Showing posts with label foreskin. Show all posts
Showing posts with label foreskin. Show all posts
Should I Circumcise My Son? The Pros and Cons of Infant Circumcision
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The Phony Phimosis Diagnosis
By Jennifer Coias, M.D.I'm writing this article because this is probably one of the most frequent misconceptions that I encounter. It seems that everyone knows of a child or man who 'had' to be circumcised due to a tight foreskin, also known as phimosis. When people hear these stories, most of them do not question the validity of the diagnosis and treatment and simply accept it as, "What had to be done". Could it really be that so many men were designed with such a flaw or is this really just an epidemic of misdiagnosis courtesy of widely foreskin-ignorant medical professionals?
In this article, I will give an overview of the development of the intact male and explain why the diagnosis of phimosis in children and teens is entirely phony. Additionally, I will outline what is true phimosis, its proper treatment, and why our doctors are so confused.
Development of the Prepuce ('foreskin' in males/'hood' in females):
During infancy the prepuce is tightly fused to the glans (head) of the penis. The tissue itself is fibrous and dense at this age, as it is composed of a whorl of muscle fibers. The opening of the prepuce acts like a sphincter and only releases to allow urine to pass. This design serves very important functions:
-It protects the developing penis from feces, bacteria and other harmful pathogens. This is especially important during the diaper-wearing years when a baby is continually exposed to his/her own feces (e-coli and other harmful bacteria/viruses).
-It protects the developing glans and keeps them from becoming desensitized and keratinized.
-It protects against urinary tract infections.
As a child grows, the foreskin will separate from the glans. This can take many years for some boys and for other boys, it seems to happen all at once. During or after the separation process, there may be some shedding of dead skin cells in the form of smegma (please note that women and girls also have smegma). This shedding of dead cells aids in separation since it helps the foreskin differentiate itself from the glans. There is no need to try to clean smegma from underneath a child's foreskin. It will slowly work itself out via the narrow opening. Once a child's foreskin is completely differentiated from the glans this is not an indication that retraction is possible.
Retraction is a separate function that is designed specifically for intercourse and masturbation. Retraction enables the foreskin to glide smoothly over the glans of the penis. This gliding stimulates nerve endings in both the foreskin and the glans. In order for retraction to occur, the foreskin must have separated from the glans and the opening of the foreskin must have widened to allow it to slip back over the glans. How does the foreskin opening widen? Throughout childhood and adolescence, there is a release of hormones. As hormone levels rise, the fiber-dense tissue of the prepuce is replaced with a more elastic tissue. A boy will begin to explore his genitals as he grows and as time passes, the elastic tissue will allow the opening of the foreskin to widen. This can happen at any age but it is not common in young boys. In fact, only 50% of boys are retractable by age ten. The other 50% usually become retractable between age ten and the completion of puberty.
So why all the fuss about retraction? Well, many parents fear that if a boy can not retract, he will get infections. This fear probably stems primarily from misinformation given to them by their doctors and their own fears about lack of hygiene. First, parents must know that there is absolutely no need to clean under a boy's foreskin. As mentioned above, the smegma produced by a boy is merely a shedding of dead skin cells. It is not harmful will not harbor bacteria. Trying to clean under a prepubescent boy's foreskin is the equivalent to trying to wash out a girl's vagina. It is entirely unnecessary and, in fact, harmful. Premature retraction introduces harmful pathogens, disturbs the natural flora, creates scar tissue, damages the intricate structures and can lead to long-term complications. Second, parents must know that retraction of the foreskin is not a necessary function in boyhood. Retraction is specifically designed for sexual relations. The only function a boy's penis needs to perform during childhood is urination. In other words, if a boy can urinate, then his penis is doing exactly what it needs to do.
The Phony Diagnosis:
When a doctor diagnoses a boy with phimosis it is because he/she does not understand the normal development of the prepuce. First, in order to diagnose this condition, the doctor would have had to either try to retract the foreskin or encourage the boy to try to retract his foreskin. This is a huge "no, no" for the reasons described above. Second, there is no expiration date on developing a retractable foreskin. Each boy is individual as to when the separation and widening processes have completed. Just as each girl will begin menstruation in her own time, each boy will experience retraction in his own time. Since hormones play an important role in changing the composition of the tissue of the prepuce, it is not abnormal if the process isn't complete until the finish of puberty. Once an adolescent's foreskin is retractable he can easily retract his foreskin in the shower, rinse with water, and replace his foreskin over the glans. Most men do this naturally during normal manipulation of their genitals while showering. In the case that a boy becomes retractable before puberty, there is no need for him to rinse under his foreskin, unless he so chooses. In the case that an adolescent is not retractable, there is still no need to worry about cleaning under the foreskin. Remember, it is not abnormal for retraction to take until the end of puberty.
True Phimosis:
True phimosis is when a post-pubescent man is unable to retract his foreskin or becomes unable to retract his foreskin and he feels discomfort during sexual activity. A small percentage of men (and women) have prepuces that never retract. This can be a normal variation, so long as it does not impede sexual activity. If it does impede sexual activity then a man should seek conservative treatment. 90% of men with this rare condition can correct the problem with the application of a steroidal cream and stretching exercises. The steroidal cream mimics the effects of puberty hormones and allows the skin to become more elastic. A man usually applies the cream several times a day and uses manual stretching exercises while he showers. Men should be wary of any doctor who recommends circumcision prior to trying a more conservative treatment.
Confused/Ignorant Doctors:
So why are most our nations doctors confused or ignorant as to the normal development of the prepuce? This question has a few answers. First, if we look at the AAP (American Academy of Pediatrics) recommendations, it wasn't until the 1990s that the AAP finally warned against the harms of forcible retraction and outlined the development of the foreskin in the intact boy. Prior to this AAP's warning, it was widely believed that parents needed to retract their intact sons for 'cleaning'. As you can imagine, this lead to many complications for intact boys and resulted in many otherwise unnecessary circumcisions. Second, there was a preliminary study of about 300 boys to determine the average age of the development of a retractable foreskin. This study concluded that most boys will become retractable by age three. This out-dated study set an expiration date in the minds of the medical professionals. A follow up study of thousands of boys concluded that, in fact, only 50% of boys are retractable by age ten. Many doctors, unaware of the most recent study, still operate under the misinformation of the preliminary study. Third, the development of the prepuce is not taught in medical schools. There is no discussion of how the prepuce is structured, how it changes throughout childhood and its protective and sensory functions. Essentially, the only thing medical students learn is how to amputate the foreskin. Some medical students may learn about the condition of phimosis but they are not informed that this only applies to adult men, as children's foreskins are designed to be tight. Fact is, the US medical profession has cut off so many foreskins over the past century that the doctors rarely if ever saw an intact boy and have lost the base of knowledge of diagnosis and treatment. Now, professionals are operating in a vacuum of information or even worse, in an environment of false information. As the nation's circumcision rates have fallen dramatically, intact boys everywhere are suffering the consequences of a widely foreskin-ignorant medical profession. Each year thousands of intact boys between ages two and up are circumcised unnecessarily at the hands of misinformed care providers. Educating parents, doctors and future doctors is an essential step to correcting this problem.
If you would like more information about this topic, please review the following resources.
