Natural Foreskin Retraction in Intact Children and Teens

Guidance for healthcare providers by Doctors Opposing Circumcision and Medical Professionals for Genital Autonomy.


Photo by David Burnett

Introduction.

There is much uncertainty among health care workers about when the foreskin of a boy should become retractable.1 This has caused many false diagnoses of phimosis, followed by unnecessary circumcision, when, in fact, the foreskin is developmentally normal.

History. 

The first data on development of retractile foreskin were provided in 1949 by the famous British paediatrician, Douglas Gairdner. (2) His data have been incorporated into many textbooks and still is repeated in the medical literature today. Gairdner said that 80 percent of boys should have a retractable foreskin by the age of two years, and 90 percent of boys should have a retractable prepuce by the age of three years. (2) Unfortunately, Gairdner’s data are inaccurate, (3-4) so most healthcare providers have been taught inaccurate data. (4) Retractability usually occurs much later than previously believed. (3) This page provides accurate data, derived from newer and better studies, for healthcare providers.

Current View.

Almost all boys are born with the foreskin fused with the underlying glans penis. Most also have a narrow foreskin that cannot retract. Non-retractile foreskin is normal at birth and remains common until after puberty (age 18). Some boys develop retractile foreskin earlier, and about 2 percent of males have a non-retractile foreskin throughout life. Non-retractile foreskin is not a disease and does not require treatment.

There are three possible conditions that cause non-retractile foreskin:

  • Fusion of the foreskin with the glans penis
  • Tightness of the foreskin orifice
  • Frenulum breve (which is rare and cannot be diagnosed until the previous two reasons have been eliminated)

The first two reasons are normal in childhood and are not pathological in children. The third can be treated conservatively, retaining the foreskin.

Infants and pre-school. 

Kayaba et al. (1996) reported that before six months of age, no boy had a retractable prepuce; 16.5 percent of boys aged 3-4 had a fully retractable prepuce. (5) Imamura (1997) examined 4521 infants and young boys. He re-ported that the foreskin is retractile in 3 percent of infants aged one to three months, 19.9 percent of those aged ten to twelve months, and 38.4 percent of three-year-old boys. (6) Ishikawa & Kawakita (2004) reported no retractability at age one, (but increasing to 77 percent at age 11-15). (7) Non-retractile foreskin is the more common condition in this age group. Compare these data with Gairdner’s data!


Øster graph
Percentage of boys with fused foreskin by age according to Øster

School-age and adolescence. 

Jakob Øster, a Danish physician who conducted school examinations, reported his findings on the examination of school-boys in Denmark, where circumcision is rare.8 Øster (1968) found that the incidence of fusion of the foreskin with the glans penis steadily declines with increasing age and foreskin retractability increases with age.8 Kayaba et al. (1996) also investigated the development of foreskin retraction in boys from age 0 to age 15.5 Kayaba et al. also reported increasing retractability with increasing age. Kayaba et al. reported that about only 42 percent of boys aged 8-10 have fully retractile foreskin, but the percentage increases to 62.9 percent in boys aged 11-15.5 Imamura (1997) reported that 77 percent of boys aged 11-15 had retractile foreskin. (6) Thorvaldsen & Meyhoff (2005) conducted a survey of 4000 young men in Denmark. (9) They report that the mean age of first foreskin retraction is 10.4 years in Denmark. (9) Non-retractile foreskin is the more common condition until about 10-11 years of age.

Kayaba graph
Percentage of boys with tight ring totally non-retractile foreskin according to Kayaba et al.

Discussion. 

Boys usually are born with a non-retractile foreskin. The foreskin gradually becomes retractable over a variable period of time ranging from birth to 18 years or more. (8,9) There is no “right” age for the foreskin to become retractable. Non-retractile foreskin does not threaten health in childhood and no intervention is necessary. Many boys only develop a retractable foreskin after puberty. Education of concerned parents usually is the only action required. (10)

Avoidance of premature retraction. 

