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

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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.

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

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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.

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,

 __________________________

Additional items at the Intact Care Resource Page.
Prevention Packs for Physicians on Etsy

Dr. John Fitton: All Genital Mutilation is a Violation

Dr. John Fitton of the East Midlands Regional Council of the British Medical Association spoke up recently against the BMA's motion 324 (pertaining to female genital cutting) because it fails to protect all children regardless of sex (male, female and intersex). Dr. Fitton begins in this video at minute 13:10: http://vimeo.com/99675872 He states:

This motion discriminates. It is downright sexist. [...] The billions of normal, uncut world populations would think it is absurd that we are even debating this in our tiny, tolerant time, let alone qualifying the phrase 'genital mutilation' with the word 'female.' FGM, MGM - all GM - is a violation.  

I was over 50 before I saw my first case of screaming infant after mutilation at one of the cutting clinics that had sprung up in our shire counties. [...] It is disgraceful that the general medical council turns a blind eye to this trade. And what a profitable bloody trade it is too! And I use the word 'bloody' to remind us of the occasional child who bleeds to death.  

This cutting trade has no place in our profession and any doctor who is profiting from it should be ashamed. And be warned, if molestation can be prosecuted after 40 years, so might mutilation.

The male (left) and female (right) clitoris/penis and prepuce are analogous and homologous organs. During the first trimester, they are also visually the same. Both are natural, normal, purposeful body organs that equally contribute to the health, functioning, and well-being of their owner.

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On the Ethics of Registered Nurses Assisting in Forced Infant Circumcision

Video Interview by James Loewen with Dolores Sangiuliano, RN
View Loewen's full channel and many stellar works at: www.YouTube.com/user/Bonobo3D

"I'm a registered nurse and we have an ethical code - the ANA Code of Ethics for Nurses - and it states very clearly that we are charged with the duty to protect our vulnerable patients. If we are not protecting our vulnerable patients, then our licenses are not worth the paper that they are written on.

If anyone is vulnerable, it is a newborn baby - a child with no voice. And that is why I carry this sign: 'I will not do anything evil or malicious and I will not knowingly assist in malpractice.' Infant circumcision is malfeasance and malpractice and it is totally unethical.

Proxy consent is only valid for a procedure. In other words, parents can give consent for a procedure for their child - that's proxy consent - in a case of treatment or diagnosis, and circumcision is neither. You are not treating a disease and you are not trying to diagnose an illness."

Comment directly on this video at: http://youtu.be/Sgy8kZqANoE

No national medical organization in the world recommends routine infant circumcision.

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Circumcision to Reduce Men's Sexual Pleasure

The complete amputation of the prepuce organ (as performed in North American style infant circumcision) initially began in an effort to curtail masturbation and 'promiscuous' behavior among boys and men. The prepuce ('foreskin') was well known to be the key organ at play in whole sexual health, and the theory was that if the prepuce was removed, men's pleasure and sexual drive would also be hampered as well.

The reason this genital surgery started to be performed on infants without anesthesia is twofold:

(1) It was commonly believed that babies 'do not feel pain' the same way adults do. Today, we know this is entirely false - newborn babies actually have a heightened sense of touch/feeling/pain so that they are able to feel their way around their mother's body in the early days/weeks of life.

(2) It was believed (and heavily promoted by key physicians at the time) that if this intense - almost unbearable - pain of genital cutting was connected with sexuality, it would further reduce a boy's desire to touch himself or use his penis 'inappropriately' as he grew older. Connect pain with sexuality right from the beginning of life, proponents taught at the time, and sexuality would take a back seat to more 'righteous' endeavors in boys' and men's later lives.

The plan to end masturbation and sexual behaviors did not work -- boys and men masturbate and have sex whether they are intact or not -- but men's sexual health in North America was impacted by this early push, and many of the myths fired up at the time still haunt and hurt us today.

What follows are several quotes from influential practitioners at the beginning of the North American push to circumcise, to offer up an example of where and why such madness began in our culture. To dismantle such pervasive myths, we must first understand where their roots lie. It is very clear when reviewing early materials on the foreskin and circumcision that physicians knew this organ played a key role in men's sexuality, normal functioning and pleasure, and that its amputation would impair each of these components of men's lives to one degree or another; a desirable outcome at the time.

"[The foreskin] is a source of serious mischief." ~William Acton, physician and venereologist (1814-1875)

"Circumcision, when performed in early life, generally lessens the voluptuous sensations of sexual intercourse." ~William Alexander Hammond, NYU physician and professor (1828-1900)

"[The physiological benefit of the foreskin] is that of maintaining the penis in a condition susceptible to more acute sensation than would otherwise exist. It may increase the pleasure of coition and the impulse to it. [...] One should be thankful [for the reduced pleasure due to circumcision and increased self-control]." ~Jonathan Hutchinson, physician, surgeon, pathologist (1828-1913)

"A remedy which is almost always successful [to stop masturbation] in small boys is circumcision, especially when there is any degree of phimosis. The operation should be performed by a surgeon without administering an anesthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment. The soreness which continues for several weeks interrupts the practice, and if it had not previously become too firmly fixed, it may be forgotten and not resumed. If any attempt is made to watch the child, he should be so carefully surrounded by vigilance that he cannot possibly transgress without detection. If he is only partially watched, he soon learns to elude observation, and thus the effect is only to make him cunning in his vice." ~John Harvey Kellogg, physician (1852-1943)

"I suggest that all male children should be circumcised. This is ‘against nature’ but that is exactly the reason why it should be done. Nature intends that the adolescent male shall copulate as often and as promiscuously as possible, and to that end covers the sensitive glans so that it shall be ever ready to receive stimuli. Civilization, on the contrary, requires chastity, and the glans of the circumcised rapidly assumes a leathery texture less sensitive than skin. Thus the adolescent has his attention drawn to his penis much less often. I am convinced that masturbation is much less common in the circumcised. With these considerations in view it does not seem apt to argue that ‘God knows best how to make little boys.’" ~R. W. Cockshut, Circumcision, British Medical Journal, Vol. 2 (1935): 764.

