Saturday, January 30, 2010

Painful Urination During Prepuce Separation

By Jennifer Coias © 2010
Photo Credit: © Darren Melrose

I've received several questions from parents regarding painful urination.

Frequently a mother will arrive describing a painful experience her son is having when he urinates. 97% of the time this is just normal separation of the prepuce (foreskin) from the glans (head) of the penis, and will not typically last more than 24-72 hours. Especially if there are no other symptoms of urinary tract infection (UTI) present such as frequent urination, fever, etc.

The experience of pain or sting during urination will be more intense when the foreskin separates suddenly, as was the case for my son. Often, there will be some swelling (edema) and/or ballooning that occurs as well. The foreskin might separate all at once on one side and then slowly detach as the pressure from the urine knocks the connections loose. This means that the pain can go on for a couple days. For my son the entire foreskin took about 24 hours to knock loose, then the glans took about 3 days to smooth over, and for him to not experience any pain when urinating.

It is unclear why some boys experience this separation symptom more suddenly than others. For my son I believe that the cause was some early manipulation of his foreskin by a doctor (forced retraction). This is just another reason that doctors should not manipulate the foreskin for any reason. For other boys, it could be that they are a little hard on themselves during self-exploration which starts the ball rolling sooner.

One of the remedies we have for painful urination during separation, is to have the child pee with his penis in a cup of water. However, this does not often work for young boys. If the foreskin opening is still very narrow, the water will not be able to mix with the urine and dilute it so that it does not sting. For these boys, they will just have to weather the experience, and it will be over as quickly as it started.

In addition, the foreskin may not separate all at once, causing painful urination to come and go until complete separation has occurred.

The sting may be worse during times of the day when the urine is more concentrated. Have you son drink LOTS OF WATER (or breastmilk if he is nursing). For my son, the discomfort was bad all day. It can be very painful. Sometimes a boy will be reluctant to pee to try to avoid the pain.

The objective of this brief article is to ensure that parents know painful urination, even when it sounds very painful, is most likely to be normal separation. Especially if there are no other symptoms of UTI. Swelling is also a good indication that it is separation, but may or may not be present. Other symptoms that can be present are smegma discharge, ballooning, and a small amount of blood.

Comfort your babe and wait and watch. It may be a rough few days, but a lifetime of normal, optimal functioning is worth it! Unless you see other symptoms that could indicate UTI, I would not run to the doctor. Most (in the U.S.) are not familiar with the normal development of the intact boy and often do more harm than good.


Additional intact information at:





Also by Jennifer Coias:

For additional information and resources on the prepuce, intact care and circumcision, see Are You Fully Informed?

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19 comments:

  1. I have a nine year old son who is too afraid of retracting his foreskin to see if it has separated from the glans. He is afraid it will hurt. I don't know much about the natural process of separation and my 6 year old's foreskin retracted a couple years ago along with the painful urination you mention in this article. Should I be concerned about a timeline for my 9 year old? Does it usually happen before puberty?

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  2. A recent Dutch study found that the average age of retraction for boys is 10 years old. This means that some boys retract earlier, some later. Your 9 year old son is perfectly normal. You should NOT be worried and he should not feel pressured to forcibly retract his own foreskin. If he is afraid it will hurt - it probably will. The best advice - leave it alone. When the time is right, he will know, it will naturally separate and retract in its own perfect timing. Your 2 boys are different - just like all boys are. No need to be concerned.

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  3. My 27 month old has been having this problem since he was very young--6 months or so. the pain isn't going away, and now his pediatrician (who is very supportive of remaining intact)has said that the pain could last until he is 7 or 8. We're finally considering circumcising him because he's in such constant pain. It's not what we want, but we also can't stand to see him like this. Any thoughts?

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  4. Thank you so much for your knowledge and reassurance. I recently discovered this blog and love it!!

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  5. For the woman with the 27 month old intact son with pain- if his foreskin is intact and there's pain like it is slowely seperating, wouldn't it make since to do the less drastic- maybe retract the foreskin (please talk to your doctor first, this is just an idea to prevent circumsision) and see if the pain stops before going any further? Hope that helps. What a scary thing for you guys to go through!

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  6. For the anonymous poster with the 27 month old. I assume you mean that the pain comes and goes since he was 6 months. This can be normal until the foreskin is completely separated. If he is aggressively self exploring you might want to keep some trainers or under pants on him and limit self-exploration time. Also you might want to check that he doesn't have a minor yeast infection. Sometimes yeast can spur on separation prematurely since it often causes a swelling to the tissues. You should try a yeast treatment (diflucan oral/nystatin/etc) and see if the symptoms improve. Probiotics, especially during a course of antibiotics, are a fantastic way to prevent yeast infection in the future. If this is something your son experiences every so often, I would not worry as he will grow out of it once the foreskin is completely separated. The losses he will suffer from circumcision will greatly outweigh any temporary benefit from circumcision.

