faq

My doctor hinted that my choice to keep my boy intact was foolish and misguided based on “evidence in the medical literature.” He believes that my decision to not circumcise my son has put him at risk for all sorts of problems, like not being able to retract his foreskin, infections, and trouble with his foreskin getting stuck behind the head of the penis, among others. Was I wrong to keep my son intact?

Not at all! Leaving your son intact was a wise and responsible decision. The foreskin is a normal, healthy, important part of your son’s body, and is no more prone to problems than any other body part. The foreskin serves many purposes, like protecting the glans (the head of the penis) in many ways, and providing for normal and full sexual sensitivity and function. The so-called “risks” of keeping his penis the way nature made it are grossly exaggerated. Most penis “problems” are due to bad medical advice, unnecessary manipulation of the child’s genitals, or lack of understanding of normal male development. Don’t forget, circumcision itself creates a whole list of problems and risks of its own for the child, not the least of which is that his normal sexual functioning is diminished. Most of the world does not circumcise, and they are just fine and healthy. See other questions on this page for more information on specific concerns.

I have no experience with an intact penis and really can’t quite understand what it means to “retract” the foreskin. Can you please explain?

foreskin-retraction-1The foreskin is not a simple “flap of skin” but a double-layered fold of tissue. At the tip of the penis, the
outer layer (a continuation of the shaft skin) turns back under itself and becomes the inner layer, which then connects back to the shaft behind the rim of the glans (the head of the penis).
At birth, the penis is an immature organ. In the early years of life, the inner foreskin layer is actually fused to the head of the penis, protecting the glans and the urinary opening from irritation and contaminants during the diaper years. With time – possibly over many years – the connections between the inner foreskin and the glans will break down naturally.
foreskin-retraction-2Also, the outlet of the foreskin is tightly closed in the young child, but with time the opening naturally becomes looser and more elastic. Eventually, the foreskin will be completely separated from the glans and be able to move back and forth freely.
When the penis is soft, the foreskin fold normally covers the glans. But, once it has separated, the foreskin can be slid back to expose the glans, if desired (for example, for washing), by gently pulling the shaft skin towards the body. This is what is called “retraction.” The foreskin may also retract on its own with erection, as the shaft of the penis elongates and the glans pushes out of the foreskin fold.
The foreskin should never be retracted by force, as when it is still attached to the glans or the foreskin outlet is still tight. Forcible retraction can cause serious harm (see next question).

The intact boy requires no special care whatsoever. He may be bathed exactly the same way as his sister. It is best to “only clean what is seen,” avoiding any retraction of the foreskin. Scrubbing should be avoided, as it may damage the delicate tissue of the foreskin and remove natural substances that help protect against infection. Bubble baths or strong soaps (those containing perfumes or deodorants) should be avoided, although mild soap may be used on the external genitals. Only clean warm water should be used on the inner foreskin and head of the penis.

The most important thing about taking care of an intact penis is what not to do. The foreskin should never be forcibly retracted by anyone! Forcible retraction can lead to pain, bleeding, tearing of the foreskin, scarring, and the introduction of bacteria where they should not be. It can also cause the foreskin to become stuck behind the glans (called paraphimosis), which can be an emergency situation; however, this is very unlikely to happen if the foreskin is left alone.

I was told that a boy who was not circumcised needs to have his foreskin pulled back at each diaper change for cleaning. Is this really necessary?

NO, boys in diapers certainly do not need to have their foreskins pulled back (retracted) for cleaning, and forced retraction can be very harmful. All caregivers, such as daycare workers, babysitters, and relatives, should only wipe off the outside of the penis – whether for diaper changes or in the bath – just as one would wipe off a finger. The intact penis is mostly self-cleaning. Its snug fit and puckered opening keep out feces and other contaminants, and it flushes itself outward every time the boy urinates. The foreskin of a young boy is typically firmly fused to the head of the penis to protect it, and the delicate urinary opening, during the diaper years. In this state, it would nearly be impossible to retract it, and to attempt to do so would be very painful for the child, as well as damaging to the tissue.

My pediatrician says my son’s foreskin should have been retractable when he reached age 5, and that he now has a condition the doctor called “phimosis.”