Meme of original Kellogg's Corn Flakes advertisement. Kellogg's Corn Flakes and other 'bland' foods, as well as circumcision, were touted as being good for the reduction of men's sexual pleasure, masturbation and 'extramarital sexual relations' (especially during war times) which would, in turn, build strong men.

Related Reading:

Marked in Your Flesh: Circumcision from Ancient Judea to Modern America (book)

Circumcision: A History of the World's Most Controversial Surgery (book)

Circumcision: An American Health Fallacy (book)

History of Circumcision (website)

History of Circumcision (CIRP.org)

Edward Wallerstein, "Circumcision: The Uniquely American Medical Enigma," Urologic Clinics of North America, Vol. 12, 1985, p. 123-32.

Circumcision in Canada: A Short Chronology of Events

The Rise and Fall of Circumcision in New Zealand

Intact vs. Circumcised: A Significant Difference in the Adult Penis

Functions of the Foreskin; Purposes of the Prepuce

Additional books on circumcision.

Are You Fully Informed? (websites, articles, books)

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AAP Reports Repeat Circumcision on the Rise

By Charles Bankhead for MedPage Today
Email Bankhead at c.bankhead@medpagetoday.com

An unexplained increase in the number of revision circumcisions has pediatric urologists wondering whether the finding is real and, if so, what caused it. Data contributed by pediatric hospitals nationwide showed a 119% increase in the rate of revision circumcision procedures from 2004 to 2009. In contrast, the rate of primary circumcision increased by 19%, and procedures to remove penile adhesions rose by 37%.

Closer inspection of the data showed wide variation by hospital in the rate of revision circumcision during the study period, Paul J. Kokorowski, MD, reported here at the American Academy of Pediatrics meeting. "We found that certain hospitals had dramatic rises in revision circumcision procedures [approaching 1,000% in some cases] while others had more modest increases," said Kokorowski, of Children's Hospital Boston. "Only three hospitals showed stable rates or slight decreases," he said.

Anecdotal evidence has suggested that an increased frequency of revision circumcision in recent years, despite historically low rates. Published data have consisted largely of small case series, some spanning several years (Int Braz J Urol 2006; 32: 454-458, Pediatr Surg 2002; 37: 1343-1346, J Urol 1995; 153: 180-182). Seeking to provide more informative data on the subject, Kokorowski and colleagues searched the Pediatric Health Information Systems (PHIS) database, which comprises 28 hospitals that contribute data on outpatient pediatric surgical services. They identified pediatric patients who underwent one of three types of specific penile procedures during 2003 to 2009:

• Revision circumcision 
• Primary circumcision 
• Lysis of penile adhesions 

]The analysis included 34,568 patients who underwent one of the targeted procedures. The total consisted of 5,632 revision circumcisions, 25,768 primary circumcisions, and 3,168 procedures for lysis of penile adhesions. The 119% increase in the volume of revision circumcision at the participating hospitals stood out as significantly greater than the increases in the other two procedures (P < 0.001).

The rate of revision procedures increased in a near-linear manner over the period reviewed, starting with a 17% rise from 2004 to 2005, and then to 47% for 2006, 71% for 2007, 91% for 2008, and 119% for 2009.

In contrast, the rate of primary circumcisions peaked at 22% to 23% during 2007 and 2008 before declining to 19% above the baseline level. The rate of adhesion-lysis procedures declined by 11% from 2004 to 2005, peaked at 45% above baseline in 2007, and then descended to 37% in 2009.

In an effort to determine factors contributing to the increased rate of revision circumcision, investigators performed an analysis limited to 13 hospitals that provided complete data on the three penile procedures for every year of the study period. They found no consistent patterns.

The findings left unanswered the question of what caused the large increase in revision circumcision procedures over a five-year period. "Revision circumcision does seem to be more common at specific PHIS hospitals and this might represent a more overall increase in revisions," said Kokorowski. "Unfortunately, due to the limitations of our dataset, we can't speculate on the reasons for this change."


Source: 

American Academy of Pediatrics. Kokorowski PJ, et al. "Is circumcision revision becoming more common?" AAP 2011; Abstract 13760.

Further medical studies and peer reviewed research on circumcision and the human foreskin.

Newborn undergoes initial circumcision. No national medical organization in the world currently recommends routine infant circumcision. 

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Ballooning in the Intact Child

By Jennifer Coias, M.D. © 2011

Penis Balloons! They are the occasional delight of growing up as an intact boy.

I always have to giggle when I hear stories about pediatricians who ignorantly warn parents that their son’s ballooning penis is now prone to infection or other complications and must be treated promptly. This makes me laugh primarily because my own son, who is now three, delights in this normal developmental process every single day, and has done so since he was around ten months of age. In fact, I'd venture to say that most intact boys will enjoy the fun of making penis balloons at some point or another during their childhood, whether his parents realize it or not. Honestly, though, I don’t know whether to laugh or cry because these types of statements from medical doctors are not only ridiculously false, but they speak to a serious delinquency in the basic understanding of the intact penis. This is a topic I revisit time and time again with parents and it seems that, despite all the information now available, parents are still being fear-mongered into unnecessary, harmful treatments and/or prepuce amputations on the grounds of one of the most normal, natural phases of the development of the intact child: ballooning.

What is Ballooning?

Ballooning occurs when the foreskin begins to separate or has separated from the glans (head) of the penis but the foreskin opening remains narrow. As a boy urinates the urine will fill the empty space between the foreskin and glans, and create a ballooning effect. As the urine escapes through the narrow opening the balloon will slowly decrease in size (deflate) and the foreskin will return to its normal state.

Ballooning penis of a two year old male child.