AAP Guidelines For the Care and Development of the Intact Male
Development of a Retractable Foreskin in a Child/Adolescent
Avoiding Circumcision after the Neonatal Period
Dangers of Forcible Retraction
Protect Your Intact Son, Expert Medical Advice
Answers to Your Questions About Your Intact Son
Also by Jennifer Coias:
The Nuts and Bolts of HIV in the U.S.A. and Why Circumcision Won't Protect Men
Learn more:
Intact Care Resource Page
~~~~
Swimming, Suits & Mesh: Cut the Lining of Your Child's Suit to Decrease Irritation Potential
By Danelle Day, PhD © 2010
Originally published in Tidewater Parent Magazine
Summer is here! And with the warm and sunny days come trips to the local swimming pool, beach and lake. Every year at this time something surprising happens to many little tykes sporting their new swimsuit -- it's something that no one talks about, and often leaves parents perplexed as to what is really going on. It is what I lightheartedly call the "mesh monster" in our child care classes. That is, the mesh lining in many swimsuits or boys swimwear is simply not a good match for the developing genitals of babies and children, and the results are something we see each year, especially among boys.
For boys who are no longer intact (i.e. they were circumcised), the extra sensitive glans (head) of the penis is left exposed, as is the meatus and opening to the urinary tract. The friction of a mesh liner can quickly exacerbate irritation, inflammation, callusing, chaffing, soreness, and may even cause blistering. In addition, the mesh assists in holding sand, salt, algae, and the bacteria that comes with these water-elements close to the genitals - further increasing chance of irritation or infection - not a good thing when striving to avoid UTIs (urinary tract infection) and other discomforts that can occur, especially in early childhood.
For boys who remain intact, the glans and meatus are protected (one function the foreskin serves) but the mesh liner of many suits is just big enough to allow for a trapping of the prepuce (foreskin). Ouch! The same also occurs with many girls (and adult women) each year if their suit or underwear is not made of solid, 'closed' material - the labia, and even external parts of the clitoris, may become pinched in mesh of any kind. Most cases of skin entrapment go unreported, but in 2006, the journal of Pediatric Emergency Care reported on three such cases when children ended up in the ER with penile injuries due to their prepuce becoming pinched in the mesh lining of their swimsuits.
No matter a child's sex, keeping wetness, sand/salt/debris from the ocean or lake, or chemicals of a pool close to the genitals is not a good idea. It throws off the delicate balance of pH and healthy microflora, increases irritation, and is cause of countless "redness" reports each year (commonly diagnosed as 'balanitis' at a physician's office). For this reason, do not have your child swim in underwear or items that don't allow for quick drying and 'breathing.' Use real swimsuits (or cloth diapers without inserts) made of fabric that wicks away and dries quickly. And when prepping this year's suits, cut the mesh liner from the suit before use. This is quick and simple to do - grab a scissors and carefully cut along the stitched-in ridge at the top of the suit. Your child will thank you, and you'll have less redness, irritation, and potential skin entrapment to deal with.
If redness does occur: coconut oil and Calmoseptine are two quality items that will not increase risk of yeast overgrowth, or further throw off pH and microflora balance of the genitals. Coconut oil alone (with some air dry time and warm water only baths) will be enough to soothe inflammation in some cases. If not, Calmoseptine will take care of everything, quickly. You can purchase at tube upon request at your local pharmacy. Always be sure to rinse with clean, fresh water post-swimming.
To prevent redness that repeats itself: apply Calmoseptine ahead of time to 'at risk' areas of the body. This is typically especially the case where swimsuit material (or a diaper, underwear) rubs on or touches the body. The Calmoseptine will serve as a barrier cream and reduce the irritation during swimming summer days. Again, be sure to rinse briefly with clean water after swimming in a pool, lake or the ocean.
If skin entrapment in a liner that was left in place occurs: GENTLY, slowly, and carefully apply vaseline or another slippery ointment if you have some nearby; stretch or tear the mesh with a tweezers or your fingers, if you are able, and/or use a scissors to cut the mesh away from the body, using extreme caution not to cut the ultra sensitive tissues of the genitals. Sliding into luke-warm water will also allow for relaxation, and a change in blood flow - potentially loosening the mesh grip on tissues as well. Post-freeing, apply Calmoseptine and/or take a soak in warm water (with Epsom salt if desired) to reduce inflammation and support the body in healing itself.
Originally published in Tidewater Parent Magazine
Summer is here! And with the warm and sunny days come trips to the local swimming pool, beach and lake. Every year at this time something surprising happens to many little tykes sporting their new swimsuit -- it's something that no one talks about, and often leaves parents perplexed as to what is really going on. It is what I lightheartedly call the "mesh monster" in our child care classes. That is, the mesh lining in many swimsuits or boys swimwear is simply not a good match for the developing genitals of babies and children, and the results are something we see each year, especially among boys.
For boys who are no longer intact (i.e. they were circumcised), the extra sensitive glans (head) of the penis is left exposed, as is the meatus and opening to the urinary tract. The friction of a mesh liner can quickly exacerbate irritation, inflammation, callusing, chaffing, soreness, and may even cause blistering. In addition, the mesh assists in holding sand, salt, algae, and the bacteria that comes with these water-elements close to the genitals - further increasing chance of irritation or infection - not a good thing when striving to avoid UTIs (urinary tract infection) and other discomforts that can occur, especially in early childhood.
For boys who remain intact, the glans and meatus are protected (one function the foreskin serves) but the mesh liner of many suits is just big enough to allow for a trapping of the prepuce (foreskin). Ouch! The same also occurs with many girls (and adult women) each year if their suit or underwear is not made of solid, 'closed' material - the labia, and even external parts of the clitoris, may become pinched in mesh of any kind. Most cases of skin entrapment go unreported, but in 2006, the journal of Pediatric Emergency Care reported on three such cases when children ended up in the ER with penile injuries due to their prepuce becoming pinched in the mesh lining of their swimsuits.
No matter a child's sex, keeping wetness, sand/salt/debris from the ocean or lake, or chemicals of a pool close to the genitals is not a good idea. It throws off the delicate balance of pH and healthy microflora, increases irritation, and is cause of countless "redness" reports each year (commonly diagnosed as 'balanitis' at a physician's office). For this reason, do not have your child swim in underwear or items that don't allow for quick drying and 'breathing.' Use real swimsuits (or cloth diapers without inserts) made of fabric that wicks away and dries quickly. And when prepping this year's suits, cut the mesh liner from the suit before use. This is quick and simple to do - grab a scissors and carefully cut along the stitched-in ridge at the top of the suit. Your child will thank you, and you'll have less redness, irritation, and potential skin entrapment to deal with.
If redness does occur: coconut oil and Calmoseptine are two quality items that will not increase risk of yeast overgrowth, or further throw off pH and microflora balance of the genitals. Coconut oil alone (with some air dry time and warm water only baths) will be enough to soothe inflammation in some cases. If not, Calmoseptine will take care of everything, quickly. You can purchase at tube upon request at your local pharmacy. Always be sure to rinse with clean, fresh water post-swimming.
To prevent redness that repeats itself: apply Calmoseptine ahead of time to 'at risk' areas of the body. This is typically especially the case where swimsuit material (or a diaper, underwear) rubs on or touches the body. The Calmoseptine will serve as a barrier cream and reduce the irritation during swimming summer days. Again, be sure to rinse briefly with clean water after swimming in a pool, lake or the ocean.