Unfortunately, many pediatricians are taught this. However, this is outdated information. Studies have shown that the average age to full retractability is about age 10, and that it is normal for some boys to take into the teen years to become retractable. The progression leading to full retractability is variable from boy to boy, and it may take many years. There is no set age by which a boy “should” be retractable. Phimosis (a Greek word meaning “muzzling”) simply means that the foreskin is not yet retractable. Physiologic phimosis, where the foreskin is still fused to the glans, is the normal state for intact boys, which will naturally mature into a retractable state over time. Pathologic phimosis is an uncommon abnormal state, often caused by scarring and trauma from repeated attempts to retract the foreskin before it has loosened naturally. Pathologic phimosis can also be caused by a skin condition called BXO (balanitis xerotica obliterans), which is extremely rare in children or young adults. Properly educated medical providers know that a foreskin that is still attached to the glans is a protective feature of the still-developing penis, and they do not worry about age expectations for retractability. Of course, if your child is complaining of pain or discomfort, a medical evaluation is warranted.

Click here for more on conservative treatment options for phimosis, including BXO.

I was told by my family practice doctor that I should pull my son’s foreskin back a little more each day, to break what he called the “adhesions” that form there. He told me that if I did not do this, that my son would develop phimosis and maybe need a circumcision. My son screams when I do this and it is very stressful for me. Is this really necessary?

NO. Daily foreskin retraction is not only not necessary, it is also quite harmful. What your doctor is calling “adhesions” is the normal attachment of the foreskin to the glans that is present at birth. The foreskin is supposed to be tight and attached in childhood to protect the penis during the diaper years. Over time, the connection between the foreskin and the glans will gradually and naturally separate on its own, and the foreskin opening will get looser all by itself. The process leading to retractability does not need any outside help and should never be forced or hurried. See the previous question for more about the problems with a diagnosis of “phimosis.”

I have a new baby boy, and we kept him whole. A friend told me her intact son was forcibly retracted at his check-up recently. She said his penis bled when this happened and stayed swollen for days, and that he was in so much pain. How can I make sure this doesn’t happen to my baby when I take him to the doctor?

More and more boys are staying intact these days, but unfortunately very few American doctors or nurses are trained in the normal development of the natural penis. All too often a health professional may try to forcibly retract a child’s foreskin, mistakenly thinking they need to check inside or “help” the boy become retractable. Until medical training catches up with teaching accurate information about normal male genital development and care of the intact penis, parents will need to be strong advocates for their child.

First, educate yourself about correct, hands-off care of the intact penis. The more you know, the better you can protect your son. Second, seek out a “foreskin-friendly” doctor – either from online lists, or by interviewing the doctor before you choose them as a caregiver, to find out their knowledge and practices about care of the intact penis. Third, at each visit, before the diaper comes off, gently but firmly remind the doctor that your son is intact, and that you do not give permission for any retraction of his foreskin. If the doctor needs to examine the foreskin, you can handle it yourself to show them what they need to see. Fourth, stand near your baby when the doctor examines him, and be prepared to move quickly to stop any attempt to forcibly retract. It can happen in an instant.

Click here (then scroll down) to order “I’m Intact, Don’t Retract” stickers that you can put on your child’s diaper when visiting the doctor – a friendly way to remind them of your wishes, or to open the conversation.

Note that if bladder catheterization should be necessary, it can be done by very gently visualizing the urinary opening, or by feel, without retracting the whole foreskin (see next question).

If your son has already been subjected to forcible foreskin retraction, click here for more information on what you can do.

My toddler has to be catheterized for a surgery he is having soon. I’ve been told they will have to retract his foreskin to put the catheter in, but I am worried this will harm him. Is there any other way to catheterize an intact boy?

There are times when bladder catheterization is necessary, for example, to collect a sterile urine sample or for a surgical procedure. (Note that catheterization may not always be necessary. Click here to read more about possible alternatives.) You are right that forced retraction would be harmful to your son’s penis. Fortunately, forced retraction of the foreskin or complete exposure of the glans are not necessary for catheterizing a boy or for cleaning the area in preparation for the catheter. The foreskin can safely be gently manipulated to allow cleaning and exposure of the meatus, but this should never be done beyond the level of natural separation. Using a gentle touch and stopping at the earliest sign of resistance will avoid any harm. For a boy who does have a loose foreskin, retraction helps assure a sterile area for the catheterization. Otherwise, if the foreskin is tight or adhered, only easily visible surfaces need be cleaned.