What Parents Need to Know

1. As discussed in Basic Care of the Intact Child, the foreskin is fused to the head of the penis at birth by a thin membrane known as synechia. At some point this natural adhesion will begin to release, allowing the foreskin to differentiate from the glans. This can happen at any age, but is quite common in toddlers and in early childhood. Keep in mind that just because the foreskin has separated from the glans, it is not an indication that the foreskin can be retracted. In order for retraction to take place a second process must occur, a widening of the foreskin opening.

The opening of the foreskin generally remains very tight and non-elastic during infancy and early childhood. This serves to protect the developing penis from feces, bacteria, viruses, and harmful pathogens. Essentially, the opening acts as a sphincter and only relaxes to allow urine to pass. With the release of hormones, predominantly during puberty, the tissues of the foreskin will become more elastic and the opening will widen. Naturally, when the foreskin opening widens in later childhood, ballooning that may have once occurred no longer happens as the urine stream is unobstructed by the once narrower opening. As noted in The Phony Phimosis Diagnosis, retraction of the foreskin is a sexual function and usually occurs after the age of ten. Full retraction of the foreskin may only take place at the end of puberty -- this is normal. Ballooning may occur for many years during toddler/childhood until a boy has the hormones of puberty kick in.

2. Ballooning actually serves a few important purposes in the development of the intact penis. The body, in fact,  knows exactly what it is doing! First, because separation of the foreskin often occurs many years before the opening widens, ballooning serves to rinse out any expired skin cells from underneath the foreskin. It’s nature’s perfect way of keeping things tidy and ridding the body of old skin cells. Second, this process serves to maintain a differentiation between the glans and foreskin during the years in which a boy remains non-retractable. Ballooning serves to gently, and over time, stretch the two organs into their own separate space, discouraging a re-adhesion of the foreskin to the glans (re-adhesion is something we commonly see in boys who have had their foreskin amputated via circumcision surgery - the body attempts to heal itself with the tissues it has left, and there is no natural ballooning process that can take place, because no foreskin any longer exists). Third, ballooning aids in helping the entire foreskin separate from the glans over a normal duration of years. Typically only a small portion of the foreskin will separate from the glans at a time, and the pressure of the urine will slowly release other areas of the foreskin, little by little. Of course, just as every girl experiences a unique separation of her prepuce ("clitoral hood") from the glans of her clitoris, every boy experiences separation unique to his foreskin and the glans of his penis. It may happen all at once, almost overnight, or over many years - all variations are normal. Nature makes very few mistakes, and this ballooning phase, when it occurs, is not only normal, but beneficial to the overall development of the intact child.

In this ballooning child, you can see that the prepuce (foreskin) has separated on one side from the glans where ballooning is taking place, while still remaining tightly adhered on the other side. This is normal, as the prepuce typically takes several weeks, months or even years to separate completely.

3. Ballooning will not cause infection, in fact, it is quite the opposite. As mentioned above, urine serves to wash out dead skin cells. Urine is sterile, and a narrow foreskin opening prevents fecal bacteria, a primary cause of urinary tract infections (UTIs), from entering the urethral opening, while urine flushes out anything that potentially enters or meets the tip of the penis. Urine does not linger or fester under the foreskin - it exits, and takes with it the body's natural waste cells and any other irritants that have come into contact with the penis. For more about the ways that the foreskin serves to protect against UTIs, see this article.

4. At onset, ballooning may be accompanied by discomfort, itching, redness and/or swelling. Often, a boy’s foreskin will separate from the glans with few or no symptoms. However, in other cases a boy will experiences one or more of these symptoms at the onset of separation. Swelling and redness are common because the foreskin is very vascular and, like the lips of the mouth when stretched or irritated, it tends to react to small traumas in this way. Some boys will experience discomfort as urine stings the freshly separated glans that is now exposed for the very first time in this child's life. This discomfort may be acute (like a quick sting) or more pronounced, depending on the situation, and is commonly mistaken for a UTI because the pain only occurs when the boy is urinating, and almost always when a child is very young and the glans has separated for the first time. The good news is that the freshly separated glans smooths over within a few days and the stinging with urination will cease. Sometimes parents can ask their son to urinate in a bucket or bathtub of water as a way to ease this temporary discomfort; however, this will not work for a many boys as the foreskin opening is simply too small to allow the water to dilute the urine prior to contact with the glans. [Note that the intense pain and stinging that would occur if the foreskin is torn and cut from the glans in infancy due to circumcision is much more intense than this natural, gentle separation of the two organs with normal development.]

After ballooning, the penis returns to its previous state.

Premature separation caused by forced retraction or manipulation of the foreskin by a care provider can make for a very painful separation experience later. After forced retraction occurs (especially if it has been a repeated event) the foreskin typically re-adheres to the glans in an effort to heal itself. Tiny tears and areas of scar tissue are left from forced retraction, that are then torn and cause an increase in pain when natural separation occurs months to years later. This is one of the many reasons that no one should ever manipulate, "mess with," or retract an intact baby or child.

Foreign microbodies on the hands of well-meaning care providers can change the pH of the genitals when introduced into the penis during forcible retraction. This change in pH may increase the likelihood of yeast spore overgrowth. Yeast infection has been known to instigate premature and painful separation episodes, so parents should be watchful for any symptoms that could indicate a yeast infection (creamy discharge, itchiness, bright red spots around the groin or anus). As with girls, yeast infection is most common during the diaper wearing years, or after exposure to chlorinated swimming pools or other harsh chemicals that interfere with the body's natural pH. Yeast (naturally present on all human beings) is only problematic when it gets out of hand and is easily treated with acidophilus and other medications. Check out Basic Care of the Intact Child for more about yeast. Symptoms of normal separation can come and go throughout childhood, as the foreskin continues to differentiate itself from the glans. These symptoms resolve themselves, are not cause for concern or doctor's visits, and do not require special medical attention. For more about this subject in particular, please refer also to Painful Urination During Prepuce Separation.