If skin entrapment in a liner that was left in place occurs: GENTLY, slowly, and carefully apply vaseline or another slippery ointment if you have some nearby; stretch or tear the mesh with a tweezers or your fingers, if you are able, and/or use a scissors to cut the mesh away from the body, using extreme caution not to cut the ultra sensitive tissues of the genitals. Sliding into luke-warm water will also allow for relaxation, and a change in blood flow - potentially loosening the mesh grip on tissues as well. Post-freeing, apply Calmoseptine and/or take a soak in warm water (with Epsom salt if desired) to reduce inflammation and support the body in healing itself.
Related reading at the Intact Care Resource Page
Public Service Announcement by Intact Indiana
Public Service Announcement by Intact Utah
Public Service Announcement by Intact Asheville
~~~~
Catheterization Without Retraction
By Adrienne Carmack, M.D. board-certified urologist, in practice in Texas, and author of The Good Mommy's Guide to Her Little Boy's Penis and Marilyn Fayre Milos, R.N. Executive Director of Genital Autonomy America, California.
Catheterization Without Retraction
Canadian Family Physician. 2017 Mar; 63(3): 218–220.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5349724/
Over the past century, numerous boys born in Canada and the United States have been circumcised. (1) However, this trend is changing, with neonatal circumcision being performed less commonly than in years past. (2,3) Because of these historical practices, many physicians and nurses have limited experience treating patients with intact foreskins and engage in ill-advised procedures such as premature foreskin retraction for purposes of “hygiene” or catheterization. Premature retraction of the foreskin can lead to tearing of healthy tissue, which is painful and increases the risk of preputial scarring and infection. (4–6) We describe a method for catheterization in which premature retraction of the foreskin is not necessary.
Technique
The foreskin should first be gently manipulated to determine if the meatus can be easily visualized. Pressure used for this should be gentle to avoid tearing of tissues, similar to the amount of pressure that would be used when spreading the labia to visualize the meatus of a girl. If the natural attachments of the foreskin to the glans (head of the penis) remain, the foreskin should not be forced back to expose the meatus.
If the foreskin can be gently moved such that the glans and meatus can be seen, catheterization can be performed under direct vision using a sterile technique. The foreskin should never be retracted past the point where it has already naturally separated. (7)
If the meatus cannot be seen, the genitals can be prepared and draped in a sterile manner without retraction. The catheter can then be lubricated and gently inserted through the foreskin opening and guided into the meatus, much like an intravenous catheter is guided into a vein by feel. Gentle pressure with the thumb along the dorsal aspect and the fingers along the ventral surface of the penis can keep the catheter from slipping between the glans and inner lining of the foreskin into the preputial space (Figure 1).
When catheterization is being performed for the purpose of collecting a urine specimen, the foreskin should also not be forcibly retracted. In both boys with an intact prepuce and girls, the initial urine obtained during catheterization should be discarded, as this will contain preputial and periurethral flora. The latter urine should be saved for culture. (8)
Discussion
An understanding of the normal anatomy and development of the foreskin illustrates why the technique of catheterization without retraction is an important skill for health care practitioners. Physiologic phimosis is the normal state of young boys. (9) This finding is characterized by a closed preputial outlet with the inner mucosa of the foreskin beginning to evert through the preputial opening, which is healthy with no scarring. The glans cannot be seen without retraction. This is in contrast to pathologic phimosis, in which the glans and meatus can often be seen, as the scarred ring of the preputial orifice is held open and no mucosa is visible at the preputial outlet. (10)
In a Danish study, 8% of healthy boys aged 6 to 7 still had complete physiologic phimosis preventing visualization of the meatus, and only 23% of boys this age had fully retractable foreskins. (11) In a Japanese study, 84.3% of boys aged 6 months to 1 year had a tight ring preventing any retraction, and this decreased gradually with time to 40% at ages 1 to 2 years, 28% at ages 3 to 4 years, 20% at ages 5 to 7 years, 16% at ages 8 to 10 years, and 8.6% at ages 11 to 15 years. (12)
The term phimosis is Greek and means “a muzzling.” Physiologic phimosis simply means the foreskin cannot be retracted and the glans is “muzzled.” Ballooning during urination is a common finding and part of the normal developmental process of foreskin separation. (10) It occurs because the opening of the immature foreskin is not yet lax enough to accommodate a full urine stream or passage of the glans through it. The foreskin and glans separate naturally as the child develops, has erections, and manipulates his foreskin. When a young boy manipulates his foreskin naturally, he tends to pull his foreskin away from his body, not toward it, as is done with retraction. As he gets older and more curious, he begins to pull his foreskin toward his body as well. (10) In most boys, physiologic phimosis resolves naturally by the end of puberty. (11)
The foreskin and glans are connected by the balanopreputial lamina, a membrane similar to the synechial membrane that connects the nail bed and the fingernail. The balanopreputial lamina is sometimes called the synechia. This membrane and the small preputial opening prevent retraction in boys with normal physiologic phimosis. The attachment might be forcefully disrupted, just as the fingernail can be torn from the nail bed, but this causes pain, is unnecessary, and can lead to infection, scarring, adhesion formation, or iatrogenic phimosis. There is no functional need for the glans to be exposed, and there is a protective effect of having the foreskin attached to and covering the glans.
Because the foreskin protects the glans penis and urethral meatus, premature exposure of the glans, as occurs after circumcision, commonly leads to meatal stenosis, in which a substantial part of the circulatory system in the glans penis is damaged (the frenular artery), and the glans tissue is exposed, denuded, and inflamed, which can lead to ulceration and subsequent scarring of the urethral opening. This inflammation and ulceration are caused by disruption of the normal attachment between the glans and foreskin, the absence of the protective foreskin, interruption in the normal circulatory system, or blisters from ammonia burns. (13–15) The blisters and ulceration at the opening of the urethra are caused by contact of urine-soaked diapers with the urethral meatus, which is no longer protected by the foreskin.
Retracting the foreskin of a prepubescent boy with physiologic phimosis, although still a common recommendation by many health care practitioners, has been shown to increase problems such as scarring and infection. These might result in iatrogenic pathologic phimosis and lead to a higher likelihood of circumcision being performed at a later date. (16) If the prepuce is unable to retract, there is nothing to clean under. The foreskin should not be retracted for cleaning until the foreskin has naturally separated and the child can do this himself. In fact, the owner of the foreskin should be the first person to retract his foreskin. Forceful retraction causes microtears that can lead to pathologic phimosis. (10)
An additional danger of premature retraction is paraphimosis, a condition in which the retracted foreskin becomes stuck behind the glans penis, cutting off circulation and leading to ischemia and possibly penile gangrene if not treated promptly. Retracting the foreskin and cleansing with soap, commonly believed to be important for proper hygiene, not only exposes the child to the risks of premature foreskin retraction, but also to the risks of infection such as balanitis, which has been shown to be associated with the use of soap on the delicate mucosal tissues of the male genitalia. (17) Soap dries out mucosal tissue and should never be used on the glans or inner foreskin. The foreskin should be left alone until it demonstrates the ability to retract. (10) Once this is possible, foreskin care is simple: retract (gently and only to the extent possible), rinse, replace. Warm water and fingertips adequately clean the tissue.