To perform the catheterization, if the foreskin is at all loose, all that is needed is to gently slide it around to visualize the urinary opening (called the meatus, pronounced mee-AY-tiss). If the foreskin outlet is tight, catheterization can be done without visualizing the meatus. The penis is steadied with one hand and the catheter advanced through the foreskin outlet with the other. In most boys, the meatus is at or near the tip of the glans, right behind the foreskin outlet, thus with very small adjustments, the meatus can easily be found by feel. The catheter can be guided with gentle fingertip pressure on the underside of the penis from the outside, to compress the space between the foreskin and the glans and direct the catheter into the meatus.

For more information on catheterizing an intact male infant, see this video from Switzerland. See also our pamphlet on Development of Retractile Foreskin in the Child and Adolescent, with information on catheterization by feel.

My doctor says my 8-year-old son has an infection of the foreskin (or glans) and needs to be circumcised or this will keep happening or get worse. This seems drastic advice just for one infection. Is this really necessary?

NO. There is no need to amputate normal, functional tissue to address a minor and transient infection. The foreskin or glans may sometimes develop a mild irritation or infection from contact with chemicals in diapers, bubble baths, soap, or swimming pools, or from bacteria or yeast. These inflammations usually resolve by themselves with simple hygiene and avoidance of the offending irritants, without any need for a doctor’s care. If needed, there are good topical ointments and antibiotics available that can help get rid of any bacterial or fungal/yeast infection or irritation that persists. In the case of recurrent infections, seeking out and treating the root cause (such as eczema, diabetes, allergies, etc.) is indicated. Circumcision should only be looked upon as a last resort, and should only rarely, if ever, be necessary.

Sometimes redness at the tip of the foreskin is misinterpreted as being an infection, whereas it actually may be normal because of the high concentration of blood vessels there. Also, the head of the penis of an intact boy is naturally very red, sometimes even purplish, because it is a thin mucous membrane surface. In a circumcised boy, the glans is paler because the surface has thickened due to exposure.

When in doubt, it is best to leave the foreskin alone and avoid using soaps or other substances on it, which may make it more red and irritated. Simply washing it off with warm water and letting time heal it is often the best medicine. (Coconut oil or other natural remedies may help the healing process, but these should be discussed with a knowledgeable health care provider before using.)

My son has had several urinary tract infections. Our family doctor says it is because we did not have him circumcised. What should we do?

The risk of a urinary tract infection (UTI) in a boy that has not been circumcised is no different than in one who has been circumcised, except possibly in the first six months of life. Even then, the risk is still quite small at less than 1 in 100. In other countries similar to the US that do not circumcise their boys, the risk of developing a UTI has not been shown to be greater than in the US. UTIs in boys typically are the result of other factors, such as a congenital abnormality of the bladder or the tubes leading to the kidneys. It is not because they have a foreskin. Treatment with antibiotics, given by mouth, is usually all that is needed for a UTI in an intact boy, the same as it would be for girls (who have a 5 times greater chance of getting a UTI). A “foreskin-friendly” urologist could help you determine if your son’s infections indicate a more serious underlying problem which might need surgical correction. However, circumcision would do nothing to solve a congenital urinary abnormality, and may create problems of its own.

Click here for more on conservative treatment options for urinary tract infections in intact boys.

Sometimes my 4-year-old son’s foreskin seems to swell up and get all puffy when he urinates. He does not complain about it so it doesn’t appear to be painful. Is this a problem?

NO. Please don’t worry. “Ballooning” of the foreskin is a natural and normal event that happens with some intact boys. When the connection between the glans and the foreskin slowly dissolves, it leaves spaces under the foreskin, while the foreskin opening may still be tight. Then, when the boy pees, the urine can sometimes briefly inflate the pockets where the foreskin has naturally detached. Urine is sterile, so this is not a problem. Young intact boys have been known to amuse themselves by pinching off the foreskin opening where urine exits to inflate their partially detached foreskins on purpose, a harmless activity.