In Closing

Hopefully, as circumcision rates in the U.S. continue to plummet, information on the normal penis and its natural development will become as commonplace as it is in the rest of the intact world. For now, we can be thankful that there are research based locations like peaceful parenting, where physicians, educators, and parents can come together with experiences and informed insight. I can remember how worried and uncertain I felt when my first son started to balloon. At the time I knew little about this normal phase of development. Thankfully, I had a fantastic network of well-educated mothers and professionals to help me decipher what was happening, and can now share this important information with others. Don't be afraid to speak up as well, you may be the only one who ever does in your circle of influence.

Related Reading:

Extreme Ballooning in the Intact Child: This, too, is normal: http://www.savingsons.org/2014/03/extreme-ballooning-in-intact-child.html

Intact Care Resource Page: http://www.drmomma.org/2009/06/how-to-care-for-intact-penis-protect.html

Also by Dr. Jennifer Coias:

The Phony Phimosis Diagnosis

Circumcision: Already Illegal?

The Nuts & Bolts of HIV in the USA and why Circumcision Won't Protect Men

Basic Care of an Intact Child

Painful Urination During Prepuce Separation

Who Are You Calling an Intactivist?

Turn Your Crib into a Co-Sleeper

For additional information and resources on the prepuce, intact care and circumcision, see: Should I Circumcise My Baby?

*******

Hypospadias: Surgery and Circumcision

By Danelle Day, Ph.D., M.A. © 2010

Current citation: Day, D. (2010). "Hypospadias: Surgery and Circumcision." At Peaceful Parenting: DrMomma.org/2010/04/hypospadias-surgery-and-circumcision.html 

For reprint permission in publication, email DrMomma.org@gmail.com
Hypospadias and Chordee Group: FB.com/groups/HypoChordee

mother and newborn oil on canvas by Pam Fox

What is hypospadias?

Hypospadias in boys is a congenital condition in which the urinary opening is not at the typical position on the end of the glans (head) of the penis.

Typically recognized at birth, the urinary opening is instead located anywhere along the underside of the penis - from the underside of the glans (most common) to behind the scrotum (very rare). In addition, the prepuce (foreskin) is often not as long, or wide, and does not cover the glans as the prepuce on most boys. [Note: A boy may be born with a small or large, long or short, foreskin - this does not mean he has any form of hypospadias. Differentiation among penile/clitoral and prepuce size is normal from human to human, among both girls and boys, men and women.] The penis may curve downward among some boys with extreme hypospadias, especially when the urinary opening is a distance away from the glans (near the scrotum for example), which again is rare. (37) In 70% of hypospadias cases, the difference between the location of the urinary opening and where it would otherwise be is only marginal and makes little difference to the full functioning of penis. (1, 13, 18, 32, 36)

Locations along the urethral plate where urinary openings may be present in cases of hypospadias. Approximately 70% of boys with hypospadias have a urinary opening in the glanular or subcoronal location which is an insignificant distance from the typical location (top mark on the diagram).

Why does hypospadias occur?

The penis forms after a bodily response to testosterone washes inutero during weeks 9-20 of pregnancy (prior to the 9th week, male and female gonads inutero are identical and the penis and clitoris form from the same tissues - they are analogous and homologous organs). Up to about Week 12, the clitoris and penis look the same to the naked eye as well - they are indeed 'the same' organ. When a male fetus' hormones respond to his mother's, the way in which the urinary channel grows is stimulated, and the penis and prepuce develop differently from a female's clitoris and prepuce. If a male does not respond to these hormone 'washes' inutero (for whatever reason), he may be born chromosomally male (XY) but with external sex organs that appear female. Again, they are all the same organs, but respond to hormone washes differently, and as a result, end up 'looking' different at birth between girls and boys.

Ultrasound images of a male (left) and female (right) baby at approximately 11 weeks gestation. While differentiation has started to occur, the homologous and analogous nature of the clitoris/penis and related organs is readily apparent to the naked, untrained eye.

The location for the urinary tract starts off developmentally below the genital bulb - the organ which will become a clitoris or penis. In girls, this urinary tract stays short and below the genital bulb (clitoris). In boys, it typically elongates and grows into the genital bulb (penis) due to hormone response. The process is not always a smooth one, however, and therefore we occasionally see male babies born with this shorter urinary tract that did not grow to the end of the genital bulb (penis) inutero.

There is some debate about whether we see this occurring more in populations impacted by artificial hormones (in our diet) and toxins in our environment, which act upon developing babies and especially impact male sperm, male embryos and male babies. (9, 29, 32, 36, 41) Another theory is that we've seen more hypospadias in the past 50 years since we started circumcising and/or forcibly retracting healthy newborns in the United States - the majority of hypospadias cases are those which could otherwise just be seen as a normal variation in the penis and men grow up to do fine with a urethral opening just below where it would otherwise be. (1, 10, 13, 23)

Although the exact causes for the hormone related alteration that results in hypospadias are not fully known, problems during the 9-20 week time frame likely result in this condition. Typically, however, boys with hypospadias have no other atypical issues at birth (i.e. nothing else in their development was impacted during those same weeks inutero). In about 8% of boys with hypospadias, one testicle may not have fully descended into the scrotum, in which case a blood test (karyotype) is often recommended to check for other chromosome abnormalities. (32, 36) Usually, the testicle drops on its own, and there is also no cause for concern.


How often do we see hypospadias?

It is important to realize that boys born with hypospadias still have the organ tissues that would have developed into the urinary channel - they extend from wherever the urinary opening is, to the end of the glans where the channel would otherwise be. This strip of tissue is referred to as the "urethral plate."

Hypospadias appears to run in families. About 7% of boys born with hypospadias also have a father born with the condition. (9, 18, 29) If one son has hypospadias, the chance a second will be born with it increases to 12%. (29, 32, 36) If both a father and his son have hypospadias, the likelihood of another boy being born with hypospadias is 21%. (32, 36) Hypospadias impacts 1 in every 150 to 300 boys born. (9, 18, 29, 32, 36) As a result, hypospadias is one of the more common concerns parents of healthy, intact boys deal with after birth -- and one which involves their son's most sensitive member.


What do we do for boys born with hypospadias?

