Wednesday, August 26, 2009

Protect Your Intact Son: Medical Advice for Parents When Your Doctor Says to Circumcise

By Dr. Paul M. Fleiss, M.D.
Author of What Your Doctor May Not Tell You About Circumcision




Increasing numbers of American parents today are protecting their sons from routine circumcision at birth, but as their boys grow up, they often find themselves at odds with doctors who cling to old-fashioned opinions and hospital routines.

I often receive calls from distraught parents who say that a doctor insists that their little boy needs to be circumcised because there is something wrong. When they bring their son into my office, I almost always find that there's nothing wrong with the child's penis. Occasionally there's a slight infection, but that can be quickly cleared up with an antibiotic cream. In all my years of practice, I've never had a patient who had to be circumcised for medical reasons.

When a doctor advises that your son be circumcised, it's usually because he or she is unfamiliar with the intact penis, misinformed about the true indications for surgical amputation of the foreskin, unaware of the functions of the foreskin, and uncomfortable with the movement away from routine circumcision.

Doctors can be psychologically challenged by the sight of an intact boy. They may see problems with the penis that do not really exist. They may try to convince you that the natural penis is somehow difficult to care for. They may cite "studies" and "statistics" that appear to support circumcision.

Probably, the only problem you will encounter with the foreskin of your intact boy is that someone will think that he has a problem. The foreskin is a perfectly normal part of the human body, and it has very definite purposes, as do all body parts, even if we do not readily recognize them. There's no need to worry about your son's intact penis.

What to Say When the Doctor Says to Cut

Below is a list of some of the things that doctors have said to parents in an attempt to convince them to agree to circumcision. After each incorrect statement, I've given the medical facts to help you understand what your doctor may not know about the intact penis and its care, and what you need to know to protect your child from unnecessary penile surgery. If you ever find yourself in a situation where a doctor suggests that your child should be circumcised, the best thing that you can say is simply: "Leave it alone."

-Your son's foreskin should be cut off in order to facilitate hygiene.
My experience as a pediatrician has convinced me that circumcision makes the penis dirtier, a fact that was confirmed by a study recently published in the British Journal of Urology.1 For at least a week after circumcision, the baby is left with a large open wound that is in almost constant contact with urine and feces--hardly a hygienic advantage. Additionally, throughout life the circumcised penis is open and exposed to dirt and contaminants of all kinds. The wrinkles and folds that often form around the circumcision scar frequently harbor dirt and germs.

Thanks to the foreskin, the intact penis is protected from dirt and contamination. While this important protective function is extremely useful while the baby is in diapers, the foreskin provides protection to the glans and urinary opening for a lifetime. At all ages, the foreskin keeps the glans safe, soft, and clean.

Throughout childhood, there is no need to wash underneath the foreskin. Mothers used to be advised to retract the foreskin and wash beneath it every day. This was very bad advice indeed. When the foreskin becomes fully retractable, usually by the end of puberty, your son can retract it and rinse his glans with warm water while he is in the shower.

-Your son's foreskin is too tight. It doesn't retract. He needs to be circumcised.
The tightness of the foreskin is a safety mechanism that protects the glans and urethra from direct exposure to contaminants and germs. The tight foreskin also keeps the boy's glans warm, clean, and moist, and when he is an adult, it will give him pleasure. As long as your son can urinate, he is perfectly normal. There is no age by which a child's foreskin must be retractable. Do not let your doctor or anyone try to retract your child's foreskin. Optimal hygiene of the penis demands that the foreskin of infants and children be left alone. Premature retraction rips the skin of the penis open and causes your child extreme pain. There is no legitimate medical justification for retraction. The child's discomfort is proof of that.

-Your son's foreskin is "adhered" to the glans. It must be amputated.
The attachment of the foreskin and glans is nature's way of protecting the undeveloped glans from premature exposure. Detachment is a normal physiological process that can take up to two decades to complete. By the end of puberty, the foreskin will have detached from the glans because hormones that are produced in great quantities at puberty help with the process. There is no age by which a child's foreskin must be fully separated from the glans.

Some misguided doctors might suggest that the "adhesions" between the foreskin and glans should be broken so that your son can retract his foreskin. This procedure is called synechotomy. To perform it, the doctor pushes a blunt metal probe under the foreskin and forcibly rips it from the glans. It's as painful and traumatic as having a metal probe stuck under your fingernail to pull if off. It will also cause bleeding and may result in infection and scarring of the inner lining of the foreskin and the glans. The wounds that are created by this forced separation can fuse together, causing true adhesions. There is no medical justification for this procedure because the foreskin is not supposed to be separated from the glans in childhood. If any doctor suggests this procedure for your son, firmly refuse, stating, "Leave it alone!"

-Your son's foreskin is getting tighter. It no longer retracts. Something is wrong. He will have to be circumcised.
Sometimes, in childhood, a previously retractable foreskin will become resistant to retraction for reasons that are unrelated to impending puberty. In these cases, the opening of the foreskin may look chapped and sting when your son urinates. This is not an indication for surgery any more than chapped lips. This is just the foreskin doing its job. If the foreskin were not there, the glans and urinary opening would be chapped instead. Chapping is most often caused by ov erly chlorinated swimming pools, harsh soap, bubble baths, or a diet that is too high in sugar, all of which destroy the natural balance of skin bacteria and should be avoided if chapping occurs. The foreskin becomes resistant to retraction until a natural and healthy bacterial balance is reestablished.