    For duasina, a nine year old boy should not be pressured to retract. It is not necessary. Please read my article about the "Phony Phimosis Diagnosis" for more information. This article will help you a great deal.

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  7. Also, to the anonymous poster. I forgot to mention that your son is at a prime age where he may start noticing his erections. When this happens for my son he often describes them as painful, especially in the morning when he has to urinate with an erection. This is also a normal phase and they usually describe it as painful because they don't know any other way to describe the sensation. So another possible reason for his "pain" might not even be separation, it might just be that he is having erections when he is trying to urinate. This happens to all boys. ;)

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  8. It is always surprising for me to read that some boys are experiencing pain.

    I question, are parents or doctors forcefully trying to retract the foreskin on these boys? Because if they are, then this causes raw wounds on the glans, and of COURSE it's going to hurt to urinate through that.

    I grew up with anatomically correct genitalia, and I must say, I have never experienced pain at urination.

    The only time I ever experienced what I would call "pain" is the first times I tried to retract my foreskin, when I would touch the fresh, bare glans with my fingers. But that was it; with my foreskin over my glans, it would not hurt to pee at all. I prefer to have the foreskin over the head of my glans when I urinate, simply because I don't like to touch my glans directly. To date, I'm still quite sensitive, though I've gotten used to touching my glans. I still prefer my glans to be enveloped by another mucous membrane, IE, either my own foreskin, my partner's mouth or vagina.

    To all the mothers having this experience I must ask; are you trying to retract your sons' foreskins? Are you making sure doctors aren't trying to do this?

    I doubt it's "rough self exploration," I think most of us have the intuition that if it hurts, we stop.

    I'm an intact male who grew up in the US, born in the early 80s. I come from a family of intact males, and threads like these surprise me, as I can't remember any of us having these "problems," or our cousins and aunts talking about them. I've seen most if not all of my cousins etc. naked so I know none of us had problems so bad we "had to be circumcised."

    Mothers, I beseech thee, have patience with your children, and educate yourselves on normal male child development.

    I post more of my growing up intact experience in another post on this same blog. Please go there and read.

    http://www.drmomma.org/2010/01/common-questions-regarding-normal.html

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  9. Joseph,
    This has happened to quite a few intact boys I've encountered through online mothering forums. The premature retraction is a definite cause. While my son wasn't forcibly retracted, a doctor did pull it back to "view the opening". It happened too quick for me to do anything. This is why I always tell parents not to let anyone manipulate the foreskin in any way, shape or form. Even gentle tugging toward the body of an infant can set a boy up for premature separation of the foreskin. Yeast infection is another cause b/c the tissues will swell slightly and can create back pressure in any open spaces that may break the natural adhesions loose. But sometimes it happens with no known cause. The good news is that it does resolve in a matter of days and no medical treatment is required. While this can happen it isn't incredibly common.

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  10. Thank you thank you for this article. I think this is Exactly what is happening to my 8-year old son these last few days. My son has been "ballooning" for some time, and a few days ago started having pain on urination. He tested negative for a UTI.
    The ped. isn't very knowledgeable about intact boys. He thinks the ballooning is a serious problem and wants to snip the frenulum if the opening in the foreskin doesn't stretch out soon. Thanks to your article, my son and I are much less worried and I am not going to let the doctor do anything about the ballooning. My son's pain is subsiding and your article lets us know that hopefully he'll be OK in a few days.

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  11. Intact yours truly has no memories whatsoever of any pain or complications of this nature. I simply had a penis whose tip looked different from that of my younger brother. To this day, we have never talked about this. Urine flowing past the tip of the foreskin felt good.

    The year I turned 7, after a conversation with my mother I could not parse, my pediatrician asked her to leave the room. He then had me lie back, pulled down my drawers, and firmly and efficiently retracted my foreskin. I had no idea that this was coming, and was never told why. There was a some mild discomfort from forcing the tip open, but I suspect that my foreskin had already fully detached from my glans. There was no lingering pain, and I do not feel damaged by this experience. I have no idea what my path to retraction would have been had my doctor not forcibly retracted me when I was 7.

    The doctor called my mother back in and began a fairly earnest conversation with her, only one detail of which I understood: she reminded him of my foreign birth. From the fact that I was the only pointed penis in my family of origin and one of 2 in my grade school class, I had guessed that my foreign birth was somehow implicated. I did not learn the specifics until I was 13.

    From then until I was about 15, my mother often told me as I was going into the bath or shower to "be sure to wash where the doctor told you to." Except that I have no memory of having been told anything, much less anything personal and specific. But somehow I knew what she meant.