Care-givers and healthcare providers must be careful to avoid premature retraction of the foreskin, which is contrary to medical recommendations, painful, traumatic, tears the attachment points (synechiae), may cause infection, is likely to generate medico-legal problems, and may cause paraphimosis, with the tight foreskin acting like a tourniquet. The first person to retract the boy’s foreskin should be the boy himself. (3)

Making the foreskin retractable. 

Occasionally a male reaches adulthood with a non-retractile foreskin. Some men with a non-retractile foreskin happily go through life and father children. Other men, however, may want to make their foreskin retractile.

The foreskin can be made retractable by:

  • Manual stretching (11-12) 
  • Application of topical steroid ointment (13-14)

Male circumcision is outmoded as a treatment for non-retractile foreskin, but it is still recommended by many urologists because of lack of adequate information, and perhaps because of the fees associated with circumcision. Nevertheless, circumcision should be avoided because of pain, trauma, cost, (15,16) complications, (15) difficult recovery, permanent injury to the appearance of the penis, loss of pleasurable erogenous sensation, (17) and impairment of erectile and ejaculatory functions. (18-20)

A website exists here where knowledable individuals give free advice to adults and teens on stretching one's foreskin to make it retractble.

References:
  1. Simpson ET, Barraclough P. The management of the paediatric foreskin. Aust Fam Physician 1998;27(5):381-3. [Full Text]
  2. Gairdner D. The fate of the foreskin: a study of circumcision. Br Med J 1949;2:1433-7. [Full Text]
  3. Wright JE. Further to the "Further Fate of the Foreskin." Med J Aust 1994;160:134-5. [Full Text]
  4. Hill G. Circumcision for phimosis and other medical indications in Western Australian boys. Med J Aust 2003;178(11):587. [Full Text]
  5. Kayaba H, Tamura H, Kitajima S, et al. Analysis of shape and retractability of the prepuce in 603 Japanese boys. J Urol 1996;156(5):1813-5. [Full Text]
  6. Imamura E. Phimosis of infants and young children in Japan. Acta Paediatr Jpn 1997;39(4):403-5. [Abstract]
  7. Ishikawa E, Kawakita M. [Preputial development in Japanese boys]. Hinyokika Kiyo 2004;50(5):305-8. [Abstract]
  8. Øster J. Further fate of the foreskin: incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child 1968;43:200-3. [Full Text]
  9. Thorvaldsen MA, Meyhoff H. Patologisk eller fysiologisk fimose? Ugeskr Læger 2005;167(17):1858-62. [Full Text]
  10. Spilsbury K, Semmens JB, Wisniewski ZS. et al. Circumcision for phimosis and other medical indications in Western Australian boys. Med J Aust 2003 178 (4):155-8. [Full Text]
  11. Dunn HP. Non-surgical management of phimosis. Aust N Z J Surg 1989;59(12):963. [Full Text]
  12. Beaugé M. The causes of adolescent phimosis. Br J Sex Med 1997; Sept/Oct: 26. [Full Text]
  13. Orsola A, Caffaratti J, Garat JM. Conservative treatment of phimosis in children using a topical steroid. Urology 2000;56(2):307-10. [Full Text]
  14. Ashfield JE, Nickel KR, Siemens DR, et al. Treatment of phimosis with topical steroids in 194 children. J Urol 2003;169(3):1106-8. [Abstract]
  15. Van Howe RS. Cost-effective treatment of phimosis. Pediatrics 1998; 102(4)/e43. [Full Text]
  16. Berdeu D, Sauze L, Ha-Vinh P. Blum-Boisgard C. Cost-effectiveness analysis of treatments for phimosis: a comparison of surgical and medicinal approaches and their economic effect. BJU Int2001;87(3):239-44. [Full Text]
  17. Williams N, Kapila L. Complications of circumcision. Brit J Surg 1993;80:1231-6. [Full Text]
  18. Denniston GC, Hill G. Circumcision in adults: effect on sexual function. Urology 2004;64(6);1267. [Full Text]
  19. Shen Z, Chen S, Zhu C, et al. [Erectile function evaluation after adult circumcision]. Zhonghua Nan Ke Xue 2004;10(1):18-9. [Abstract]
  20. Masood S, Patel HRH, Himpson RC, et al. Penile sensitivity and sexual satisfaction after circumcision: Are we informing men correctly? Urol Int 2005;75(1):62-5. [Full Text]

Related Reading on Intact Care: 




How to care for your son if he is retracting pre-puberty.
Foreskin Facts postcards available at Etsy

Breastfeeding Latch Trick

By Danelle Day, PhD © 2010




Preface: The information on this page is meant to help breastfeeding mothers who need latch assistance for their nursing baby. Photos and videos are for education and may not be suitable for all work environments.