You can aid healing by having your son apply a little barrier cream or some ointment to the opening of the foreskin. Acidophilus culture (which can be purchased from a health food store) can be taken internally and also applied to the foreskin several times a day to assist healing, and should be given any time a child is taking antibiotics.

-Your son's foreskin is red, inflamed, itching, and uncomfortable. It has an infection and needs to be cut off.
Sometimes the tip of the foreskin does become reddened. During the diaper-wearing years, this is usually ammoniacal dermatitis, commonly known as diaper rash. When normal skin bacteria and feces react with urine, they produce ammonia, which burns the skin and causes inflammation and discomfort. If the foreskin were amputated, the inflammation would be on the glans itself and could enter the urethra. When the foreskin becomes reddened, it is doing its job of protecting the glans and urinary meatus.

Circumcision will have no effect on diaper rash. Change your baby's diapers more frequently and use a barrier cream until the rash clears. Harsh bath soaps can also cause inflammation of the foreskin. Use only the gentlest and purest of soap on your child's tender skin. Resist the temptation to give your child bubble baths, because these are harmful to the skin. Never use soap to wash the inner foreskin because it is mucous membrane, just like the inner lining of the eyelid.

Foreskin infections are extremely rare, but if they occur, one of the many simple treatment options is antibiotic ointment along with bacterial replacement therapy (Acidophilus culture). We don't amputate body parts because of an infection. Most infections of the foreskin are actually caused by washing the foreskin with soap. Leave the foreskin alone, remembering that it doesn't need any special washing, and infections will be unlikely to occur.

-Your son is always pulling on his foreskin. He should be circumcised.
I can assure you that, whether circumcised or not, all little boys touch and pull on their penis. It is perfectly normal. Intact boys pull on the foreskin because it is there to pull on. Circumcised boys pull on the glans because that is all they have to pull on. Little boys sometimes will adjust the position of their penis in their underpants. They will also sometimes explore the interior of the foreskin with their fingers--a perfectly normal curiosity and nothing to worry about. It is important for parents to cultivate an enlightened and tender congeniality about such matters, otherwise they risk transferring unhealthy attitudes to their children.

Sometimes a boy will pull on his foreskin because it itches. All parts of the body itch occasionally. Even a circumcised boy has to scratch his penis. Just as you don't worry every time your child scratches his knee, so you should not worry when he scratches his penis. If the itch is caused by dry skin, then have your son avoid using soap on his penis. Treat the foreskin just as you would any other part of the body.

If the real fear is of masturbation, calmly remind yourself of the simple, natural fact that all children will explore their bodies, including their genitals. Touching their genitals gives children a pleasant feeling and relaxes them. Classic anatomical studies demonstrate that the foreskin is the most pleasurably sensitive part of the penis. You can congratulate yourself for having protected your child from a surgical amputation that would have permanently denied him normal sensations.

-Your son's foreskin is too long. It should be cut off.
There is tremendous variation in foreskin length. In some boys, the foreskin represents over half the length of the penis. In others, it barely reaches the end of the glans. All variations are normal. The foreskin is never "just extra skin" or "redundant." It is all there for a reason.

-Your child should be circumcised now because it will hurt more if it has to be done later, or worse, when he is an adult.
This excuse is tragically wrong and has resulted in a very serious crisis in American medical practice. It's based on the false idea that infants and young children don't feel pain. Babies can see, hear, taste, smell, and feel. In fact, babies feel pain more acutely than adults, and the younger the baby, the more acutely the pain is felt. If an adult needed to be circumcised, he would be given anesthesia and postoperative pain relief. Doctors almost never give babies either of these. The only reason doctors get away with circumcising babies without anesthesia is because the baby is defenseless and cannot protect himself. His screams of pain, terror, and agony are ignored. In any event, this all too common excuse is merely a scare tactic, one with tragic consequences for any baby forced to endure a surgical amputation without the benefit of anesthesia.

-Since your son is having anesthesia for another operation, we'll just go ahead and circumcise him.
Most parents are never told that their son is in danger of being circumcised during a tonsillectomy or surgery for a hernia or an undescended testicle. It would never occur to them. If your child is going into the hospital for any reason, be certain that you tell the physician, surgeon, and nurse that under no circumstances is your child to be circumcised. Write "No Circumcision" on the consent form, too. Then if your child is circumcised against your wishes, remember that you do have legal recourse.

-Your son has cysts under his foreskin. He needs to be circumcised.
During the period when the foreskin is undergoing the slow process of detaching itself from the glans, sloughed skin cells (smegma) may collect into small pockets of white "pearls." These are not cysts. Some doctors mistakenly think that the smegma under the foreskin is an infection, even though it is white rather than red, is cold to the touch, and is painless. As the foreskin proceeds with detachment, the body will do its job, and these pearls will pass out of the foreskin all by themselves. These collected pockets of cells are nothing to worry about. They are simply an indication that the natural process of detachment is occurring.