    At age 9, I learned to retract completely before extracting my tool to pee. Retraction soon became easy and natural. I have no memories of any tender bits under the foreskin being uncomfortably sensitive.

    On that and one other occasion, I sensed that my doctor was not fully comfortable with my being intact. But 6 months ago, my mother (who is 88) told me that this very doctor fully supported her decision to leave me intact. She claimed he even said "your common sense makes you almost unique among the mothers of my patients." (He may not have known of the "routine circumcision policies" common in USA maternity wards during the 1940s and 50s.)

    Absent infection or other discomfort, there is no need for a man to retract completely until he is ready to have responsible sex.

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  12. Please help.....
    My son is 17 months old and he screams and cries when he pees. His penis ballons and I now know this is normal, but it has been 7 days now, and I know he doesn't have a UTI, but continues to cry....I know it stings him! We took him to the emergency on Sunday and they had to put a catheter on him as he was holding his urine and wouldn't pee in a external bag.......I hate that we did that, but at the time, I did not know what I've read here with regard to an intact penis. Does it help for me to gently squeeze his penis when he balloons, or should I just leave my hands off.

    I read this from "A Natural Penis" website and it caused me more concern: "However if a foreskin becomes distended - 'balloons out' - when a boy urinates this is a serious cause for concern since it shows that the opening of the foreskin is too small to be adequate for the passage of urine. This may be congenital - in which case the baby will probably scream or cry when he urinates - but it may also be acquired in boyhood as a consequence of infections in or under the foreskin. In either case treatment, preferably by circumcision, is urgently required to avoid kidney damage. Dilation (stretching) of the orifice may be sufficient treatment but recurrence of the problem remains a significant possibility in this case, and even if the passage of urine is eased there remains a high likelihood of long-term problems with retraction of the foreskin."
    So now, I wondered if I should just continue to comfort him to get him trough this, and at what point should I take him in again. They said he may have Balanitus and put him on antibiotics(sulfamethoxazole/trimethoprim), but we stopped them after 3 days because he developed a rash and his appetite was decreased. What is your best suggestion for me at this point? Today is now Friday, so it has been 6 days and I am desperate to get him some relief. I would appreciate any help you ight be willing to share.
    Thank you,
    Lena

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  13. Lena,
    Ballooning does not mean that the opening is too small or that there will be a possibility of UTI or infections. It simply means that the opening is small as of now b/c your son doesn't have the adequate hormone levels to maintain a more elastic opening. You don't need to worry about that, I can assure you. I am the writer of this article and my son still balloons to this day at almost 3 years of age and has suffered zero negative consequences due to the ballooning. It really is very normal and COMMON. Your son is experiencing sudden separation symptoms which can include pain, sting, swelling, redness, etc. These symptoms can be aggravated by a yeast infection so it is important to rule that out. Your son should never have been given antibiotics without a culture as these medications worsen any potential yeast overgrowth. Bacterial infections present with extreme continued swelling all the way into the groin and fever. It is very unlikely that he has one unless there was a wound to his penis.

    What to do: You need to leave his penis alone. The added trauma of the catheter and handling by the ER could have worsened the situation. If they tried to pull back his foreskin they probably created micro tears in the opening and tore more adhesions. The opening is sphincter and designed to be very tight and it only relaxes during urination. Urination will be painful for him for a few days but if left alone it goes away. Since your son has had some interventions you can expect the time to have been lengthened due to manipulation of his foreskin. Sometimes it helps to put boys in water to pee when this happens. This can help dilute the urine a little, but it doesn't always work for young boys since the opening is so small still. The bad news is that he is just going to have to weather it, the more he is messed with by doctors the longer it will take. The ballooning is knocking any remaining adhesions lose, this is painful since the glans are still raw as the urine passes over them. A steriodal cream can be used to aid in TEMPORARILY relaxing the opening but it should NOT be used for more than a couple days. The foreskin will return to the tight opening after discontinued use but by then the glans will have smoothed over and developed a layer of skin. I want to emphasize that this is a TEMPORARY aid and not to be used more than 4-5 days. Long term use of steroid creams can thin the foreskin of pre-pubescent boys and is damaging in the long term.

    Feel free to email me with any other questions: latinalonestar@gmail.com

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  14. Have you changed diaper brands or do you use cloth diapers? If you use cloth diapers, have you changed soaps for your wash? Does your son take bubble baths? Do you use soap or shampoo in the bath tub? If so, for now, only use warm water in the bath. Nothing else. And, finally, the worst offender is antibiotics. Bubble baths, soaps, shampoos, and antibiotics kill bacteria and often cause a yeast overgrowth, stinging or burning with urination, and redness. I suggest you purchase some liquid Acidophilus culture from the healthfood store and apply it to directly onto the outside of his foreskin, especially the tip, six times a day. If the tightness is caused by bacterial imbalance, the problem should be resolved in just three days. This is the least invasive therapy and will help if yeast overgrowth is the cause of the foreskin tightening down. If it isn't, then it's time to consider other things, but this is a first step.

