foreskin becomes stuck behind the glans penis, can be avoided by not forcibly retracting the foreskin. Parents and healthcare providers sometimes express concern that a boy's foreskin is “too tight” if his preputial sphincter does not allow visualization of the meatus, but this is a natural occurrence. Ballooning, spraying, and smegma pearls under the foreskin are also all normal aspects of preputial development.
Consequences of Forced Retraction
“. . . I have had to do circumcisions on young boys because of scarring . . . that developed as a result of either doctors forcibly retracting their foreskins or parents doing it on doctor’s advice.” (Dr. Adrienne Carmack, Board-Certified Urological Surgeon)
“Forced retraction also may lead to cracking and bleeding of the foreskin tip. Over time, this may cause scarring of the tip making retraction impossible.” (Canadian Urological Association)
More Statements on Forced Retraction
“As a boy becomes more aware of his body, he will most likely discover how to retract his own foreskin. But foreskin retraction should never be forced. Until the foreskin fully separates, do not try to pull it back. Forcing the foreskin to retract before it is ready can cause severe pain, bleeding and tears in the skin.” (The American Academy of Pediatrics)
“At birth, the inner foreskin is usually fused to the glans. . . . This prevents it from being pulled back or retracted to uncover the glans. . . . The foreskin should never be retracted forcefully.” (The Canadian Urological Association)
“It has become quite common in the United States for doctors, nurses, and other parents to tell mommies that they need to retract their son's foreskin when he bathes. This is not true . . . your son's foreskin is able to separate on its own, with time. . . . Pulling on this sensitive tissue can cause tearing and lead to infections and scarring. Many boys who need emergency care and even circumcision . . . do so because of premature retraction of the foreskin . . .” (Dr. Adrienne Carmack, Board-Certified Urological Surgeon and author of The Good Mommy's Guide to Her Little Boy's Penis)
Forced retraction is painful and can cause complications requiring corrective surgery. As the number of intact U.S. males increases, it is important for healthcare providers to educate themselves on correct intact penis care.
At What Age Does Foreskin Become Retractable?
Current research demonstrates wide variance in normal age of retractability. Some boys will be able to retract their foreskins before puberty, while other boys may not have retractable foreskins until the late teens.
A 2005 Danish study of more than 1,000 male children found 10.4 years to be the average age participants were first able to retract their foreskins. (1)
Two Japanese studies, together following 845 boys from birth, found that between one quarter and one third of healthy participants ages 11-15 were not yet able to retract their foreskins. (2,3)
While some medical professionals may mistakenly assume the naturally adhered foreskin of a male patient is problematic, “The fused mucosa of the glans penis and the inner lining of the prepuce separates gradually over years, as a spontaneous biological process” (4) and should not be forced apart. This natural fusion, sometimes incorrectly referred to as “adhesions,” dissolves on its own with hormone production and self-exploration.
Help to ensure your son is not a victim of forced retraction with the help of these informational materials. You can provide them to caregivers, healthcare professionals, expecting parents, and more.
1 Thorvaldsen MA, Meyhoff H. Patologisk eller fysiologisk fimose? Ugeskr Læger 2005;167(17):1858-62.
2 Ishikawa E, Kawakita M. Preputial development in Japanese boys. Hinyokika Kiyo. 2004;50(5):305-8.
3 Kayaba H et al. Analysis of shape and retractability of the prepuce in 603 Japanese boys. J Urol. 1996 Nov;156(5):1813-5.
4 Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83 Suppl. 1:34-44.
5 Van Howe, R.S. (1998). Cost-effective treatment of phimosis. Pediatrics, 102(4). Retrieved from http://pediatrics.aappublications.org/content/102/4/e43