The 'treatment' for hypospadias in the United States today is to surgically move the urinary opening to the end of the glans and to straighten bending of the penis that may be present in extreme cases (although there are no bones or muscle in the penis except for the smooth muscle of the prepuce organ). (33, 37) Surgery is often performed on an infant of 3-18 months of age (but is often more successfully performed later in childhood or adulthood). The theory behind this early age of genital reconstruction is that baby boys are "not yet aware of their penis" - although I would adamantly disagree with this justification.

Hypospadias surgery is typically completed within 3 hours and can often be done in 1 surgical attempt. There have been over 200 different methods developed to complete this surgery over the last century that it has been performed. (26, 27, 31) Today only a handful of techniques are still used, but the type of hypospadias surgery conducted on any given baby will depend on the doctor cutting him, what his/her training is, and what his/her preference is. (16, 35, 43) A boy will not receive the same hypospadias surgery from one doctor to the next.

There are many U.S. doctors who continue to routinely perform prepuce amputation (circumcision) and cut off the foreskin during hypospadias surgery. (9) This is never necessary. Surgeons occasionally advocate for circumcision during hypospadias surgery because (while this is typically not mentioned as the reason to parents) by cutting away more of the penis, there is less to 'mess' with, which can make penile reconstructive surgery easier to complete - less organs in the mix to worry about. (1, 9, 13, 23) In addition, more money is brought in because circumcision surgery is added to the tab.

However, surgeons informed and up to date on the important functions of the foreskin, the many purposes of the prepuce, and the harm that results from its amputation, will leave the foreskin alone (or reconstruct it as well) and not circumcise during hypospadias 'repair'. (13, 16, 27, 34, 38, 39) There is no problem in having a short (or partially covering) prepuce. Typically, the prepuce will elongate, loosen and grow as the boy grows into and throughout his years of puberty. The prepuce can also be surgically altered in cases of partial covering (or 'hooded' foreskin) to cover the whole glans.

Below is a diagram of the prepuce being reconstructed to cover the glans during hypospadias surgery. This is commonly performed in the majority of the world today during hypospadias 'repair'. Only in the U.S. does circumcision surgery often come into the surgical mix with hypospadias.

Healing and Side Effects from Hypospadias Surgery

The healing process from hypospadias surgery typically lasts several weeks to several months (6 months is not uncommon). (5, 26, 31, 46) The penis is bandaged, and a urinary catheter is in place for about 1 week following surgery. In addition, antibiotics are prescribed while the catheter is in to fight foreign invaders that are common to post-surgical infection. An antispasmodic medication is typically given to reduce bladder irritation from a catheter being in place for so long. None of this is 'fun' for a baby, toddler, child or adult to endure - but I would argue it may be especially difficult to deal with when you are already a tiny human being with a new, wild world around you, and you do not yet have the ability to understand why this pain is being inflicted upon your little body. In addition, post-op infection in an infant can be much more life-threatening than infection in an older child or adult. (1, 27, 43, 46)

The Children's Medical Center in Dallas, TX (home to the nation's top pediatric urologist) highlights the surgical problems that can occur from hypospadias surgery:

* The most common problem that results is "fistulas," which are abnormal openings under the penis that leak urine during voiding.

* Sometimes part, or all, of the repair comes open (dehiscence), returning the urinary opening back towards its original location.

* Scar tissue at the urinary opening (meatal stenosis) or along the new urinary channel (urethral stricture) may cause blockage to urination.

* If the new urinary channel enlarges, a "diverticulum" results, which looks like a swelling under the shin during urination from which urine dribbles after voiding.

Other complications can also occur, but these four account for most of the post-op problems in hypospadias cases. (25, 30, 43) It is not unheard of for infants to undergo as many as 20 surgeries over the course of their lifetime after the first cut is made in an effort to 'fix' and 're-fix' problems that arise from genital cutting. (30) The Children's Medical Center offers parents this information on the frequency of these surgical complications:

Rate of surgical repair complications depends upon several factors. One is the severity of the condition, as distal hypospadias operations have fewer problems after surgery than do more severe proximal ones. Various techniques used to correct the defect are known to have different rates and types of complications. Finally, experience of the surgeon may also affect the likelihood of problems after the repair. It is reasonable to ask about the personal experience of the surgeon when deciding who is going to operate upon your son. Nevertheless, even the most experienced pediatric urologist occasionally has complications after hypospadias repair.

One of the most common forms of hypospadias - the urinary opening is at the bottom of the glans and there is no bending or other atypical aspect of the penis.

Is Surgery Necessary?

Cases of hypospadias in boys vary in severity - the vast majority are minor and do not require surgical alterations for a boy/man to live normally. (1, 13, 23) In fact, there are multitudes of adult men the world over who were born with hypospadias, have never been surgically altered, and they function just fine. They are able to pee standing up, and engage in intercourse with no issues. They are able to reproduce equally as well, as semen leaves the penis in relatively the same area as it otherwise would during intercourse. Approximately 70% of hypospadias cases are those in which the urinary opening is on the bottom side of the glans. (1, 13, 18, 32, 36)

There are also healthy adult men born with more rare forms of hypospadias (further down the shaft, or near the scrotum for example) who are happy with their intact body and never chose to be surgically altered. (1, 13, 23, 29) They may urinate while sitting down, and may need alternative methods for procreation (to effectively place semen into a female partner, for example). But their penis functions fully as any other would. Men with severe hypospadias continue to experience vascocongestion (erection) and orgasm (muscle contraction) the same as any other man.

Rare, extreme case of hypospadias - the urinary opening is near the scrotum along the shaft of the penis. The penis also has a bend to it due to the atypical formation of the tissues and organs.

With a shorter urethra that is not fully covered/protected by the prepuce, there is an increased chance of UTI (in the first 12 months of life), but this is no greater than the risk of UTI for an infant girl as she, too, has a shorter urethra. UTIs are easily treated with antibiotics and this is not reason to surgically and permanently alter or amputate body organs. Even in cases of repeated UTIs (which happens often among baby girls prone to them) circumcision is not the answer.