Nipple Twist Latch Steps:

1) Pinch the areola right next to your nipple so the nipple can be moved (it may take a second for the nipple to evert if it was otherwise flat). You can use your thumb and first finger, or 2 fingers - whichever is easier for that side and the shape of your breasts. If you have 'puffy' breasts, you can also position the rest of your hand under your breast to lift it up slightly and away from your chest.

2) Turn the nipple up so it is pointing at your face. Do not be shocked if some milk exits. This is normal as you are putting very slight pressure on the milk ducts. There is no need to wipe off the milk as the scent will only help to encourage baby to nurse.

3) Position baby's mouth at the bottom of your upturned nipple, so baby's mouth is open over your nipple/finger and onto the above areola.

4) When you let go, the nipple will land deep into baby's mouth - where it is meant to be for comfortable latch and sucking.

Thank you to Bronwyn Millar for sharing her technique with DrMomma readers via video examples below. [Note: Millar's videos are not currently working due to online bullying of the Peaceful Parenting account and Google losses.]

Helpful items for breastfeeding mothers in the Breastfeeding Group: FB.com/groups/Breastfed.








How to compress the nipple upward to allow it to fall into baby's mouth for a good latch: 


Fetal Ejection Reflex


Meme by Christine Murray  

The fetal ejection reflex is real -- and it is amazing! Gloria Lemay writes in her excellent article, Pushing for First Time Moms:

Dr. Michel Odent [repeats] over and over, "Zee most important thing is: do NOT disturb zee birthing woman." We think we know what this means. The more births I attend, the more I realize how much I disturb the birthing woman. Disturbing often comes disguised in the form of "helping." Asking the mother questions, constant verbal coaching, side conversations in the room, clicking cameras—there are so many ways to draw the mother from her ancient brain trance (necessary for a smooth expulsion of the baby) into the present-time world (using the neocortex which interferes with smooth birth). This must be avoided. [...] Recognizing ways in which we can support the mother to enter that deep trance brain wave state that leads to smooth birth is imperative. I find it very helpful to have new language and concepts for explaining the process to practitioners. Dr. Odent has taught me to wait for the "fetus ejection reflex." This is a reflex like a sneeze. Once it is there you can't stop it, but if you don't have it, you can't force it. While waiting for the "fetus ejection reflex," I imagine the mother dilating to "eleven centimeters." This concept reminds me there may be dilation out of the reach of gloved fingers that we don't know about, but that some women have to do in order to begin the ejection of the baby. I also find it valuable to view birth as an "elimination process" like other elimination processes-coughing, pooping, peeing, crying and sweating. All are valuable (like giving birth is) for maintaining the health of the body. They all require removing the thinking mind and changing one's "state." My friend Leilah is fond of saying, "Birth is a no brainer." After all "elimination processes" are finished, we feel a lot better until the next time. Each individual is competent to handle her bodily elimination functions without a lot of input from others. Birth complications, especially in the first-time mother, are often the result of helpful tampering with something that simply needs time and privacy to unfold as intended.

The fetal ejection reflex is one that happens for most birthing women -- when they are fully safe, supported, and allowed to birth in peace. This, unfortunately, rarely happens in today's modern, North American birth world -- and is especially hard to come by in induction/pitocin-filled labor and delivery rooms. However, this primal state of birth still exists, and is waiting for us, as human mammals, to return to it: to make birth better, for babies and for mothers.