Besides false beliefs about hygiene, one of the main reasons boys are subject to premature foreskin retraction is that many health care professionals believe that the foreskin must be retracted to obtain a clean specimen for urine culture. Fortunately, this is not the case. With proper technique, as described above, urine specimens can be obtained from boys with intact foreskins without exposing these patients to the risks of premature foreskin retraction. Although the focus of this article is on a technique for catheterization, it must be remembered that catheterization is an intervention that carries risks. The risks of catheterization include discomfort and introduction of bacteria into the urinary tract, which could lead to infection. Indications for catheterization include the need to monitor urine output for medical management, emptying the bladder in patients who are unable to do so, introducing contrast material for imaging procedures such as a voiding cystourethrogram, and obtaining a urine specimen for analysis in patients who are unable to provide one.
If a patient can reliably void into a collection container, catheterization for monitoring urine output can be avoided. Patients who cannot empty their bladders have the options of clean intermittent catheterization, indwelling urethral catheterization, and suprapubic catheter placement. Other options for collection of a urine specimen for analysis and culture include a midstream voided sample and suprapubic aspiration, and these should be considered when determining the optimal approach for specimen collection.8 Suprapubic aspiration is significantly more painful than urethral catheterization in premature male infants (P < .001). (18) Contamination is possible with catheterized samples as it is with voided samples.19 This suggests that catheterization for urine specimen culture should be reserved for those patients who are unable to provide a voided specimen into a clean container, and suprapubic catheterization should only be used if previous efforts to obtain a specimen have resulted in contamination.
Conclusion
In boys with intact prepuces and physiologic phimosis, catheterization without retraction minimizes potential long-term problems and is an effective technique. Understanding how to catheterize without direct vision of the meatus and discarding the initial urine if culture is desired allow this procedure to be performed with high validity and minimal risk of iatrogenic problems for the child.
References
1. Weiss H, Polonsky J, Bailey R, Hankins C, Halperin D, Schmid G. Male circumcision. Global trends and determinants of prevalence, safety and acceptability. Geneva, Switz: World Health Organization, Joint United Nations Programme on HIV/AIDS; 2007.
2. Maeda JL, Chari R, Elixhauser A. Circumcisions performed in U.S. community hospitals, 2009. Rockville, MD: Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality; 2012. Available from: www.hcup-us.ahrq.gov/reports/statbriefs/sb126.jsp. Accessed 2015 Jun 15.
3. Fetus and Newborn Committee, Canadian Paediatric Society Neonatal circumcision revisited. CMAJ. 1996;154(6):769–80. [PMC free article] [PubMed]
4. Kaplan GW, McAleer . Structural abnormalities of the genitourinary tract. In: Mac-Donald MG, Mullett MD, Seshia MMK, editors. Avery’s neonatology. Pathophysiology and management of the newborn. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005. p. 1088.
5. Roberton NRC. Care of the normal term newborn baby. In: Rennie JM, Roberton NRC, editors. Textbook of neonatology. 3rd ed. Edinburgh, UK: Churchill Livingstone; 1999. pp. 378–9.
6. American Academy of Pediatrics . Newborns: care of the uncircumcised penis. Guidelines for parents [pamphlet] Elk Grove Village, IL: American Academy of Pediatrics; 1984.
7. Lacroix LE, Vunda A, Bajwa NM, Galetto-Lacour A, Gervaix A. Catheterization of the urethra in male children [video] N Engl J Med. 2010;363(14):e19. [PubMed]
8. Schaeffer AJ, Schaeffer EM. Infections of the urinary tract. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell-Walshurology. 9th ed. Philadelphia, PA: Saunders-Elsevier; 2007. pp. 238–9.
9. Smeulders N, Wilcox DT. Urology. Disorders of the kidney and urinary tract. In: Rennie J, editor. Rennie & Roberton’s textbook of neonatology. 5th ed. London, UK: Churchill Livingstone–Elsevier; 2012. p. 949.
10. McGregor TB, Pike JG, Leonard MP. Pathologic and physiologic phimosis. Approach to the phimotic foreskin. Can Fam Physician. 2007;53:445–8. [PMC free article] [PubMed]
11. Oster J. Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child. 1968;43(228):200–3. [PMC free article] [PubMed]
12. Kayaba H, Tamura H, Kitajima S, Fujiwara Y, Kato T, Kato T. Analysis of shape and retractability of the prepuce in 603 Japanese boys. J Urol. 1996;156(5):1813–5. [PubMed]
13. Canning DA, Nguyen MT. Evaluation of the pediatric urology patient. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell-Walsh urology. 9th ed. Philadelphia, PA: Saunders-Elsevier; 2007. p. 3215.
14. Elder JS. Abnormalities of the genitalia in boys and their surgical management. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell-Walsh urology. 9th ed. Philadelphia, PA: Saunders-Elsevier; 2007. p. 3749.
15. McGrath K. The frenular delta. A new preputial structure. In: Denniston GC, Hodges FM, Milos MF, editors. Understanding circumcision. A multi-disciplinary approach to a multidimensional problem. New York, NY: Springer; 2001. pp. 199–206.
16. Metcalfe PD, Elyas R. Foreskin management. Survey of Canadian pediatric urologists. Can Fam Physician. 2010;56:e290–5. Available from: www.cfp.ca/content/56/8/e290.full.pdf+html. Accessed 2017 Feb 2. [PMC free article] [PubMed]
17. Birley HD, Walker MM, Luzzi GA, Bell R, Taylor-Robinson D, Byrne M, et al. Clinical features and management of recurrent balanitis; association with atopy and genital washing. Genitourin Med. 1993;69(5):400–3. [PMC free article] [PubMed]
18. Badiee Z, Sadeghnia A, Zarean N. Suprapubic bladder aspiration or urethral catheterization: which is more painful in uncircumcised male newborns? Int J Prev Med. 2014;5(9):1125–30. [PMC free article] [PubMed]
19. Lau AY, Wong SN, Yip KT, Fong KW, Li SP, Que TL. A comparative study on bacterial cultures of urine samples obtained by clean-void technique versus urethral catheterization. Acta Paediatr. 2007;96(3):432–6. [PubMed]
Related Reading
Urine Samples and Catheter Insertion for Intact Boys: http://www.drmomma.org/2011/12/urine-samples-and-catheter-insertion.html
Using a Catheter Without Retraction: My Nurse Did It, and So Can Yours! http://www.savingsons.org/2013/01/using-catheter-without-retraction-my.html
How the Foreskin Protects Against UTIs: http://www.drmomma.org/2009/12/how-foreskin-protects-against-uti.html
UTI and Circumcision Resources: http://www.savingsons.org/2014/11/uti-resource-page.html
Catheterization Without Retraction
Canadian Family Physician. 2017 Mar; 63(3): 218–220.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5349724/
Over the past century, numerous boys born in Canada and the United States have been circumcised. (1) However, this trend is changing, with neonatal circumcision being performed less commonly than in years past. (2,3) Because of these historical practices, many physicians and nurses have limited experience treating patients with intact foreskins and engage in ill-advised procedures such as premature foreskin retraction for purposes of “hygiene” or catheterization. Premature retraction of the foreskin can lead to tearing of healthy tissue, which is painful and increases the risk of preputial scarring and infection. (4–6) We describe a method for catheterization in which premature retraction of the foreskin is not necessary.