-Your son has a urinary tract infection (UTI) and needs to be circumcised to prevent it from happening again.
The belief that the foreskin slightly increases the chances of a boy having a UTI is highly controversial and, more importantly, unproven. Members of the medical profession in Europe do not accept it. Medical research proves that UTIs are most often caused by internal congenital deformities of the urinary tract. 2,3,4 The foreskin has nothing to do with this. Even if it could be proven that circumcision slightly reduces the risk of UTI, it is an absurd proposal because UTIs in boys are extremely rare and are easily treated with antibiotics. Breastfeeding, too, helps prevent UTIs. Child-friendly doctors advocate breastfeeding not penile surgery.

-Your son sprays when he urinates. Circumcision will correct this.
In almost every intact boy, the urine stream flows out of the urinary opening in the glans and through the foreskin in a neat stream. During the process of penile growth and development, some boys go through a period where the urine stream is diffused. Undoubtedly, many of these boys take great delight in this phase, while mothers, understandably, find it less amusing. If your boy has entered a spraying phase, simply instruct him to retract his foreskin enough to expose the meatus when he urinates. He will soon outgrow this phase.

-Your son's foreskin balloons when he urinates. He needs to be circumcised or else he will suffer kidney damage.
Ballooning of the foreskin during urination is a normal and temporary condition in some boys. It results in no discomfort and is usually a source of great delight for little boys. Ballooning comes as a surprise only to those adults who have no experience with this phase of penile development. It certainly does not cause kidney damage; it has nothing to do with the kidneys. Ballooning disappears as the foreskin and glans separate and the opening of the foreskin increases in diameter. It requires no treatment.

-Your son caught his foreskin in the zipper of his trousers; we will have to cut it off.
There have been rare cases where a boy has accidentally caught part of the skin of his penis in the zipper of his trousers. This is painful and can cause a lot of bleeding. Cutting off the foreskin, however, is illogical in this situation. By cutting across the bottom of the zipper with scissors, the zipper can easily be opened to release the penile tissue. Any lacerations in the skin can then be closed with either sutures or surgical tape, depending on the situation. The proper standard of care in this situation is to minimize and repair the injury, not make it worse by cutting off the foreskin and creating a larger and more painful surgical wound.

-Your son has phimosis. He needs to be circumcised to correct this problem.
Phimosis is often used as a diagnosis when a doctor does not understand that the child's foreskin is supposed to be long, narrow, attached to the glans, and resistant to retraction. Some doctors are prescribing steroid creams for phimosis, but this is unnecessary in children, since the foreskin does not need to be retractable in young boys. The hormones of puberty will do the same thing at the appropriate time that a steroid cream is doing prematurely. In adults who still have a foreskin that is attached to the glans or a foreskin with such a narrow opening that the glans cannot easily pass through it, steroid creams are a conservative therapy. This is if the adult wants a foreskin that fully retracts. Many males don't, preferring a foreskin that remains securely over the glans. It is purely a matter of personal choice, one that only each male can decide for himself.

-Your son has paraphimosis and must be circumcised to prevent it from happening again.
Paraphimosis is a rare dislocation of the foreskin. It is caused by the foreskin being prematurely retracted and becoming stuck behind the glans. The dislocation can most often be corrected by applying firm but gentle pressure on the glans with the thumbs, as if you were pushing a cork into a bottle. To reduce the swelling, an injection of hyaluronidase may be effective. Doctors in Britain have also reported good results from packing the penis in granulated sugar.5 Ice packs work well, too.

-Your son has BXO and will have to be circumcised.
Some doctors equate phimosis with an extremely rare skin disorder called balanitis xerotica obliterans (BXO), which is also called lichen sclerosus et atrophicus (LSA). BXO can appear anywhere on the body, but if this disorder affects the foreskin, it may turn the opening of the foreskin hard, white, sclerotic, and make retraction almost impossible. BXO is usually painless and progresses very slowly. Many times, it goes away by itself. To an experienced dermatologist, there is no mistaking BXO, but a diagnosis must be confirmed by a biopsy. The good news is that BXO can almost always be successfully cured with steroid creams, carbon dioxide laser treatment, or even antibiotics. Circumcision should be considered only after every other treatment option has failed. Just as we do not amputate the labia of females with BXO or the glans of circumcised boys with BXO, it is logical that we should not amputate the foreskin of intact boys with BXO.

-Your son needs to be circumcised or else he won't enjoy oral sex as an adult.
I'm afraid that doctors really have said such inappropriate things to parents. Such a statement is evidence of ignorance of the normal functions and sensations of the intact penis. Classic anatomical investigations have proven that the foreskin is the most richly innervated part of the penis. It has specialized nerve receptors that are directly connected to the pleasure centers of the brain. Your intact son is far better equipped to enjoy all aspects of lovemaking than his circumcised peers. The myth that American women prefer the circumcised penis is, in my opinion, demeaning to women. It may be true that American women of a certain generation and social background were more likely to be familiar with the circumcised penis than the intact penis, but this was the result of the mass circumcision campaigns of the 1950s not personal preference. I suspect that what women prefer in men is more related to the personal qualities of consideration, gentleness, sensitivity, warmth, and supportiveness. It is very unlikely that circumcision increases a male's capacity to develop these qualities.