Related reading:

Pushing for First Time Moms: https://www.midwiferytoday.com/articles/pushing.asp

Do not disturb: The importance of privacy in labor: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1595201

What is the Fetal Ejection Reflex? http://www.spiritualbirth.net/what-is-the-fetus-ejection-reflex

Optimal Use of Language for Creating Birth Outcomes: http://wisewomanwayofbirth.com/optimal-use-of-language-for-creating-birth-outcomes

Birth from the baby's perspective: https://midwifethinking.com/2010/08/07/birth-from-the-babys-perspective

Excellent birth books: http://astore.amazon.com/peacefparent-20?_encoding=UTF8&node=3





10 Year Old with Autism Composes "I AM" - Wowing Teachers and Parents


As part of a multi-grade understudy, Benjamin Giroux was given a school assignment to compose a ballad. His specific project was to write the lyrics to a title of "I Am." The initial two words in each sentence were given, and it was up to Benjamin to write the rest. What resulted is a finished product that he poured his heart into.

Benjamin is a 10-year-old child from Plattsburgh, New York, who has been diagnosed with Asperger syndrome. He does not express much emotion with others, but was excited for this assignment. At work on the project at home, Benjamin's family said he didn't look up from his paper until he was finished.

When he showed his poem to his parents and his teacher, each adult was overwhelmed with emotion. 

Benjamin had always felt different because of autism, and at times said it made him stand out from the other children. Through his completed poem, the real, raw, reflection of living as himself comes through in a bold and beautiful way.

I Am

I am odd, I am new
I wonder if you are too
I hear voices in the air
I see you don’t, and that’s not fair
I want to not feel blue
I am odd, I am new
I pretend that you are too
I feel like a boy in outer space
I touch the stars and feel out of place
I worry what others might think
I cry when people laugh, it makes me shrink
I am odd, I am new
I understand now that so are you
I say I, “feel like a castaway”
I dream of a day that that’s okay
I try to fit in
I hope that someday I do
I am odd, I am new.

-Benjamin Giroux






Cry It Out: What is the 'It'?

What is the 'it' in cry-it-out?

When we give babies no choice but to 'cry it out' we need to ask ourselves, what is the 'it'?

The 'it' is safety.
The 'it' is connection.
The 'it' is us - their parents.
They are crying for us.

-Tracy Gillett 

Sleep training: a review of research: http://www.DrMomma.org/2009/12/sleep-training-review-of-research.html 

Healthy baby sleep resources: http://www.DrMomma.org/2009/06/truth-about-co-sleeping-how-stats.html

Home Learning Resources and Things to Do During Coronavirus School Closing


Businesses are offering free subscriptions, and learning opportunities abound during this time of school closings during the coronavirus social distancing and quarantines. Below are some of the opportunities that have been shared with Peaceful Parenting. We will add more as they come in. Contact us any time at PeacefulParentingOrg(at)gmail.com

• Free Educational Resources during school closing: https://docs.google.com/spreadsheets/d/1NUKLZN7hGSu1Hzm70kfzBKs-lsSELaEMggS60Bi2O2I/htmlview?usp=embed_facebook&sle=true&pru=AAABcPe22BE%2AnPzlwaKU76E7xyX22h-7OA&fbclid=IwAR2ojtxrWhsWoPLgwLcPDHBh4YtCrAH_ecBhvXixTZGpgQULWgRxLBOvNzw

• Ideas to do at home with kids during social distancing: https://docs.google.com/document/d/1o6kEgCKLn3cyIm2hehhhSTIk7yRTd0C3zx49JS4wwCI/mobilebasic?fbclid=IwAR0BIKgzRwQXMgO-2TLbg0i6f8ZmM6A6Uo3iX7-wN9GUQ7IYVE9jRLiym_4

• Free, easy science for remote learning of all ages: https://mysteryscience.com/school-closure-planning?fbclid=IwAR2ET7f-60T_9ZLPMXz5LyNEDEd8uiFv3B52_mU81AHFWUABAqWqGDJQloU

• Using Purple Mash when School is Closed: https://2simple.com/blog/using-purple-mash-when-school-closed/

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