Technique
The foreskin should first be gently manipulated to determine if the meatus can be easily visualized. Pressure used for this should be gentle to avoid tearing of tissues, similar to the amount of pressure that would be used when spreading the labia to visualize the meatus of a girl. If the natural attachments of the foreskin to the glans (head of the penis) remain, the foreskin should not be forced back to expose the meatus.
If the foreskin can be gently moved such that the glans and meatus can be seen, catheterization can be performed under direct vision using a sterile technique. The foreskin should never be retracted past the point where it has already naturally separated. (7)
If the meatus cannot be seen, the genitals can be prepared and draped in a sterile manner without retraction. The catheter can then be lubricated and gently inserted through the foreskin opening and guided into the meatus, much like an intravenous catheter is guided into a vein by feel. Gentle pressure with the thumb along the dorsal aspect and the fingers along the ventral surface of the penis can keep the catheter from slipping between the glans and inner lining of the foreskin into the preputial space (Figure 1).
When catheterization is being performed for the purpose of collecting a urine specimen, the foreskin should also not be forcibly retracted. In both boys with an intact prepuce and girls, the initial urine obtained during catheterization should be discarded, as this will contain preputial and periurethral flora. The latter urine should be saved for culture. (8)
An understanding of the normal anatomy and development of the foreskin illustrates why the technique of catheterization without retraction is an important skill for health care practitioners. Physiologic phimosis is the normal state of young boys. (9) This finding is characterized by a closed preputial outlet with the inner mucosa of the foreskin beginning to evert through the preputial opening, which is healthy with no scarring. The glans cannot be seen without retraction. This is in contrast to pathologic phimosis, in which the glans and meatus can often be seen, as the scarred ring of the preputial orifice is held open and no mucosa is visible at the preputial outlet. (10)
In a Danish study, 8% of healthy boys aged 6 to 7 still had complete physiologic phimosis preventing visualization of the meatus, and only 23% of boys this age had fully retractable foreskins. (11) In a Japanese study, 84.3% of boys aged 6 months to 1 year had a tight ring preventing any retraction, and this decreased gradually with time to 40% at ages 1 to 2 years, 28% at ages 3 to 4 years, 20% at ages 5 to 7 years, 16% at ages 8 to 10 years, and 8.6% at ages 11 to 15 years. (12)
The term phimosis is Greek and means “a muzzling.” Physiologic phimosis simply means the foreskin cannot be retracted and the glans is “muzzled.” Ballooning during urination is a common finding and part of the normal developmental process of foreskin separation. (10) It occurs because the opening of the immature foreskin is not yet lax enough to accommodate a full urine stream or passage of the glans through it. The foreskin and glans separate naturally as the child develops, has erections, and manipulates his foreskin. When a young boy manipulates his foreskin naturally, he tends to pull his foreskin away from his body, not toward it, as is done with retraction. As he gets older and more curious, he begins to pull his foreskin toward his body as well. (10) In most boys, physiologic phimosis resolves naturally by the end of puberty. (11)
The foreskin and glans are connected by the balanopreputial lamina, a membrane similar to the synechial membrane that connects the nail bed and the fingernail. The balanopreputial lamina is sometimes called the synechia. This membrane and the small preputial opening prevent retraction in boys with normal physiologic phimosis. The attachment might be forcefully disrupted, just as the fingernail can be torn from the nail bed, but this causes pain, is unnecessary, and can lead to infection, scarring, adhesion formation, or iatrogenic phimosis. There is no functional need for the glans to be exposed, and there is a protective effect of having the foreskin attached to and covering the glans.
Because the foreskin protects the glans penis and urethral meatus, premature exposure of the glans, as occurs after circumcision, commonly leads to meatal stenosis, in which a substantial part of the circulatory system in the glans penis is damaged (the frenular artery), and the glans tissue is exposed, denuded, and inflamed, which can lead to ulceration and subsequent scarring of the urethral opening. This inflammation and ulceration are caused by disruption of the normal attachment between the glans and foreskin, the absence of the protective foreskin, interruption in the normal circulatory system, or blisters from ammonia burns. (13–15) The blisters and ulceration at the opening of the urethra are caused by contact of urine-soaked diapers with the urethral meatus, which is no longer protected by the foreskin.
Retracting the foreskin of a prepubescent boy with physiologic phimosis, although still a common recommendation by many health care practitioners, has been shown to increase problems such as scarring and infection. These might result in iatrogenic pathologic phimosis and lead to a higher likelihood of circumcision being performed at a later date. (16) If the prepuce is unable to retract, there is nothing to clean under. The foreskin should not be retracted for cleaning until the foreskin has naturally separated and the child can do this himself. In fact, the owner of the foreskin should be the first person to retract his foreskin. Forceful retraction causes microtears that can lead to pathologic phimosis. (10)
An additional danger of premature retraction is paraphimosis, a condition in which the retracted foreskin becomes stuck behind the glans penis, cutting off circulation and leading to ischemia and possibly penile gangrene if not treated promptly. Retracting the foreskin and cleansing with soap, commonly believed to be important for proper hygiene, not only exposes the child to the risks of premature foreskin retraction, but also to the risks of infection such as balanitis, which has been shown to be associated with the use of soap on the delicate mucosal tissues of the male genitalia. (17) Soap dries out mucosal tissue and should never be used on the glans or inner foreskin. The foreskin should be left alone until it demonstrates the ability to retract. (10) Once this is possible, foreskin care is simple: retract (gently and only to the extent possible), rinse, replace. Warm water and fingertips adequately clean the tissue.
Besides false beliefs about hygiene, one of the main reasons boys are subject to premature foreskin retraction is that many health care professionals believe that the foreskin must be retracted to obtain a clean specimen for urine culture. Fortunately, this is not the case. With proper technique, as described above, urine specimens can be obtained from boys with intact foreskins without exposing these patients to the risks of premature foreskin retraction. Although the focus of this article is on a technique for catheterization, it must be remembered that catheterization is an intervention that carries risks. The risks of catheterization include discomfort and introduction of bacteria into the urinary tract, which could lead to infection. Indications for catheterization include the need to monitor urine output for medical management, emptying the bladder in patients who are unable to do so, introducing contrast material for imaging procedures such as a voiding cystourethrogram, and obtaining a urine specimen for analysis in patients who are unable to provide one.
If a patient can reliably void into a collection container, catheterization for monitoring urine output can be avoided. Patients who cannot empty their bladders have the options of clean intermittent catheterization, indwelling urethral catheterization, and suprapubic catheter placement. Other options for collection of a urine specimen for analysis and culture include a midstream voided sample and suprapubic aspiration, and these should be considered when determining the optimal approach for specimen collection.8 Suprapubic aspiration is significantly more painful than urethral catheterization in premature male infants (P < .001). (18) Contamination is possible with catheterized samples as it is with voided samples.19 This suggests that catheterization for urine specimen culture should be reserved for those patients who are unable to provide a voided specimen into a clean container, and suprapubic catheterization should only be used if previous efforts to obtain a specimen have resulted in contamination.
Conclusion
In boys with intact prepuces and physiologic phimosis, catheterization without retraction minimizes potential long-term problems and is an effective technique. Understanding how to catheterize without direct vision of the meatus and discarding the initial urine if culture is desired allow this procedure to be performed with high validity and minimal risk of iatrogenic problems for the child.