-Your son needs to be circumcised so that he looks like his father.
A child is a mixture of both his mother's and his father's genetic heritage. He doesn't need to look like his father, nor will he ever look like his father in every way. Each child is a unique gift, and that uniqueness should be cherished. The idea that a boy will be disturbed if his penis does not look like his father's was invented to manipulate people into letting doctors circumcise their children. It has no basis in medical fact.

There are no published reports of an intact boy being disturbed because part of his penis was not cut off when he realized that part of his father's penis had been cut off. When intact boys with circumcised fathers express their feelings on the matter, they consistently report their immense relief and gratitude that they were spared penile surgery. They express sadness, as well, for the suffering their dads experienced as infants.6

Occasionally, a circumcised father will state that he wants his child circumcised because he thinks that it will create a bond between him and his son. It is a wonderful thing for a father to want to establish such a bond, but circumcision cannot accomplish this worthy goal. If a father wants to establish a lasting and meaningful bond with his son, the very best way, and perhaps the only way, he can achieve this is by spending quality time with him and by showing him much affection.

Sadly, some fathers who have been circumcised have an unhealthy attitude and may look for any excuse to schedule the child for circumcision. Putting a child in a position where he fears that part of his penis is going to be cut off is abusive. When fathers demand that their sons be circumcised, I suspect that they are desperately trying to justify their own circumcised condition. The emotions that some fathers feel when they are forced to confront the fact that part of their own penis is missing can be so disturbing that they will do anything to block them out.

A father who forcibly circumcises his son will not win his son's gratitude, affection, trust, or love. I am aware of instances where such events have permanently destroyed the father-son bond and changed a son's love for his father into rage and bitter resentment. In situations where the father suffers from an unhealthy attitude about his son's normal penis, I think it is best for everyone concerned--especially the son--for the father to receive compassionate psychological counseling to help him overcome his problem. All children deserve the saf est, most nurturing, and most loving home possible.

When physicians realize the important functions of the foreskin, they'll realize that just about every problem with it can and should be solved without cutting it off. Cutting off part of the body--especially part of the penis--is an extreme measure that should be reserved for the most extreme of circumstances. The only legitimate indications for cutting off any part of the body, including the foreskin, are life-threatening disease, life-threatening deformity, or irreparable damage. These situations are extremely rare.

The best advice for the care of the intact penis is simply to leave it alone. The intact penis needs no special care. Let your boy take care of it himself, and when he's old enough, he will enjoy taking care of his own body. After all, it's his business. Just relax and avoid worrying about your son's intact penis. Remind yourself that the foreskin is a normal and natural part of the body. If European boys grow up healthy and unconcerned with their foreskins, so can your son.


NOTES

1. R. S. Van Howe, "Variability in Penile Appearance and Penile Findings: A Prospective Study," British Journal of Urology 80, no. 5 (November 1997): 776-782.
2. J. Winberg, I. Bollgren, L. Gothefors, M. Herthelius, and K. Tullus, "The Prepuce: A Mistake of Nature?" The Lancet 8638, no. 1 (March 1989): 598-599.
3. S. M. Downs, "Technical Report: Urinary Tract Infections in Febrile Infants and Young Children," The Urinary Tract Subcommittee of the American Academy of Pediatrics Committee on Quality Improvement, Pediatrics 103, no. 4 (April 1999): e54.
4. M. A. Gill and G. E. Schutze, "Citrobacter Urinary Tract Infections in Children," Pediatric Infectious Disease Journal 18, no. 10 (October 1999): 889-892.
5. R. Kerwat, A. Shandall, and B. Stephenson, "Reduction of Paraphimosis with Granulated Sugar," British Journal of Urology 82, no. 5 (November 1998): 755.
6. Rosemary Romberg, Circumcision: The Painful Dilemma (South Hadley, Mass.: Bergan & Garvey, 1985).


 
Organizations

If your physician or healthcare provider ever recommends that your child be circumcised, get another opinion from a physician who understands the important functions of the foreskin, no matter how "urgent" the situation may be. For help finding one in your area, contact:

National Organization of Circumcision Information Resource Centers (NOCIRC). PO Box 2512, San Anselmo, CA 94979-2512. 415-488-9883. Fax: 415-488-9660. www.nocirc.org/

Saving Our Sons (SOS). P.O. Box 1302 Virginia Beach, VA 23451 www.SavingSons.org www.Facebook.com/SavingOurSons  

Doctors Opposing Circumcision (DOC). 2442 NW Market Street #42, Seattle, WA 98107. 360-385-1882. Fax: 360-385-1948. faculty.washington.edu/gcd/DOC/

Nurses for the Rights of the Child. 369 Montezuma #354, Santa Fe, NM 87501. 505-989-7377. www.cirp.org/nrc/

Circumcision Resource Center. Ronald Goldman, PhD. PO Box 232, Boston, MA 02133. 617-523-0088. www.circumcision.org/