In preparation for this article, I interviewed several colleagues in the fields of human sexuality, as well as those in pediatric urology who are well informed in all areas regarding the prepuce, the urethra, hypospadias, and circumcision. When asked if they would operate on their own infant or child with minor hypospadias (the most common form) the response was a unanimous, NO. Especially not at a young (toddler or infant) age. Many said that even in more extreme forms, they would wait to give their son a voice in the decision.

There are simply too many risk factors and no definite benefits in operating on an infant. At 15 months old (for example) the penis is small and the tissues and organs have not yet developed or elongated as they will do as a boy ages (throughout puberty). Any genital modification at this point via surgery is going to impact the way that his body is able to grow/stretch/develop, naturally. It may not seem like a big deal, but because each individual surgeon decides how much to cut, what repairs to do/not do, how the technique will be performed, how to treat the prepuce (foreskin), etc., all these small cuts on a tiny penis equal BIG changes when a penis gets to be...well, "BIG".

The results can be compared to the way that a balloon looks if we write on it in tiny letters when it is deflated and then blow it up, vs. the way it looks if we write on it in tiny letters when it is already blown up. The impact of the writing on the balloon changes based on size/shape/growth and what still needs to occur in getting bigger (developmentally).

Another issue brought up among the panel I interviewed said that by waiting until a boy is older, he is given the option of his own body choices. This allows him to be fully anesthetized at a time when surgery is not as risky, should he choose surgery, and it allows him to understand what is being done, while preventing him from having the exacerbated painful recovery due to diaper wearing over a surgical wound. Diapers alone agitate a surgical site and I've heard from many parents with toddlers in agony for weeks (one recently said for MONTHS) because of circumcision and/or hypospadias surgery. It is no way to live your days when you are so very young and do not yet fully understand what is going on. Especially not at a stage in developmental growth when time really 'stands still' when you are in pain.


Hypospadias 'Repair' as Cosmetic Surgery

Overall, most baby boys with minor hypospodias do NOT go on to have any issues later in life - without ever having any type of surgery on their penis. The question then becomes, why do cosmetic surgery on an infant/toddler when we do not know for sure there will ever exist the need or desire for it later?

As mentioned, the majority of hypospodias 'repair' surgeries are done on mild cases - not for medical/bodily need, but for cosmetic reasons (to make the urethral opening on the penis 'look like' other penises). (1, 5) The Children's Hospital states that, "The final cosmetic appearance is assessed at 6 months to allow adequate time for healing and to identify the most common surgical complications that can occur." It is the appearance of a child's penis that is of most concern in most cases of hypospadias surgery - not the functioning of his organ.

Marilyn Milos, founder of The National Organization for Circumcision Information Resource Centers, reports, "In the case of minor hypospadias, the advice we have today is to leave it alone. What's the worse that can happen? That a boy must sit to urinate? Many men sit to avoid the splash factors, and their wives are happy, too. The surgery is much more traumatic for a child than a minor malady, which can always be repaired if that is what the boy wants when he can make the decision for himself."

In fact, there are many adult men I spoke with who did undergo surgical hypospadias 'repair' as infants, and are unhappy with the results today. They wish their penis had been left alone. Most Americans were also circumcised during the surgery, so it does become difficult to determine whether it is the actual hypospadias reconstruction, or the prepuce amputation, that causes their grief.

One man shared his experience:

Many of you know my personal experience in this area, and know that I have time and time again advised mothers to NOT get hypospadias "repair" surgery on a child of theirs. I say this because often those boys can do everything normally, (like peeing standing up, and having sex/reproduction) and the surgery often becomes a "well I think his penis should look 'normal' argument. Which suddenly makes this all a cosmetic issue. But studies that have been done have shown time and again that men with mild hypo were overall happier with their penis then men who had mild hypo and had it "fixed" in infancy.

There are RARE cases where the urethra opens so low, (i.e. midshaft, or at the base of the penis, where it really is a medical problem). For these cases, where surgery truly is needed, there are hypo repair doctors in the United States who provide the surgery that keeps the foreskin intact! Because hypospadias is getting more common each year, please take my story and this doctor's page, and save it for the next time you find a parent concerned about hypo repair, and worried their son will have to be circumcised.

Not only is it beneficial to wait for any type of hypospadias surgery until your son is older and can decide for himself, but in waiting his genitals are allowed to become fully developed. If he elects for surgery, foreskin-saving methods are easier to perform on an adult penis than on a very small infant/toddler's penis. There is more to 'work with' on an adult, and surgical mistakes are not as common.

Inutero differentiation of external sexual organs.

My Son Won't Remember It Anyway...

I do appreciate parents' good intentions when they say that they wish to have hypospadias surgery performed upon their infant son when he cannot 'remember' it on a conscious level. Parents are certainly well meaning for their little loved one. However, we have countless studies that demonstrate surgical procedures and pain in infancy and toddlerhood impact the brain, enzymes, cortisol and other stress hormones, blood pressure, vascoconstriction, and that even pain response and sensitivity in adulthood is impacted. (2, 3, 4, 6, 7, 8, 11, 12, 14, 15, 19, 20, 22, 24, 44, 45) Obviously the brain knows what is going on and there are memories being formed through the pain and discomfort.

The body and brain DO seem to remember traumatic events in infancy/toddlerhood - and it may even be more damaging when a little person cannot understand what is going on, or why they feel the way they do, or what is being done to them. (2, 6, 7, 8, 14, 15, 24, 44) There are cases when pain and surgery cannot be avoided in infancy - when the medical need and benefit outweigh the detriments on a child. But mild hypospadias, and especially circumcision, is not one of those cases.