References
1. Weiss H, Polonsky J, Bailey R, Hankins C, Halperin D, Schmid G. Male circumcision. Global trends and determinants of prevalence, safety and acceptability. Geneva, Switz: World Health Organization, Joint United Nations Programme on HIV/AIDS; 2007.
2. Maeda JL, Chari R, Elixhauser A. Circumcisions performed in U.S. community hospitals, 2009. Rockville, MD: Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality; 2012. Available from: www.hcup-us.ahrq.gov/reports/statbriefs/sb126.jsp. Accessed 2015 Jun 15.
3. Fetus and Newborn Committee, Canadian Paediatric Society Neonatal circumcision revisited. CMAJ. 1996;154(6):769–80. [PMC free article] [PubMed]
4. Kaplan GW, McAleer . Structural abnormalities of the genitourinary tract. In: Mac-Donald MG, Mullett MD, Seshia MMK, editors. Avery’s neonatology. Pathophysiology and management of the newborn. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005. p. 1088.
5. Roberton NRC. Care of the normal term newborn baby. In: Rennie JM, Roberton NRC, editors. Textbook of neonatology. 3rd ed. Edinburgh, UK: Churchill Livingstone; 1999. pp. 378–9.
6. American Academy of Pediatrics . Newborns: care of the uncircumcised penis. Guidelines for parents [pamphlet] Elk Grove Village, IL: American Academy of Pediatrics; 1984.
7. Lacroix LE, Vunda A, Bajwa NM, Galetto-Lacour A, Gervaix A. Catheterization of the urethra in male children [video] N Engl J Med. 2010;363(14):e19. [PubMed]
8. Schaeffer AJ, Schaeffer EM. Infections of the urinary tract. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell-Walshurology. 9th ed. Philadelphia, PA: Saunders-Elsevier; 2007. pp. 238–9.
9. Smeulders N, Wilcox DT. Urology. Disorders of the kidney and urinary tract. In: Rennie J, editor. Rennie & Roberton’s textbook of neonatology. 5th ed. London, UK: Churchill Livingstone–Elsevier; 2012. p. 949.
10. McGregor TB, Pike JG, Leonard MP. Pathologic and physiologic phimosis. Approach to the phimotic foreskin. Can Fam Physician. 2007;53:445–8. [PMC free article] [PubMed]
11. Oster J. Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child. 1968;43(228):200–3. [PMC free article] [PubMed]
12. Kayaba H, Tamura H, Kitajima S, Fujiwara Y, Kato T, Kato T. Analysis of shape and retractability of the prepuce in 603 Japanese boys. J Urol. 1996;156(5):1813–5. [PubMed]
13. Canning DA, Nguyen MT. Evaluation of the pediatric urology patient. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell-Walsh urology. 9th ed. Philadelphia, PA: Saunders-Elsevier; 2007. p. 3215.
14. Elder JS. Abnormalities of the genitalia in boys and their surgical management. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell-Walsh urology. 9th ed. Philadelphia, PA: Saunders-Elsevier; 2007. p. 3749.
15. McGrath K. The frenular delta. A new preputial structure. In: Denniston GC, Hodges FM, Milos MF, editors. Understanding circumcision. A multi-disciplinary approach to a multidimensional problem. New York, NY: Springer; 2001. pp. 199–206.
16. Metcalfe PD, Elyas R. Foreskin management. Survey of Canadian pediatric urologists. Can Fam Physician. 2010;56:e290–5. Available from: www.cfp.ca/content/56/8/e290.full.pdf+html. Accessed 2017 Feb 2. [PMC free article] [PubMed]
17. Birley HD, Walker MM, Luzzi GA, Bell R, Taylor-Robinson D, Byrne M, et al. Clinical features and management of recurrent balanitis; association with atopy and genital washing. Genitourin Med. 1993;69(5):400–3. [PMC free article] [PubMed]
18. Badiee Z, Sadeghnia A, Zarean N. Suprapubic bladder aspiration or urethral catheterization: which is more painful in uncircumcised male newborns? Int J Prev Med. 2014;5(9):1125–30. [PMC free article] [PubMed]
19. Lau AY, Wong SN, Yip KT, Fong KW, Li SP, Que TL. A comparative study on bacterial cultures of urine samples obtained by clean-void technique versus urethral catheterization. Acta Paediatr. 2007;96(3):432–6. [PubMed]
Related Reading
Urine Samples and Catheter Insertion for Intact Boys: http://www.drmomma.org/2011/12/urine-samples-and-catheter-insertion.html
Using a Catheter Without Retraction: My Nurse Did It, and So Can Yours! http://www.savingsons.org/2013/01/using-catheter-without-retraction-my.html
How the Foreskin Protects Against UTIs: http://www.drmomma.org/2009/12/how-foreskin-protects-against-uti.html
UTI and Circumcision Resources: http://www.savingsons.org/2014/11/uti-resource-page.html
Deep, dark, red, purple, or blue: the normal glans in the intact child
By Danelle Day, PhD © 2014
Frequent questions arise when parents accidentally spot the normal penile glans ('head' of the penis) on their intact son when he is exploring his own body, usually as a very young child. This occurs most frequently between the ages of 3-5, and is nothing to be alarmed by. Girls and boys will both explore their genitals, and while it is a good idea to have clean hands, or do so in the bath to reduce bacteria/viruses present on the hands, there is nothing wrong with retraction, poking, probing, pulling, by a child him/herself.
However, we've been conditioned culturally in the United States to see anything that is deep, dark, red, purple or blue as potentially problematic - blood, veins, the insides of the body, etc. When this shade represents a normal coloring of a organ or body part, it typically means that this part of the body is meant to be internal for the majority (or all) of its existence. So it is the case with the glans of the penis or clitoris on the human child, and tends to be this deep, dark shade regardless of exterior body skin color.
The prepuce ('foreskin' or 'clitoral hood') is designed as an important protective organ over the glans, keeping it internal, moist, warm, balanced in pH and microflora, and preventing damage to the many sensitive nerve endings and blood vessels just beneath the surface. The deep, dark coloring is thanks to these rich beds of nerves and blood vessels - necessary for normal sexual functioning such as lifelong vascocongestion (the swelling with blood during arousal and for erection) and sensory response (everything from pulling back when something doesn't feel good, to the powerful sensations of orgasm). Both girls and boys have a glans colored in such a way (if they have remained intact from birth). Parents tend to spot the glans more often in their exploring-sons than daughters simply because the glans is much larger on boys. The majority of the penis is outside the body = larger external glans, larger prepuce; the majority of the clitoris is housed inside the body, requiring less external coverage = smaller external glans, smaller prepuce.
It is only when the prepuce is removed from the body (via the genital cutting of circumcision) that the glans must struggle to compensate for its unnatural exposure as a newly external organ (something it was not designed to be). When this occurs, the glans must callus over with skin layers to protect itself - changing the coloring from a deep, dark, red, purple or blue color to a lighter, 'dry' looking shade that typically matches the body's external skin more closely. These protective layers are not a natural, original feature of the human body, and prevent the underlying nerve endings and blood vessels of the glans to function in their normal manner. A change of form, in this case, equals a change in function. Many adult men who had their prepuce forcefully removed as infants, and the glans exposed for a lifetime, may opt for foreskin restoration, which can bring back a portion of the glans' original state.