Circumcision Information and Resource Pages. www.cirp.org/

Books (All books can be found here on Amazon)
Denniston, G. C., F. M. Hodges, and M. F. Milos, eds. Male and Female Circumcision: Medical, Ethical, and Legal Issues in Pediatric Practice. Kluwer Academic/Plenum Press, 1999.
Goldman, Ronald. Circumcision: The Hidden Trauma. Vanguard, 1996.
Illingworth, Ronald S. The Normal Child: Some Problems of the Early Years and Their Treatment. Tenth edition. Churchill Livingstone, 1991.
O'Mara, Peggy, ed. Circumcision: The Rest of the Story. Mothering, 1993.
Ritter, Thomas, and George C. Denniston. Say No to Circumcision! Second edition. Hourglass, 1996.
Books of special interest for Jewish parents: Goldman, Ronald. Questioning Circumcision: A Jewish Perspective. Vanguard, 1997.
Hoffman, Lawrence A. Covenant of Blood: Circumcision and Gender in Rabbinic Judaism. University of Chicago Press, 1996.
Weiner, Kayla. Jewish Women Speak Out: Expanding the Boundaries of Psychology. Canopy Press, 1995.
Important medical journal articles: DeVries, C. R., A. K. Miller, and M. G. Packer. "Reduction of Paraphimosis with Hyaluronidase." Urology 48 (1996): 464-465.
Fleiss, P. M., F. M. Hodges, and R. S. Van Howe. "Immunological Functions of the Human Prepuce." Sexually Transmitted Infections 74 (1998): 364-367.
Jorgensen, E. T., and A. Svensson. "Problems with the Penis and Prepuce in Children: Lichen Sclerosus Should Be Treated with Coricosteroids to Reduce Need for Surgery." British Medical Journal 313 (September 14, 1996): 692.
Nolan, J. F., T. J. Stillwell, and J. P. Sands, Jr. "Acute Management of the Zipper-Entrapped Penis." Journal of Emergency Medicine 8 (1990): 305-307.
Shaw, Angus. "Africa to Address AIDS at Conference." Science (September 10, 1999).
Van Howe, R. S. "Circumcision and HIV Infection: Review of the Literature and Meta-analysis." International Journal of STD & AIDS 10 (1999): 8-16.
Van Howe, R. S. "Does Circumcision Influence Sexually Transmitted Diseases? A Literature Review." British Journal of Urology International 83, Supplement 1 (1999 ): 52-62.


Paul M. Fleiss, MD, MPH, is assistant clinical professor of pediatrics at the University of Southern California Medical Center and is in private pediatric practice in Los Angeles, California. He is the author of numerous scientific articles published in leading national and international medical journals.

24 comments:

  1. This is a wonderful article. I wish my parents could have read it. If they had, I would not have to restore my foreskin.

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  2. I love your blog but what I really want to know if where do you get all his fun onsies ?

    Roxanne

    ReplyDelete
  3. The onesies came from http://madebymomma.spreadshirt.com
    They do an EXCELLENT job on their baby clothes. Great quality. Great colors. And stand up well to lots of washes. We've bought several for gifts and always get rave reviews on them.

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  4. What an excellent and informative posting! Thank you so much! I could never imagine circumcising my son and wish this was something that was talked about more in our society.

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  5. My intact son has a neurogenic bladder and urinary reflux for which he is taking prophylactic antibiotics and oxybutinin. I catheterize him every few hours during the day and he has to have routine urodynamics studies to monitor his bladder health. After birth, he was in the NICU for two weeks, and every time we see a doctor (besides our pediatrician) they offer to circumcise him since "we didn't have a chance to at birth." I tell them no thank you, we're leaving him intact. But I was shocked when the tech and the doctor both insisted on retracting his foreskin to get a sterile urine sample to test for a UTI before proceeding with a urodynamics study. They said they had to because if they didn't, they'd have a contaminated sample and couldn't do the testing because they wouldn't know if he had an infection or not, which is a contraindication for the test. I ended up sitting there crying for him as they did it. Of course I cannot find any information on whether this is actually necessary, and I do NOT want it repeated if it's unnecessary. Do you have any solid research I can present to them? And no, changing doctors is not an option.

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  6. Sylvia - I am SO sorry to hear of what you have had to endure in order to protect your son through all of these trials with ignorant medical staff.

    I have written a blog with more links in response to this question because yours is not the first time I (or my colleagues) have heard of this occurring: http://drmomma.blogspot.com/2009/09/uti-testing-on-boys-do-not-retract.html

    Please see the linked book by Drs. Fleiss and Hodges (experts in all things urology and foreskin), the statement on Forced Retraction by Doctors Opposing Circ, and the additional article by doctors who have studied this particular issue for much longer than I have: http://drmomma.blogspot.com/2009/09/only-clean-what-is-seen-reversing.html

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  7. It is very troubling every time I receive an email from a parent telling me that their doctor/nurse/medical tech said it was necessary to forcibly retract their infant's foreskin (causing immense pain and tearing and possible future problems) for routine check-ups and testing. Forced retraction often occurs by medical staff because they were simply not taught how to insert a catheter, extract a urine sample, or properly examine the natural, normal, intact penis.

    In fact, in my graduate research (Frisbie 2006), I found that the vast majority of medical school urology textbooks only contained depictions and descriptions of circumcised penises! When U.S. medical students practiced on cadavers, these too, were often circumcised. It is no wonder our doctors and medical staff do not know what they are doing with and to our intact boys.