A mother recently shared her story with us:

My son was just 2 1/2 years old when he and I were watching Jurassic Park together. There is a scene when the mother dinosaur is fighting to protect her egg. My son was troubled by this - why would the mommy dino kill people? I explained to him that she would do anything to protect her baby inside the egg - just like I would do anything to protect him. My son seemed to be in deep thought, but nothing could have prepared me for what he said next. "Yeah, I know. Except the one time when you let them do this [and he made chopping motions with his hands and arms on his penis] to me." In that moment I almost died of guilt and remorse and shock that everything I had assumed to be true of infant memories is wrong. My son was circumcised after birth and this is not a subject we had ever discussed. In fact, I had never even thought about it until this day. If I had it to do over again, I would protect him against the pain and suffering and loss of any unnecessary surgery - especially the cosmetic one of circumcision.

The number of boys cut today in the United States for cosmetic excuses does not match up with pro-cutting numbers that advocate for circumcision/hypoplasia surgery 'packages.' Even if ALL boys born with hypoplasia underwent surgery and ALL of them were also circumcised during the surgery, this would still be just 0.3 - 0.6% of boys who faced genital cutting and the loss of their prepuce. (1, 13, 18, 32, 36) The rate of intact boys and men in the U.S. would match the rest of the intact world at 99.4 - 99.7%. This statistic is significantly different than the current 50% intact rate in the United States, which tells us this is a subject that continues to warrant our immediate and astute attention.


The "Foreskin-Friendly" Approach

Dr. Warren Snodgrass is Chief of Pediatric Urology at Children's Medical Center (Dallas, TX) and Professor of Urology at UT Southwestern. He is internationally renowned for his version of hypospadias surgery - the Tubularized Incised Plate (TIP) operation, which most surgeons refer to as the "Snodgrass Repair" and he is 'foreskin-friendly' - i.e. he will perform hypospadias surgery without amputating the prepuce (circumcision).

While some physicians in the U.S. continue to automatically circumcise boys during hypospadias surgery, Snodgrass offers foreskin reconstruction even in extreme cases of hypospadias. He has a success rate of 95% and has helped boys and men who have endured as many as 20 previous 'failed' operations and side-effect complications due to hypospadias surgery. (16, 25, 30, 38, 39, 40)

The fact that Snodgrass advocates for hypospadias surgery while keeping boys intact is significant because he is a leader among pediatric urologists and surgeons operating on boys with hypospadias. No other active surgeon has published more scholarly articles on hypospadias surgery than he has. No other method to correct hypospadias has been the subject of more publications than Snodgrass' technique. Surgeons travel from around the world to observe him performing hypospadias surgery (which does not include circumcision unless parents/patients request it) at the Children’s Medical Center in Dallas, TX. He has taught and practiced in more than 20 countries throughout North and South America, Europe, the Middle East and Asia.

Additional 'foreskin-friendly' physicians and surgeons can be found here or through your local chapter of The Intact Network.

What would I do?

I am frequently posed with the question, "What would you do?" This I know for certain: If I had a son born with mild hypospadias (as is generally the case), I would leave his body alone and let him decide if he wanted to do anything when he was old enough to fully understand and make the choice for himself. I am 100% certain that the many men with hypospadias who function perfectly well (urinary, sexually, and reproductively) are testimony to the less-is-more intervention response in this situation.

If I had a son born with severe hypospadias (urinary opening under his scrotum for example), I would wait as long as possible (for the reasons stated above in not performing infant surgery and having the risk of consequences on a baby/toddler), and then if I felt it was absolutely necessary for his well being, or if my son chose the surgery for himself, I would seek the services of someone who was well-informed in prepuce-sparing techniques (a 'foreskin-friendly' doctor like Snodgrass) and one who I knew regularly does effective hypospadias surgery in one attempt without also circumcising babies. A large part of me would caution to wait, and let my son decide, no matter the severity of hypospadias. The British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) reminds parents in Britain that even the rare and severe hypospadias cases are not urgently in need of treatment. There is nothing wrong with allowing a boy to decide for himself as he grows to understand the implications of his options and choose for himself.

As parents it is our job to protect, to love, to nurture, and to wisely do what is best for our children - to seek out information and make educated choices along the way. One in 150-300 of you will face this hypospadias decision. May it be a fully informed one.



Note:

For photographs of actual hypospadias cases in infants and adults, see this page [in progress - link soon to be added].

For additional information on circumcision, see resources at Should I Circumcise My Son? Pros and Cons of Infant Circumcision.

References

1) Aho M., Tammela O., Somppic E. & Tammela, T. (2000). "Sexual and Social Life of Men Operated in Childhood for Hypospadias and Phimosis: A Comparative Study." European Urology, 37:95-101

2) Anand, K. (1999). "Effects of perinatal pain." Progressive Brain Research Journal, 122:117–129.

3) Anand, K. & Hickey, P. (1987). "Special Article: Pain and its effects in the human neonate and fetus." New England Journal of Medicine, 317:1321–1329.

4) Anand, K. & Scalzo, F. (2000). "Can adverse neonatal experiences alter brain development and subsequent behavior?" Biology of the Neonate, 77:69–82. 20:9–16.

5) Baskin L. "Hypospadias: a critical analysis of cosmetic outcomes using photography." BJU International, 87:6, 534-539.

6) Boyle G., Goldman R., Svoboda J. & Fernandez E. (2002). "Male Circumcision: Pain, Trauma and Psychosexual Sequelae." Journal of Health Psychology, 7:3, 329-343.

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8) Chamberlain D.B. (1989) "Babies Remember Pain". Pre- and Peri-natal Psychology, 3(4): 297-310.

9) Dawson C. & Whitfield H. (1996). "ABC of Urology: Common Paediatric Problems." British Journal of Medicine, 312:1291-1294. (pro-cutting, docs who cut, for phimosis)

10) Elmore J., Baker L. & Snodgrass W. (2002). "Topical Steroid Therapy as an Alternative to Circumcision for Phimosis in Boys Younger than 3 Years." Journal of Urology, 168:1746.

11) Fitzgerald M. (1991). "Development of pain mechanisms." British Medical Bulletin, 47:667-675.