Parents whose sons and daughters have maintained their full genitalia can rest easy, knowing that this internal glans coloring is normal, natural and healthy. Should irritation, inflammation, or redness occur on the external prepuce during the rough-and-tumble early days of childhood (also common for a baby in diapers or a child who is regularly exploring him/herself), using coconut oil and/or Calmoseptine (which can be requested at any local pharmacy) at the first sign will calm, soothe and allow the prepuce to regulate itself quickly. When applying, it is important to remember to only place ointment on the outside of the genitals. It will work its own way in, and never should there be retraction or manipulation of the foreskin/clitoral hood by anyone other than the child whose body it belongs to.
Frequent questions arise when parents accidentally spot the normal penile glans ('head' of the penis) on their intact son when he is exploring his own body, usually as a very young child. This occurs most frequently between the ages of 3-5, and is nothing to be alarmed by. Girls and boys will both explore their genitals, and while it is a good idea to have clean hands, or do so in the bath to reduce bacteria/viruses present on the hands, there is nothing wrong with retraction, poking, probing, pulling, by a child him/herself.
However, we've been conditioned culturally in the United States to see anything that is deep, dark, red, purple or blue as potentially problematic - blood, veins, the insides of the body, etc. When this shade represents a normal coloring of a organ or body part, it typically means that this part of the body is meant to be internal for the majority (or all) of its existence. So it is the case with the glans of the penis or clitoris on the human child, and tends to be this deep, dark shade regardless of exterior body skin color.
The prepuce ('foreskin' or 'clitoral hood') is designed as an important protective organ over the glans, keeping it internal, moist, warm, balanced in pH and microflora, and preventing damage to the many sensitive nerve endings and blood vessels just beneath the surface. The deep, dark coloring is thanks to these rich beds of nerves and blood vessels - necessary for normal sexual functioning such as lifelong vascocongestion (the swelling with blood during arousal and for erection) and sensory response (everything from pulling back when something doesn't feel good, to the powerful sensations of orgasm). Both girls and boys have a glans colored in such a way (if they have remained intact from birth). Parents tend to spot the glans more often in their exploring-sons than daughters simply because the glans is much larger on boys. The majority of the penis is outside the body = larger external glans, larger prepuce; the majority of the clitoris is housed inside the body, requiring less external coverage = smaller external glans, smaller prepuce.
It is only when the prepuce is removed from the body (via the genital cutting of circumcision) that the glans must struggle to compensate for its unnatural exposure as a newly external organ (something it was not designed to be). When this occurs, the glans must callus over with skin layers to protect itself - changing the coloring from a deep, dark, red, purple or blue color to a lighter, 'dry' looking shade that typically matches the body's external skin more closely. These protective layers are not a natural, original feature of the human body, and prevent the underlying nerve endings and blood vessels of the glans to function in their normal manner. A change of form, in this case, equals a change in function. Many adult men who had their prepuce forcefully removed as infants, and the glans exposed for a lifetime, may opt for foreskin restoration, which can bring back a portion of the glans' original state.
Parents whose sons and daughters have maintained their full genitalia can rest easy, knowing that this internal glans coloring is normal, natural and healthy. Should irritation, inflammation, or redness occur on the external prepuce during the rough-and-tumble early days of childhood (also common for a baby in diapers or a child who is regularly exploring him/herself), using coconut oil and/or Calmoseptine (which can be requested at any local pharmacy) at the first sign will calm, soothe and allow the prepuce to regulate itself quickly. When applying, it is important to remember to only place ointment on the outside of the genitals. It will work its own way in, and never should there be retraction or manipulation of the foreskin/clitoral hood by anyone other than the child whose body it belongs to.
Note: an image of the glans is purposefully not included with this article because to obtain one a child must be forcibly retracted or circumcised,
both of which damage the prepuce and violate a child's genital autonomy.
both of which damage the prepuce and violate a child's genital autonomy.
Further related materials can be found at the Intact Care Resource Page:
http://www.drmomma.org/2009/06/how-to-care-for-intact-penis-protect.html
http://www.drmomma.org/2009/06/how-to-care-for-intact-penis-protect.html
~~~~
Intact Care and No Retraction Agreement
The following intact care agreement was written by Jennifer Gardner and originally appeared at Mothers Against Circumcision. It has been edited slightly for sharing at DrMomma.org, with updates in care (i.e. water only to clean the genitals - no soap), advising physicians and terminology. Gardner shares that she, "Wrote this after my family and I moved from Michigan to Massachusetts. In taking my son to a new pediatrician for his four month check-up, I made the mistake of trusting the doctor to know not to retract the infant foreskin. I was wrong. He did - while I was standing right next to him. I then wrote up this agreement, which has been signed - and adhered to - by our current pediatrician. (It also helps that he's already "foreskin-friendly.") Many other parents of intact boys have since relayed their own stories, requesting a copy of the agreement."
Medical Professionals for Genital Autonomy has also assisted in the creation of a Prevention Pack for Physicians, that can be sent to any physician directly via Etsy.
To:_______________________
Healthcare provider/s of our son
From: ____________________
His Parents
In providing health care for the above named person, I agree to the following:
1. This boy is not circumcised. He was left intact, on purpose, by his parents at birth, who refused the operation at that time, as they feel that it is not a medically indicated procedure for infants. They intend to keep him intact, and are informed on the proper (and wary of the improper) care of the intact penis.
2. The proper care of the intact penis is to "leave it alone" (per Dr. Sears, Dr. Fleiss, Dr. Winckler, the AAP, among others). His parents do not retract his foreskin, as it is unnecessary, and likewise will not allow anyone else to do so either. Only a very small percentage of babies and young children have foreskin that is retractable. In the majority, the foreskin is firmly attached to the glans (head) of the penis in much the same way as the fingernail is attached to the finger, and DOES NOT retract.
Furthermore, any retraction of the foreskin before natural separation has occurred, as early as age three, but as late as early adulthood, can cause irreparable damage through bleeding and the formation of adhesions. The ONLY person who may retract our son's foreskin is our son himself, once natural separation has occurred.
3. There is NO reason whatsoever to touch our son's penis during an exam: Not "to see inside," not "out of curiosity," not "to break adhesions” (the attach points are synechiae, not adhesions), not "to see if the foreskin retracts," not "to clean it," etcetera. I therefore agree that I will not touch this child’s penis for any reason. If I genuinely have a concern about whether his urethral opening is "fine" I will bring this point up to his parents and they can decide if there needs to be anything done. If they do decide that it needs to be looked at, only THEY, not I, will touch his penis.
4. The intact penis needs no special care, such as "irrigation" or "loosening of the foreskin." His parents wipe the OUTSIDE with a wipe at diaper changes, or with warm water at bath time. Any "cleaning" other than the afore-mentioned can cause irritation, infection, and problems down the road. When his foreskin has naturally separated on its own, his parents will inform him of the proper care concerning retraction, and concerning cleaning; (i.e. to retract gently when showering, rinse with warm water, and replace.)
5. As our son's parents, we have written this document as a preventative measure only, in response to a previous negative experience. It is not meant to single out any one person, but is meant to relay our wishes and concerns to all health care providers who see our son.
I have read the above information. I understand what I have read, fully, and agree to what is written herein. I will adhere to the above information, and know that if I do not, it will be seen in the eyes of his parents as purposeful abuse toward our son. If I sign, I will receive a copy of this document. If I do not agree to all that is written here, this child will not be looked after by me for his medical care.
