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posted with author's permission
Photos © 2010 Danelle Frisbie and Jennifer Quesada
The following information is to help answer some of the questions we see most often in regards to the normal separation of the prepuce (foreskin) from the glans (head) of the intact boy. In the course of the normal development of the intact penis some things might happen that may be alarming to those who have never been around an intact boy/man before. Many boys will have none of these things happen, and some will have one or more of them.
The following information has been compiled through many sources, along with personal experiences from myself and others.
When babies are born the prepuce is fused to the head of the penis much like the fingernail is to the nail bed. As a child grows, the process of separation starts (prepuce separating from the clitoris or penis glans). This process can start shortly after birth, or it may not be until the teenage years, and in some cases even into adulthood. (Some men and women go their entire lives without their prepuce (foreskin) retracting with no problems at all). There is no set age on when the foreskin will become or should be retractable just as they are is no set age when a girl will reach menarche. It appears that 2.5-3 years old is a time when a lot of the following separation questions arise. However, they can occur at any age.
The separation process in general does not happen all at once. It happens over a period of time from weeks to months, and in many cases even years. It can appear to happen overnight for some boys. The foreskin will often have spots that are still attached even after the rest of the foreskin has released from the glans. This is not cause for concern, when the time is right the spot will release just like the rest of the foreskin has. Unless trauma (such as forcible retraction) has occurred, in which case a skin bridge may form that may or may not need to be fixed. Generally, when the hormones of puberty hit, these attachments will release on their own. This can cause soreness in the spot that will usually resolve within 24-48 hours.
(prepuce has just started to open to begin separation process at the very end)
When the separation process starts there are some things you may, or may not see. These things include: ballooning, soreness, swelling and possibly some discharge.
Ballooning
Ballooning is a normal developmental stage and is not a cause for concern and does not require treatment, it is actually a sign that nature is doing it's job. Ballooning occurs when separation of the foreskin from the glans has started but the sphincter at the tip of the foreskin is still tight causing urine to pool under the foreskin. This is not harmful but it can be disconcerting to see it as the foreskin can balloon up quiet dramatically. It can last a short time or can come and go for months or years.
A child temporarily may report some discomfort or pain while urinating during this period. This occurs because the ballooning may tear at any residual connection to the glans. The discomfort will stop when separation is complete. The foreskin may still not be retractable at this point because the opening of the foreskin, sphincter, is still narrow. With increased growth and maturity, the ballooning will end when opening of the foreskin widens.
Pain, Swelling, Redness
Pain, swelling and redness can also go along with the ballooning or it can be seen without it. If either case 9 times out of 10 the pain and redness will resolve within 24-48 hours. If anything lasts longer than that the odds are higher that there is a infection present. It is important to note that if the problems last longer than the above mentioned time frame or you feel something is really wrong a trip to the Dr. is warranted since long term untreated infections can lead to scaring of the glans resulting in loss of sensation in those area's. Sometimes you may see small amounts of blood but it should not be much and it shouldn't last very long.
The most common infections are yeast or bacterial. The treatment for these is not at all difficult. Depending which is present treatment will either be anti fungal, OTC yeast medications like Monistat 7 day treatment (not the 3 day kind) and for bacterial infections OTC Bacitracin (a safer less reactive cream than Neosporin) can be used. Sometimes a prescription of oral antibiotics is required as well. If you do go the antibiotic route make sure to finish the whole prescription even if you son's penis looks healed in just a few days.
Neosporin is not recommended since some people react badly to it. It is important to figure out if you are dealing with yeast or bacterial since the treatment for bacterial infection can make yeast worse. So a swab culture is essential to figure out exactly what you are dealing with.
If you do take your child to the doctor make sure that his foreskin is not pushed back on at all (See the Warning For Parents Of Intact Sons for more information as well as The Definition Of Retraction & Why it is BAD) If there is infection present this will make it easier to spread and cause more pain and trauma. To check to see exactly what pathogen is present a swab culture should be done. This is done with the long q-tip and a gentle rub of the very tip of the foreskin will pick anything up that is present without pushing on the foreskin at all.
Helpful tips for dealing with pain
Some things you can do to help if your son is in pain is letting him urinate in a cup of water or the bath tub this will dilute the urine so that wont sting. If your son is old enough you can tell him to retract just enough that the urinary opening is exposed so the urine doesn't go back under the foreskin. Long soaks in the bath with baking soda or a very small amount of Tea Tree Oil can also help sooth the pain.
If you are breastfeeding you can also put breast milk on at every diaper change to help kill off bad bacteria and help reestablish normal balance. Diaper free time and stripping your diapers if you use cloth can be very helpful as well. Especially if dealing with yeast.