12) Fitzgerald, M. & McIntosh N. (1989). "Pain and analgesia in the newborn." Archives of Disease in Childhod, 64:441-443

13) Fleiss, P. & Hodges, F. (2002). What Your Doctor May Not Tell You About Circumcision. Warner Books: NY.

14) Fraiberg S., Adelson E. & Shapiro V. (1975). "Ghosts in the nursery: a psychoanalytic approach to the problems of impaired infant-mother relationships." Journal of the American Academy of Childhood and Adolescent Psychiatry, 14(3):387-421.

15) Goldman, R. (1997). Circumcision: The Hidden Trauma. Vanguard Publications: Boston, MA.

16) “Latest Developments in Snodgrass Operation for Hypospadias.” American College of Surgeons 90th Annual Clinical Congress, New Orleans, Louisiana, 2004.

17) O'Hara, K. & O'Hara, J. (2002). Sex As Nature Intended It. Turning Point Publications: Hudson, MA.

18) Pfeil M. & Lindsay B. (2010). "Hypospadias repair: an overview." International Journal of Urological Nursing, 4:1.

19) Porter, F. & Anand, K. (1998). "Epidemiology of pain in neonates." Research & Clinical Forums,

20) Porter, F., Grunau, R., & Anand, K. (1999). Longterm effects of neonatal pain." Journal of Developmental and Behavioral Pediatrics, 20:253–261.

21) Povenmire R. (1999). "Do Parents Have the Legal Authority to Consent to the Surgical Amputation of Normal, Healthy Tissue from Their Infant Children: The Practice of Circumcision in the United States." American University Journal of Gender, Social Policy & the Law, 87.

22) Reynolds, M. & Fitzgerald, M. (1995). "Long-term sensory hyper-innervation following neonatal skin wounds." Journal of Comparative Neurology, 358:487–498.

23) Ritter, T. & Denniston, G. (2002). Doctors Re-examine Circumcision. Third Millennium Publishing: Seattle, WA.

24) Shapiro, V. & Gisynski, M. (1989). "Ghosts in the nursery revisited." Journal Child and Adolescent Social Work Journal, 6:1.

25) Snodgrass W. (1999). "Tubularized, Incised Plate Hypospadias Repair: Indications, Technique and Complications." Urology, 54: 6-11.

26) Snodgrass W. (2001). "Editorial comment: Histological Analysis of Urethral Healing after Tubularized Incised Plate Urethroplasty." Journal of Urology, 166:1016.

27) Snodgrass W. (2002). "Hypospadias surgery – Current Techniques and Management of Complications." International Journal Urology, 9:S34.

28) Snodgrass W. (2003). "Letter to the Editor. Skin Graft for 2-Stage Treatment of Severe Hypospadias: Back to the Future?" Journal of Urology, 170(1):193-4.

29) Snodgrass W. (2004). "Consultation with the specialist: Hypospadias." Pediatrics in Review, 25(2): 63-7.

30) Snodgrass W. (2004). "Reoperative Urethroplasty after Failed Hypospadias Repair." Atlas of the Urological Clinics of North America, 12:105.

31) Snodgrass W. (2005). "Editorial. Assessing Outcomes of Hypospadias Surgery." Journal of Urology, 174:816-7.

32) Snodgrass W. (2005). "Hypospadias and Related Conditions." Clinical Problems in Pediatric Urology. Eds: Godbole, P., Gearhart, J., and Wilcox, D. Blackwell Publishing.

33) Snodgrass W. (2005). "Snodgrass Technique for Hypospadias Repair." British Journal of Urology International, 95(4):683-93.

34) Snodgrass W. (2006). "Extensive Skin Bridging with Glans Epithelium Replacement by Penile Shaft Skin Following Newborn Circumcision." Journal of Pediatric Urology, 2(6):555-8.

35) Snodgrass W. (2006). "Letter to the Editor. Re: The ‘Learning Curve’ in Hypospadias Surgery." BJU International, 100(1):217.

36) Snodgrass W. (2007). "Hypospadias." The Kilalis-King-Belman Textbook of Clinical Pediatric Urology. Eds: Canning, D. and Khoury, A. Informa Publishing.

37) Snodgrass W. (2008). "Management of Penile Curvature in Children." Current Opinion in Urology, 18:431.

38) Snodgrass W. & Khavari, R. (2006). "Prior Circumcision does not Complicate Repair of Hypospadias with an Intact Prepuce." Journal of Urology, 176(1):296-8.

39) Snodgrass W., Koyle M., Baskin L., Caldamone A. (2006). "Foreskin Preservation in Penile Surgery." Journal of Urology, 176(2):711-4.

40) Snodgrass W. & Nguyen M. (2002). "Current Technique of Tubularized Incised Plate Hypospadias Repair." Urology, 60(1):157-62.

41) Snodgrass W., Patterson K., Plaire J., Grady R. & Mitchell M. (2000). "Histology of the Urethral Plate: Implications for Hypospadias Repair." Journal of Urology, 164:988-90.

42) Snodgrass W. & Yucel S. (2007). "Tubularized Incised Plate for Mid Shaft and Proximal Hypospadias Repair." Journal of Urology, 177(2):698-702.

43) Snodgrass W., Ziada A., Yucel S. & Gupta A. (2008). "Comparison of Outcomes of Tubularized Incised Plate Hypospadias Repair and Circumcision: A Questionnaire-based Survey of Parents and Surgeons." Journal of Pediatric Urology, 4(4):250-4.

44) Taddio, A., Katz, J., Ilersich, A. & Koren, G. (1997). "Effect of neonatal circumcision on pain response during subsequent routine vaccination." Lancet, 349:599–603.

45) von Baeyer, C., Marche, T., Rocha, E. & Salmon, K. "Children's memory for pain: overview and implications for practice." The Journal of Pain, 5:5, 241-249

46) Wilcox D. & Snodgrass W. (2006). "Long-term Outcome Following Hypospadias Repair." World Journal of Urology, 24(3):240-3.