Signed,
__________________________
Medical Professionals for Genital Autonomy has also assisted in the creation of a Prevention Pack for Physicians, that can be sent to any physician directly via Etsy.
Above graphic available as stickers or informational card here.
To:_______________________
Healthcare provider/s of our son
From: ____________________
His Parents
In providing health care for the above named person, I agree to the following:
1. This boy is not circumcised. He was left intact, on purpose, by his parents at birth, who refused the operation at that time, as they feel that it is not a medically indicated procedure for infants. They intend to keep him intact, and are informed on the proper (and wary of the improper) care of the intact penis.
2. The proper care of the intact penis is to "leave it alone" (per Dr. Sears, Dr. Fleiss, Dr. Winckler, the AAP, among others). His parents do not retract his foreskin, as it is unnecessary, and likewise will not allow anyone else to do so either. Only a very small percentage of babies and young children have foreskin that is retractable. In the majority, the foreskin is firmly attached to the glans (head) of the penis in much the same way as the fingernail is attached to the finger, and DOES NOT retract.
Furthermore, any retraction of the foreskin before natural separation has occurred, as early as age three, but as late as early adulthood, can cause irreparable damage through bleeding and the formation of adhesions. The ONLY person who may retract our son's foreskin is our son himself, once natural separation has occurred.
3. There is NO reason whatsoever to touch our son's penis during an exam: Not "to see inside," not "out of curiosity," not "to break adhesions” (the attach points are synechiae, not adhesions), not "to see if the foreskin retracts," not "to clean it," etcetera. I therefore agree that I will not touch this child’s penis for any reason. If I genuinely have a concern about whether his urethral opening is "fine" I will bring this point up to his parents and they can decide if there needs to be anything done. If they do decide that it needs to be looked at, only THEY, not I, will touch his penis.
4. The intact penis needs no special care, such as "irrigation" or "loosening of the foreskin." His parents wipe the OUTSIDE with a wipe at diaper changes, or with warm water at bath time. Any "cleaning" other than the afore-mentioned can cause irritation, infection, and problems down the road. When his foreskin has naturally separated on its own, his parents will inform him of the proper care concerning retraction, and concerning cleaning; (i.e. to retract gently when showering, rinse with warm water, and replace.)
5. As our son's parents, we have written this document as a preventative measure only, in response to a previous negative experience. It is not meant to single out any one person, but is meant to relay our wishes and concerns to all health care providers who see our son.
I have read the above information. I understand what I have read, fully, and agree to what is written herein. I will adhere to the above information, and know that if I do not, it will be seen in the eyes of his parents as purposeful abuse toward our son. If I sign, I will receive a copy of this document. If I do not agree to all that is written here, this child will not be looked after by me for his medical care.
Signed,
__________________________
Top 100 Names of the Year for Boys!
Expecting a beautiful little BOY? Congratulations! The fun is only just beginning as you search for the best name for your new little sweetheart. Some adore using popular names of the time, others desire a unique name of their own creation. But no matter which direction you go on his name, your perfectly made little baby will soon fill your life with wonder and delight - and your heart will never again be the same.
Included below are the 100 most popular names for boys in the United States this year, based on the Social Security Administration's latest statistics. Does your little one's name make the Top 100? We'd love to hear from you and know what name you chose. Drop a comment below, or join in the conversation any time on the Peaceful Parenting Facebook page, or private discussion group.
And if you have questions about all things BOY, drop a note any time to SavingSons@gmail.com and our clinicians and volunteers will do their best to get you the resources you are seeking.
❤ Happy Babymoon! ❤
1. Noah
2. Liam
3. Jacob
4. Mason
5. William
6. Ethan
7. Michael
8. Alexander
9. Jayden
10. Daniel
11. Elijah
12. Aiden
13. James
14. Benjamin
15. Matthew
16. Jackson
17. Logan
18. David
19. Anthony
20. Joseph
21. Joshua
22. Andrew
23. Lucas
24. Gabriel
25. Samuel
26. Christopher
27. John
28. Dylan
29. Isaac
30. Ryan
31. Nathan
32. Carter
33. Caleb
34. Luke
35. Christian
36. Hunter
37. Henry
38. Owen
39. Landon
40. Jack
41. Wyatt
42. Jonathan
43. Eli
44. Isaiah
45. Sebastian
46. Jaxon
47. Julian
48. Brayden
49. Gavin
50. Levi
51. Aaron
52. Oliver
53. Jordan
54. Nicholas
55. Evan
56. Connor
57. Charles
58. Jeremiah
59. Cameron
60. Adrian
61. Thomas
62. Robert
63. Tyler
64. Colton
65. Austin
66. Jace
67. Angel
68. Dominic
69. Josiah
70. Brandon
71. Ayden
72. Kevin
73. Zachary
74. Parker
75. Blake
76. Jose
77. Chase
78. Grayson
79. Jason
80. Ian
81. Bentley
82. Adam
83. Xavier
84. Cooper
85. Justin
86. Nolan
87. Hudson
88. Easton
89. Jase
90. Carson
91. Nathaniel
92. Jaxson
93. Kayden
94. Brody
95. Lincoln
96. Luis
97. Tristan
98. Damian
99. Camden
Photograph by Clare Fisher
Related Reading:
Saving Our Sons public community page
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Medical Organization Position Statements on Circumcision
No national medical organization recommends the routine genital cutting of infants without medically justified need for such surgery to take place. Infant circumcision is clearly spoken against in many nations, regardless of babies' sex (female, male, intersex) and is not supported for all babies in any nation, even those that otherwise stem from within a cutting culture.
What follows are current medical position statements from organizations across the globe today. Full statements are readily available via online searches. When we recognize that no national medical organization recommends routine infant circumcision, it becomes clear that such things should not be funded with tax payer dollars (Medicaid and similar programs), covered by health insurance (genital cutting of infants is not performed as a health treatment), or pushed upon unknowing parents by any medical staff who stands to financially gain from performing unnecessary genital surgery upon a non-consenting human being.
You are welcome to download and print the above card,
or they arrive with most items via Etsy as large, glossy placards.
Related Reading:
Peer reviewed published research on circumcision and the functions of the foreskin: DrMomma.org/2007/01/circumcision-studies.html
Scholarly books: https://amzn.to/2L0tf4t
Registered Nurses on Circumcision: http://www.DrMomma.org/2014/01/registered-nurses-on-circumcision.html
On the ethics of registered nurses assisting in forced infant circumcision: http://www.DrMomma.org/2014/04/on-ethics-of-registered-nurses.html
The Day I Withdrew from Nursing School: http://www.DrMomma.org/2010/01/day-i-withdrew-from-nursing-school.html
The Medical Benefits of Infant Circumcision: http://www.DrMomma.org/2013/05/the-medical-benefits-of-infant.html
Foreskin Friendly Physicians by State: http://www.DrMomma.org/2007/01/foreskin-friendly-physicians.html
Intact Care & Circumcision Physician Packs (by/for those practicing in medical fields today): https://www.etsy.com/listing/538608349/physician-do-not-retract-prevention
Expecting Packs (for friends and family, can be mailed anonymously or with a personalized note): https://www.etsy.com/shop/SavingOurSons?section_id=21167625
to join our advisory panel of physicians, email SavingSons@gmail.com
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