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  15. I respect articles like this for helping boys and parents where it is needed. However, I cringe to think that some unknowing parents will come to believe this is the norm for intact boys. I'm a 30 year old intact man and never experienced anything like this that I can remember, nor did any of my brothers, or any of the other guys I've asked. So while it may happen, and thank goodness we have helpful resources like this for those instances, I just wanted to drop a comment with my experience because (like Joseph above) I don't believe this is common. And if it is in some circles, I almost have to wonder what is going on? Is there some type of chemical detergent being used or something being done to these boys that is causing such things? Are infants routinely retracted by doctors without parents even knowing? Are there other products (baby lotion, for example) being used that is increasing irritation and discomfort? It just should not be something that is hardly ever heard of.

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  16. My son has experienced the ballooning and painful urination for 5 days now. He's 7 years old. I'm mainly concerned because of the pain of course , but also the foreskin opening has decreased in size and has a bit of white skin around the tightened opening. His doctor, since birth has pulled back the foreskin to view the glans and has recommended he continue to play with it and pull it back as he gets older. Again, the foreskin opening has narrrowed quite a bit since the discomfort began, it didn't used to be that narrow. He can't stand and pee any more b/c it sprays everywhere. Help! I'm worried doctors will want to circumcise.... And thank you so much for the info! This site has been the best! Amy

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  17. I also have a son that is 6.5 years of age experiencing pain longer than 72 hours. Two weeks ago I took him to the Pediatrician because he was screaming while urinating. No UTI, pain subsided the next day. My Pediatrician admitted that he was unfamiliar with intact boys, especially when they have not retracted before age 4. I have read all the articles on this site (thank you for the peace of mind it has brought me in regards to the ballooning and tight foreskin) HOWEVER.. his brief painless stint is over and I feel terrible for him. He has now wet the bed twice. Probably because he is afraid to urinate during the day. My question, is.. if he has a yeast infection, how can topical meds help if you can't get inside? He is so tight that he is ballooning.

    The pediatrician made us an appointment with a pediatric urologist in Columbus, OH but not for another 30 days. I'm wondering if we should call and see if we can get that moved up?

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    Replies
    1. Have you looked over the Ballooning article as well?

      http://www.drmomma.org/2011/06/ballooning-in-intact-child.html

      One thing that will work to soothe the penis - a couple things, actually, while he is going through this stage of prepuce separation:

      -Calmoseptine (request a tube at your local pharmacy) all around the outside of the penis (and outside of the foreskin). Just as with Lotrimin (used for yeast) this, too, will go through the skin to soothe things and reduce irritation.

      -warm water baths and peeing in a cup of warm water as the article above suggests

      -if it is truly a snug foreskin that is causing discomfort, then steroid cream may be in order (to put on the penis and gently tug - the boy himself).

      However, he is within a normal range for this. Average age of retraction is 10 1/2 years, and some boys (not most, but some) have this time of discomfort that comes and goes when the prepuce is loosening up.

      I'd not see a urologist unless there was truly something wrong, because far too many do more harm than damage (or jump to circumcision, forcibly retract) when this is just another stage in intact development.

      But much love to you and your son -- and I hope you guys find some good, helpful, useful, child-friendly answers. :)

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    2. The topical medications for yeast do help being placed only on the exterior of the penis because they work their own way inside (the reason they are exterior skin ointments). Lotrimin works, or if you get the types made for women's yeast infections, get the 7 day treatment types -- the 3 day do not work as well for yeast overgrowth (in women or men) because they are composed differently.

      Both my son (intact) and my husband (circumcised) have had 1 bout each with increased yeast, and it was easily eliminated with Lotrimin. However, this is also often due to diet -- yeast thrives on sugars and processed, refined foods, so if you suspect yeast, I'd also look at diet as well.

      It sounds moreso that it is separation, not yeast, however. This same pain occurs when the prepuce is ripped from the glans of an infant being circumcised -- only then it is forced and intense and takes 5-10 minutes (followed by weeks of festering pain), whereas the separation naturally is typically more gradual, gentle, and can take months or years.

      I think we have to be careful when reading through these threads of comments, though, because it makes an unknowing parent think all boys experience these things, when in fact, most do not. I know MANY intact children and I've never met another parent whose child experiences this pain (I've only read about it and responded to people in online forums).

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