    Dr. Paul Fleiss (a pediatrician who has studied the foreskin and circumcision extensively for 30 years) and Dr. Frederick Hodges (who has studied and written in the field of urology) wrote a book called, "What Your Doctor May Not Tell You about Circumcision". If you are able, PLEASE get this book, read it, and share with other parents you know. Amazon Link. Half.Com Link

    In this book, Drs. Fleiss and Hodges discuss forced retraction and how it is NEVER medically necessary - NEVER. They specifically discuss doctors and nurses who go 'looking for UTIs' and tell parents they must retract the foreskin. This is NOT necessary.

    Not only do babies NOT produce lubrication (even pre-pubescent children produce very, very little), the prepuce is securely attached to the glans of the penis as an infant - much like your fingernail is securely attached to your finger. It does not need to be forcibly torn away in order to get a sterile urine sample.

    Fleiss and Hodges write, "You are a lioness defending her cub...We would never pull out our fingernails to improve hand hygiene...Be on your guard. Never let a doctor or anyone attempt to retract your son's foreskin. Optimal hygiene of the penis demands that the foreskin of infants and children be left alone. Premature retraction may tear the skin of the penis causing your child extreme pain. There is NO LEGITIMATE MEDICAL JUSTIFICATION FOR RETRACTION. If any doctor suggestions [forced retraction] for your son, firmly refuse, stating, "Just leave it alone."

    Drs. Fleiss and Hodges also inform parents, "Doctors have made up some strange reasons for wanting to retract a child's foreskin during checkups. None of them are valid. They may sound convincing, but I assure you, they are ALL WRONG. If a doctor tries to retract your child's foreskin, stop him. Tell him that this is inappropriate, unnecessary, and traumatic. Please, be on your guard. Many parents have made their feelings clear only to have doctors retract their son's foreskin anyway, causing the child enormous pain and trauma. Regardless of your child's age, and even if your child's foreskin is already fully retractable, doctors have no business fiddling with your child's penis and foreskin. Sometimes they say they are looking for a urinary tract infection (UTI). This is absolutely ridiculous, but many doctors have actually said this to parents. [Sterile urine samples can be easily obtained from girls AND boys from simply wiping the outside of the genitals first.] Doctors who [attempt retraction for UTI testing] are usually circumcised and upset at the sight of an intact penis. They are unfamiliar with it and anxious. You know more than they do about this body part. You MUST take charge. Protect your child from any attempt to retract or tamper with his foreskin."

    ** FOR LINKS AND MORE INFO PLEASE SEE ORIGINAL POST: http://drmomma.blogspot.com/2009/09/uti-testing-on-boys-do-not-retract.html **

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  8. Sylvia I am sorry your doctors ignore how unnecessary and damaging is the retraction of your son's foreskin. you need to tell them they are wrong and you don't want them to retract your son's foreskin anymore.

    Avery's Neonatology, issues a warning:

    Forcible retraction of the foreskin tends to produce tears in the preputial orifice resulting in scarring that may lead to pathologic phimosis.


    Foreskin retraction for catheterisation

    …is never necessary. Sometimes, when a child has a fever of unknown origin, urinary tract infection (UTI) is suspected, though these are routinely over-diagnosed. (And ironically, many genuine UTIs are the direct result of unnecessary genital tampering by or on the advice of medical professionals—forced foreskin retraction being a prime example.)

    The doctor might order the child catheterised to test for infection. Catheterisation itself poses a risk of pushing surface bacteria into the bladder causing a UTI, which always runs the risk of going further up into the kidneys. Better and less risky methods of testing for UTIs are available. Even when absolutely necessary, catheterisation can be done without retracting the foreskin. After threading the catheter through the preputial opening, the physician or nurse need only gently probe to find the inner urethral opening by 'feel'. Even partial retraction should not be needed. But especially in the US, where so many are circumcised and normal male genitalia get minimal respect, this conservative protocol has become a lost art.


    Please read all about it here, and the print out version is here includes references to all the pediatrics texts.

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  9. A question in NOCIRC pamphlet 6 asks, "Would my son's foreskin need to be retracted if her were catheterized for a urinalysis or medical treatment?," with the answer: "No. A catheter can be inserted when the foreskin is retracted just enough to see the meatus (urinary opening). If the foreskin's opening is too small to retract far enough to the meatus, a catheter can be inserted through the foreskin's opening and into the meatus "by feel." The foreskin should never be retracted by force for any reason."

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  10. Marilyn's got it here!!! My son...who suffered from VUR (vesicoureteral reflux...I posted before.....you can google it) often had to be cathed to make sure he didn't have a UTI while on prophylactic antibiotics. One nurse nearly butchered him to the disgust of our pediatric nephrologist. Scarred my son...he wouldn't pee...had to have rushed ultrasound .... crystals in his bladder from holding his urine for so long because of the trauma from the retraction and the fear. Our pedi nephro was AWESOME and I see why he wins Best NY doctor for years and years in a row. He specifically explained that the foreskin need to be pulled back to just see the opening. THAT IS IT. It never needs to be forcefully retracted. AND MY SON...who is now 4...and fully recovered with no surgery....actually has said that DR. Singh (the pedi nephro) is the only doctor that looks at his penis without HURTING IT. And our pedi nephro specifically told us "I don't want you going out and circing your son because people have told you it will help with his VUR. It has NOTHING to do with it". HOWEVER....he did joke with us saying that NOT circing Matthew made one of the ER doctors RIGHT away think of checking him for a UTI when he got his first unexplained 104 fever. It was better than the alternative (testing for meningitis....a spinal tap). It got us on to the problem right away, and my son has NO kidney damage. And frequent UTI's is not a circ issue anyway. It is an indication of VUR in the majority of the cases (or another type of structural anomoly).

