Pediatric
Bedwetting or nocturnal enuresis (nighttime wetting) is a common problem in children.
Up until the age of five years it is considered normal and does not require investigation
or treatment. Among five year olds, about one in six will wet the bed.
Foreskin Care for Boys
The foreskin (or prepuce) is the sheath of thin skin normally covering the head
of the penis (glans). The inner foreskin is attached to the penile shaft just beyond
the glans, with a small band (the frenulum) approaching the opening of the urinary
passage (urethral meatus) on the undersurface. Its function and natural development
must be understood to ensure proper care.
The foreskin protects the glans and urethral meatus in the diapered baby, preventing
irritation from contact with urine. In older boys and men, the foreskin continues
to protect the sensitive glans. The foreskin may also have specific functions related
to sensation and immunity.
At birth, the inner foreskin is usually fused to the glans. This prevents it from
being pulled back or retracted to uncover the glans. Normal urination should not
be affected. As your child matures, the inner foreskin will gradually separate from
the glans, allowing progressive retraction. The foreskin should never be retracted
forcefully.
The age at which the foreskin becomes completely retractable is quite variable.
By three years, most boys can retract their foreskin at least partially. Only 1-2%
of boys are still not able to retract their foreskin by the age of seventeen.
Circumcision is the surgical removal of the foreskin. Some
parents chose to have their sons circumcised for social, cosmetic or ritual reasons.
In others this operation is necessary due to problems with the foreskin. Routine
circumcision of newborn boys, once very popular, is now much less common. Several
medical organizations have discouraged routine circumcision after considering the
risks and benefits of this surgery.
Care of the Normal Foreskin
The uncircumcised penis requires no special care. It can be kept clean with a gentle
soap and warm water wash daily. No attempt should be made to retract the foreskin
until it can be pulled back with ease. Then, your son should be taught to pull his
foreskin back gently to clean its inner surface and the glans with soap and water.
It should be thoroughly rinsed with water before being dried with a towel. The foreskin
must always be brought back to its usual position covering the glans after washing.
It is important not to retract the foreskin forcefully for
any reason. Some parents feel the need to pull the foreskin back to “clean under
it”. Since the young boy’s inner foreskin and the glans are initially fused, there
is no space to clean.
Forceful retraction also may lead to cracking and bleeding of the foreskin tip.
Over time, this may cause scarring of the tip making retraction impossible. Circumcision
may then be necessary.
Possible Problems
Occasionally, a problem with the foreskin may require medical attention.
- All over the body, skin cells are shed continuously as they die off and are replaced
by new ones. This turnover usually occurs without notice. Cell replacement also
takes place on the inner foreskin and glans. When the foreskin is not yet retractable,
the dead skin cells may build up into soft, yellow or white lumps apparent under
the skin. This is called smegma. This buildup is a natural and harmless process
that may help separate the foreskin from the glans. The smegma will
eventually work its way out as the foreskin becomes retractable.
- In some boys, the foreskin may be retractable even if the tip is a bit narrow. If
the foreskin is replaced over the glans shortly after your child voids or bathes,
this narrowing should not cause any trouble. In time the tight area should stretch
and disappear. However, if your child leaves the foreskin retracted, this narrow
ring may become trapped behind the glans causing pain and swelling of the penis.
This is called a paraphimosis. Medical attention should be
sought promptly so that the foreskin can be brought down.
- In the diapered baby, irritating substances in the urine may cause inflammation
with redness and swelling of the foreskin. Inflammation can be managed simply with
more frequent diaper changes, the application of antibiotic ointment (e.g. Polysporin™)
to the foreskin tip and regular bathing. In some cases the entire penis may become
red, swollen and tender (balanitis). In this case, the child should be seen by a
doctor who may prescribe a course of oral antibiotics.
- As the inner foreskin separates from the glans, some areas may remain attached.
These attachments are called adhesions. Most boys will have adhesions at some
time. As the inner foreskin continues to separate, these adhesions usually break
down on their own. By the age of 17, they should have all disappeared. The adhesions
should not be forcefully broken down – time and normal exploratory behaviour will
take care of them as your child ages.
- In some boys with incompletely retractable foreskins, voiding may causeballooning
of the foreskin with urine. The ballooning disappears as the urine dribbles
out through the foreskin opening. This is not harmful. Rarely, the entire penis
may become swollen with voiding and urine must be squeezed out of the foreskin.
This condition is called megaprepuce and requires referral to a us and we will often
recommend a circumcision.
- Persistent narrowing of the foreskin preventing retraction after the age at which
it should normally come back easily is called phimosis. This may be the result
of delayed maturation or scarring of the foreskin tip. In some cases, the foreskin
will soften up and become retractable with the use of a steroid ointment. In others,
circumcision may be necessary.
The foreskin is a normal part of your child’s anatomy. With proper care and understanding
of its natural development, foreskin problems can be avoided. If you have concerns
regarding your child’s foreskin, please do not hesitate to discuss them with your
doctor.