The things to watch for that would indicate more than separation injury is going on are: severe swelling that keeps getting worse, fever, discharge with a foul smell or dark green in color, unusual redness accompanied by any of the things mentioned above. If your son is having trouble urinating he needs immediate medical help.
The reason the foreskin reacts so strongly sometimes when separation is happening is because it is a very vascular organ and much like the lips even a small bump can cause swelling and pain.
The normal appearance of the glans and inner foreskin is usually a bright red/purple color. This is often disconcerting to parents who see it for the first time and they think that it is irritated, when in fact it is how it should look. The washed out color of the glans on a circumcised boy/man is caused from the drying out and keritinization of the skin caused by being exposed and rubbed against the clothing.
Smegma Pearl (Picture) Note: The penis in this picture is being partially retracted something that should NOT be done. The pearl is on the right side near the base of the glans it is the very large whitish area.
Something you may also see is called a smegma pearl. This is a whitish lump that can range in size from very tiny to pea size or larger. Smegma (the Greek word for soap) is a substance that consists of dead skin cells, body oil and other debris that clumps together forming a ball. It is not damaging and will work its way out once separation is sufficient for it to do so. It is not recommended that you try to massage it out or mess with it since this could cause tearing between the foreskin and the glans and result in pain and possible infection.
The time that smegma pearls are seen is when separation has started. It may make the glans under the foreskin appear like it is crooked. When touched it may feel hard but slightly squishy. It may also look like a blister under the foreskin. If there is any pain in that area odds are that it is being caused by separation and not the pearl, since Smegma is not a irritating substance in itself, unless there is a foreign body in there like lint, that can cause a bit of irritation. For the most part nothing will get under the foreskin but sometimes it happens, especially if separation is well underway.
You may also see a milky whitish discharge. This is smegma mixed with urine and is no cause for alarm. On occasion you may see a very large amount come out or it may just be a small amount.
Smegma can be the consistency of cottage cheese or it can be like liquid. It comes in many colors, pure white, yellowish, greenish, tan or a combination, it is often confused with pus. But the main thing between pus and smegma is that pus will have a really bad odor like an infection. While smegma may smell strong like unwashed genitals depending on how long it has been under the foreskin but not have a odor you would associate with sickness.
Preputial Cyst (Picture) Note: The penis in this picture is fully retracted something that should NOT be done.
There is also something called a Preputial Cyst that occurs on occasion. Sometimes known as a Keratin Pearl caused by dead skin cells accumulating under the top layer of skin on the glans. The appearance of swelling may occur sporadically as preputial cysts break through adhesions (push up against them) to allow separation of the prepuce, foreskin, from the glans. These whitish cysts are sometimes mistaken for pus due to infection, but they merely represent sterile collections of dead skin. It is a lot like a Smegma pearl but is not between the glans and foreskin but under the skin of the glans. In either case nothing special needs to be done.
Foreskin was retracting now it is not? (From Dr. Paul Fliess)
Sometimes 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 overly 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.
Spraying While Urinating
Some boys will spray at one time or another during the process of penile growth. If your son has entered a spraying phase, simply instruct him to retract his foreskin enough to expose the meatus when he urinates (if he can do so himself and without pain of course). This is a phase and won't last that long. But it might come and go several times during the separation process. There is no difference in the amount of spraying between intact or circumcised boys - this has much more to do with a child's aim and the development of his urethra than whether or not he is intact.
Hygiene
A question we see here a lot as well is if the toddler/child is retractable should the parent retract the foreskin to clean. The answer to this is no, if the boy is not old enough to do it himself then the penis should continue to be cleaned by washing like a finger from base to tip, outside only, with warm water (no soap). Once the boy is old enough to retract on his own foreskin, he can retract, rinse with pure water, and replace - do not use soap on the exposed glans of the penis as this can cause pain, irritation and/or infection.
Paraphimosis (very rare, but good information to have)
Once your son is retracting on his own (for some boys this will not occur until their teenage years) be sure to let your son know to replace the foreskin over the glans any time he has retracted, so that it does not become trapped behind the glans. If this happens, it is known as paraphimosis and needs immediate attention. There are a few simple things that work most of the time to get it back in the proper position.
(Actual medical pictures of reduction, genitals shown)
Here are two great article on reducing paraphimosis:
British Journal of Urology 1999
Circumstitions Paraphimosis
How the foreskin works animated pictures:
NOHARMM Anatomy & Functions
Circumstitions Functions & Mobility of the Foreskin
Related Reading:
Painful Urination During Prepuce Separation
Ballooning in the Intact Child
How to Care for Your Intact Son (resource list of articles)
Basic Care of an Intact Child
Q&A For Intact Men
Protect Your Intact Son
For more information on the prepuce, intact care and circumcision see resources on this page.
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