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  11. Thanks everyone. We have no questions about why he has the VUR or neurogenic bladder, they're a direct result of his spina bifida. Thankfully the doctor didn't fully retract, but he did go further than I was comfortable with. I know he can be easily cathed without retracting, I do it six times a day because he doesn't urinate due to the ditropan he's taking for the neurogenic bladder. The exact situation was that they did the first cath UA to rule out an asymptomatic UTI prior to doing the urodynamics without retracting. But since he is cathed so frequently, it's GOING to come back with white blood cells and bacteria on the dip. There's always going to be bacteria in his urine, plain and simple. So then they insisted on a "real" sterile sample, meaning they retracted him to the point where they could see his meatus.

    The kicker? They decided he did have a minor UTI and upped his prophylactic antibiotic to a therapeutic dose but still did the test anyway.

    I think in the future I will request an order for a urine culture 3 days before the test is scheduled so we can have culture results rather than play a guessing game of whether it's normal flora or an acute infection.

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  12. My son was forcibly retracted today, he is 5 months old and it was by a pediatric urologist. What can I do to help my son heal? I am so upset from what happened. The doc also prescribed a strong topical steroid to apply twice daily to the meatus which I feel uncomfortable with. I no longer have any faith in this doc since he injured my son. What can I do from here?? He had a UTI a few weeks ago and recovered, this was just a follow-up.

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  13. Hello Valerie,

    I am SO sorry that your little boy had to endure this awful treatment. No one should do this as it is purely medical incompetence.

    The BEST thing you can do for your son right now is to LEAVE his prepuce ALONE. When you bath him, wash him with warm water only (no soap as this can irritate his foreskin further). Babies (especially this young) heal quickly and hopefully no damage was done. It sounds like your doctor is pro-cutting (or at least not knowledgeable as to the care of an intact, normal boy) and to advise you to do MORE things to your son's very sensitive penis is not sound advice. Your son's prepuce will be working overtime to heal and adhere back to the glans (to protect it as is its job to do) so the best thing to do is allow this healing to take place.

    Make sure that if anyone else takes care of him, they also do NOT touch or mess with it in any way. If it were me, NO ONE would be changing his diaper but me for a little while to come... 95% of problems with the penis (in infancy and adulthood) are because someone forcibly retracted and/or then tried to 'mess with' and over-clean the foreskin.

    I get this question a lot, so I am going to address it a bit further in a different post. Read it here:
    http://drmomma.blogspot.com/2009/12/forced-retraction-what-now.html

    Feel free to message/email (IntactInternational@gmail.com) or leave further comments/questions if I can be of additional assistance.

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  14. Valerie,
    Never allow a doctor to retract your son again and do not apply the steroidal cream. Steroidal cream is not for use in children who have not completed puberty. Children do not have the hormone levels to maintain a retractable foreskin. Why? B/c retraction is a sexual function. The steroidal cream will actually damage your son's penis b/c it causes the foreskin to thin. Steroidal cream is a treatment for ADULT men who have a tight foreskin, a condition called phimosis. This condition is actually caused by forcible retraction in childhood. Boys who have been left alone have a very slim chance of having phimosis as an adult. Any doctor who says that a child has a tight foreskin or has phimosis is completely ignorant to the normal development of the intact boy. There is no way a child can have this condition b/c their foreskins are designed to be tight and only allow urine to exit. I'm sorry you received such terrible advice. I strongly suggest you find a foreskin-friendly pedi. This is a Pedi who fully understands the normal development of the intact boy. You can contact DOC to find one in your area. www.doctorsopposingcircumcision.org

    Sylvia,
    The answer is "NO". Retraction is not necessary for insertion of a catheter. In fact retraction will actually create a wound that can allow bad bacteria to enter. There is no harmful bacteria within the foreskin itself. The only harmful bacteria comes from forcible retraction b/c feces now has a place to enter and a wounded area that can harbor the bacteria. The opening of the foreskin in babies is a sphincter so if left alone it does its job to keep harmful bacteria out.

    Further, babies with your son's kidney condition are much better off with a foreskin intact b/c it is even more important to keep bacteria out. The foreskin itself is not responsible for introducing any bacteria.

    Here is a good research about this. This outlines why breastfeeding is the best method to prevent UTI in children, especially if there is a urinary tract abnormality. It also explains how the foreskin protects harmful bacteria from entering.

    http://www.nocirc.org/statements/breastfeeding.php

    A skilled care provider knows how to insert a catheter without retraction. You actually gently tug the foreskin AWAY from the body. This will allow the sphincter to relax and the catheter can be inserted. I always recommend that a parent avoid catheters, as they actually introduce bacteria and can be responsible for repeat UTIs. If they insist on getting urine from your son I would either try to get a clean catch when he first wakes up--hold him over a sterile bowl-- or have them bag his penis. This is especially important if they want repeat urine samples. You don't want them to repeatedly catheter your son.