My son has white lumps under his foreskin. He also has a whitish discharge sometimes. Should I be concerned?

Probably not. The whitish discharge is most likely a harmless substance that is called “smegma” (Greek for “soap”). Smegma is just cells that have been sloughed off as the foreskin separates from the head of the penis. Girls also produce smegma in the folds of their genitals. Smegma may appear as small whitish crumbs at the foreskin opening, which can be easily wiped or washed away, or it may occasionally be washed out with urination. It can also accumulate under the foreskin as whitish lumps, sometimes called “smegma pearls.” These lumps will eventually go away naturally without treatment, as separation progresses and the mass works its way to the foreskin outlet. Smegma is not harmful, and is nothing to worry about, unless the child has other signs of infection, such as abnormal swelling, redness, discoloration, pain on urination, or over-frequent urination.

My child has a particularly long, overhanging foreskin. It seems like a lot of floppy skin he does not need. I am opposed to circumcision generally, but it seems like he needs a “trim.” What do you think?

Infants are commonly born with a foreskin that extends beyond the end of the head of the penis. The child’s penis can also sometimes pull inward because of temperature changes, fear, or other factors, leaving a floppy, unfilled tube of foreskin. It may seem that the foreskin is way too long for his penis, but as the boy matures into adulthood, his penis will grow into that “extra” skin. No one can tell in a baby how much the penis will grow as he becomes a man. A “trim” could lead to problems with discomfort as the penis grows or cause him to have tight, painful erections. More importantly, it will remove the most sensitive part of the penis. There is no such thing as redundant, extra, or unnecessary penile skin. Every penis is different, and however much foreskin a boy is born with is just fine.

My toddler likes to tug and pull on his foreskin, but sometimes he does this so hard that I am afraid he will hurt himself. Is this OK?

All boys tend to tug and play with their penises either because it feels good or just because it is there. The skin of the intact penis is very stretchy and can be manipulated in all kinds of ways that may seem extreme to parents, but are really not harmful. If whatever he’s doing hurts, the boy will stop doing it on his own. Stretching the foreskin may actually be beneficial in that it may help in the process of foreskin separation.

I worry that my intact son is being teased by his circumcised friends. He has told me that he feels “different” and wants to look like the other boys. I did not want him circumcised because I felt that nature designed the human body the way it is for a reason. What should I tell him?

First, let’s put teasing into perspective. Children often tease each other for all kinds of “differences” – freckles, braces, glasses, or the size of nose, breasts, or ears. The penis is the least likely part of the body that anyone else will ever see, and with more and more boys being left intact, teasing for being intact simply doesn’t happen as much as a parent might fear. While many intact boys are never bothered at all about the status of their penis, some may be more sensitive about needing to “fit in.” But there is much that a parent can do to support an intact boy who may be feeling this way.

When it comes to teasing, the basic approach for parents is to build self-esteem and to teach kids how to deal with bullies. What every intact boy needs to hear is that his body is wonderful and perfect the way it is, and that he can feel lucky and proud to have all his parts – in fact, that he has something the other boys don’t have. If he is old enough to understand human sexuality (perhaps 10 or above), you might reassure him that his adult sexual sensation will be far more important to him later than any momentary urge to look like others. Your son could be taught to speak up for himself by saying, “My parents wanted me to make my own decision about circumcision,” which avoids hurting the feelings of circumcised boys. It is worth pointing out to him that he is not alone, and that more and more boys are being left whole in the U.S. and Canada.

If your son thinks he wants to get circumcised out of feelings of insecurity or peer pressure, educate him, give him emotional support, and protect him from making an immature decision that he may later come to deeply regret. Eventually his maturing sexuality and self-image will overcome his youthful concerns of conformity, and he will count himself very lucky to be intact.

By
Michelle Storms, MD
George C. Denniston, MD, MPH
Mark D. Reiss, MD
Morris L. Sorrells, MD
Adrienne Carmack, MD
Gillian Longley, RN, BSN, MSS

Revised March 2016