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  15. Unfortunately, I can't avoid catheters. My son cannot urinate on his own due to nerve damage from his spina bifida. He is 8 months old and does not urinate without a cath. He has never had a UTI even with the VUR, and we're hoping that his next VCUG in January will show no more reflux!

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  16. I was asked to comment about forcible foreskin retraction and use of steroid cream. The people who have already responded have done a wonderful job. Additional information on forced retraction can be found at www.nocirc.org/publish/6pam.pdf.

    After forcible retraction, put the infant or child into warm bath water (no bubbles, soap, or shampoo)six times a day, which will allow the child to urinate in the water without any stinging. Urine is sterile and the child can be rinsed with fresh water before leaving the tub.

    The foreskin does not need to be retracted after the first forcible retraction. Foreskin care is the same, wash the outside, otherwise, leave it alone! Even if adhesions form, we're learning that they, like the normal synechia most often resolve by themselves.

    As for steroid creams to make retraction possible, it's simply not necessary. A boy's foreskin will retract in its own time--the average age is 10.4 years, so no one needs to hurry the process. To do so is to sexually assault the child! Steroid creams should not be used until after age 18 in most cases, and not before gentle stretching techniques have been tried and failed. Parents need not worry about this, it's rare that a male's foreskin doesn't retract, and it helps to know that 1-2% of males lives their entire lives with a trouble-free non-retractile foreskin.

    I'm delighted to see how much so many of you know about the structures, functions, development, and care of the normal penis! Thirty years ago, moms knew nothing of these things and today you make me proud!

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  17. I really do love this. It will come in handy one day when my brothers and father bring up circumcision again. Also, where do you get all your sons intact onesies? I have been looking and have found none as cute as those!

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  18. Ashley - we purchase the onesies (and tshirts) here:

    http://madebymomma.spreadshirt.com/intactivism-C46978D3

    They are in no specific order (although there are groupings or sizes) so you kind of have to look around.

    Great quality! And we also get the onesie extenders which make them last 2ce as long: http://astore.amazon.com/peacefparent-20/detail/B002YQU6KC

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  19. I have read many of the comments and still have quesitons. My intact son's foreskin was forcibly retracted at 4 months by the pediatrician. He now seems to have adhesions that make nighttime urination difficult. His stream is smaller than it used to be at all times. I see that you say to leave it alone but I am concerned that he has to push to pee. The pediatrician that I trust said that he has some reddness under the foreskin that may be a fungal infection. She was going to consult with a pediatric urologist that is against circumcision. She thought that he would say to use steroid cream. I don't want to mess with his foreskin but I feel worried.

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  20. To the last Anon - how old is your son at this point? If readhesion is truly impairing urination, it should be the same at night vs. the day. However, using some steroid cream is not problematic - the issue becomes tugging and stretching a baby's prepuce - readhesion is the body's way of healing. So it should only be interfered with if truly necessary.

    A little bit of redness or irritation can be solved with Calmoseptine. Pick some up at your local pharmacy. Put it all around the outside of the penis and scrotum. I would do this before taking any further measures. Calmoseptine is soothing, healing, and does not interfere with the body's pH. It may just take care of the issue without further need for intervention.

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  21. Hi Dr Momma, I am age 80 and have skin adhesions to the glans and am intact. Don't recall any problem during my 70's.
    The adhesion are about 90%. Have tried to tear them away but wow! Painful. Should I worry about it? Please comment.
    RS

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  22. Amazing article... Truly helpful .. Thank you for this.

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  23. I would love some insight to a problem we have encountered. My hubby opted to have a circumcision for our son. I left it up to him because I felt he was a man and knew more about these things. Anyway, my son has extra foreskin and his circumcision did not really do the job. Our doctor also said that he has a lot of fat on his "fat plate" causing his penis to look like it was not circumcised. I was very worried and read a lot about it and the websites I read said to retracted the foreskin every diaper change, after consulting with my doctor she said to leave it alone and it will correct its self (his foreskin had reattached to his glands and looked just like it did when he was born (intaked, so we put him through that pain and ridiculous procedure for nothing and we will never do this again). We recently changed doctors and today our new doctor said our son had penile adhesion. She told us to push down on the foreskin every diaper change and if no progress in 2 weeks then we would move to steroid cream. I did this today and was horrified. After just one day my sons penis is red, puffy, he cries, I cry, I do not like this and neither does he. Can we stop? Can I just treat his penis like an intaked penis? Please help, I have read and searched all over and nothing I can find addresses our issue specifically, usually the content is about intaked penises. If I leave it alone how far up the head is ok for the foreskin to reattach? I have tried to find pictures but yielded nothing.

    I greatly appreciate any help and advice and so does my son

    thank you

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    Replies
    1. There are varying schools of thought on this. The newer research is saying it is OK to leave it alone. If he can pee and the adhesions aren't hurting leave them alone. As he reaches puberty the hormones of his body will start to break down the adhesions. If they don't release at puberty then you can use a steroid cream.

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