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Journal of Indian Association of Pediatric Surgeons
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Year : 2005  |  Volume : 10  |  Issue : 2  |  Page : 89-91

Preputial retraction in children

Department of Surgery, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, Delhi, India

Correspondence Address:
Anup Mohta
28-B, Pocket-C, S.F.S. Flats, Mayur Vihar Phase-III, Delhi - 110 096
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9261.16468

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OBJECTIVE: The aim of the study was to assess preputial retractability in children at various ages. MATERIALS AND METHODS: Nine hundred and sixty boys attending the hospital were included in the study. Children with hypospadias or history of preputial manipulation were excluded. Preputial anatomy was studied and subjects were classified into five groups as described by Kayaba et al . RESULTS: The prepuce could not be retracted at all so as to make even the external urethral meatus visible in 61.4% children aged 0-6 months while this decreased to only 0.9% in children aged 10-12 years. At the other end of the spectrum, while prepuce could not be fully retracted in any child below 6 months, it could be done in about 60% in the age group of 10-12 years. CONCLUSION Preputial nonseparation is the major cause of preputial nonretraction in the pediatric age group. Prepuce spontaneously separates from the glans as age increases and true phimosis is rare in children. Surgical intervention should be avoided for nonseparation of prepuce.

Keywords: Circumcision; phimosis; prepuce; retraction

How to cite this article:
Agarwal A, Mohta A, Anand RK. Preputial retraction in children. J Indian Assoc Pediatr Surg 2005;10:89-91

How to cite this URL:
Agarwal A, Mohta A, Anand RK. Preputial retraction in children. J Indian Assoc Pediatr Surg [serial online] 2005 [cited 2021 Sep 20];10:89-91. Available from: https://www.jiaps.com/text.asp?2005/10/2/89/16468

Circumcision is the most commonly performed surgical procedure in children. Most common indications for this procedure include religious reasons and phimosis.

Prepuce develops and separates from the glans. As it takes time to do so, normal physiological nonseparation is mistaken as phimosis and referred for circumcision.

The present study was carried out to study the preputial anatomy at various ages to understand the natural history of preputial separation in pediatric population so that unnecessary circumcisions due to over diagnosis of phimosis could be avoided.

   Materials and methods Top

The present study was carried out in the University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi. After obtaining parental consent, boys under 12 years of age attending the hospital were examined for preputial retractability. They were divided into eight age groups of less than 6 months; 6 months to 1 year; 1-2 years; 2-4 years; 4-6 years; 6-8 years; 8-10 years, and 10-12 years. Patients having hypospadias or any previous surgical intervention on the prepuce were excluded from the study.

The preputial retractability was assigned as per the classification given by Kayaba et al .[1]

  • Type I - No retraction of prepuce at all.
  • Type II - External urethral meatus exposure only.
  • Type III - Glans exposure halfway to the sulcus of the corona.
  • Type IV - Glans exposure to above the corona at the site of preputial adhesion.

   Results Top

A total of 960 boys below the age of 12 years visiting the hospital as outpatients or inpatients were examined for the preputial retraction. Distribution of the preputial anatomy in the subjects according to classification is given in [Table - 1].

The prepuce could not be retracted at all so as to make even the external urethral meatus visible in 61.4% children aged 0-6 months while this decreased to only 0.9% in children aged 10-12 years. At the other end of the spectrum, while the prepuce could not be fully retracted in any child below 6 months, it could be done in about 60% in the age group of 10-12 years. There was increase in the number of children with higher degree of preputial separation with increasing age.

It is evident that the prepuce separated on its own with age without any intervention.

True phimosis was seen in only three children in the age group of 8-10 years and two children in the 10-12 years age group.

   Discussion Top

Deibert[2] in 1933 studied the separation of prepuce in human beings and concluded that it occurs due to a process of keratinization of the epithelium. The prepuce appears in the fetus at eight weeks as a ring of thickened epidermis, which grows forward at the base of the glans penis.[3] By 16 weeks, the prepuce has grown forwards to the tip of the glans. At this stage, the epidermis of the deep surface of the prepuce is continuous with the epidermis covering the glans. By a process of desquamation, the preputial space is formed. The squamous cells arrange themselves in whorls, forming epithelial cell nests. The centers of these degenerate, so forming a series of spaces; these, as they increase in size, link up, until finally a continuous preputial space is formed. The prepuce is still in the course of developing at the time of birth and incomplete separation renders it nonretractable. Gairdner[3] in his landmark study found that of the newborns, only 4% had a fully retractable prepuce, in 54% the glans could be uncovered enough to reveal the external meatus, and in the remaining 42% even the tips of the glans could not be uncovered.

From 9545 observations of the state of the prepuce in 1968 schoolboys aged 6-17 years examined annually for up to 8 years, Øster[4] concluded that physiological phimosis is a rare condition in schoolboys, and it has a tendency to regress spontaneously. Preputial nonseparation (adhesion) occurs frequently but epithelial separation takes place gradually and spontaneously as a normal biological process in childhood and may continue till the age of 17 years. Attempts at retraction probably cause secondary phimosis, due to tissue damage and scar formation, which may then require operation.

According to Wright,[5] the prepuce is designed to be nonretractable in infancy and early childhood when the developing glans needs protection from the mechanical trauma due to clothing and chemical trauma of ammonical urine and he stressed that the time to pull the foreskin back is when the child is old enough to do it himself. Kayaba et al .[1] studied the process of preputial separation in Japanese population and concluded that the degree of preputial separation increases with age.

Phimosis is defined as an abnormal degree of the narrowing of preputial opening, causing obstruction to urine flow, or nonretractability persisting into childhood.[5] It could be phimosis with supple but inadequately yielding skin or associated with abnormal skin or scarring of the prepuce. Rickwood et al .[6] stressed the need to differentiate between true phimosis and nonseparation of prepuce. The nonretractile skin is asymptomatic and harmless requiring no intervention. Shankar et al .[7] found an incidence of pathological phimosis in only 0.4 cases/1000 boys per year and found that the number of circumcisions far exceeded the estimated number.

The usual reason for referral and the most common indication for circumcision is phimosis. However, it is has been observed that phimosis is over-diagnosed. This diagnosis is made not only by the family of the parents but also the primary physician and the pediatrician.

By their studies, Gairdner[3] and Øster[4] concluded that prepuce is adherent to glans during the natural course of development of prepuce and separates gradually with age. Most of the cases diagnosed as phimosis are due to nonseparation of the prepuce from the glans. Gairdner[3] found that of the newborns, only 4% had fully retractable prepuce while in 42%, even the tip of the external meatus could not be uncovered. The present study has shown that 65% children belonged to Category I in which the external meatus cannot be seen. In none of the subjects in this study the prepuce could not be fully retracted. In the older age group, the number of the children in Category I decreased with age and in 65.7% subjects the foreskin could be fully retracted. Only one child had Category I prepuce.

To study the true natural history of preputial separation in children, it is necessary to follow the children over years as Øster[4]. He asserted that any manipulation or surgical intervention is unnecessary to hasten the separation of prepuce from the glans.

The practice of circumcision proliferated during World War I and II with the view that it could aid hygiene and prevent venereal disease. Circumcision decreases the incidence of urinary tract infections and also the incidence of invasive penile cancer. In Turkey, circumcision is a necessity for boys to gain masculine identity.[8] Thus, common indications for circumcision include phimosis along with religious, ritual, cultural, and medical indications such as balanoposthitis and balanitis xerotica obliterans. Although phimosis is one of the most important indications, it is necessary to differentiate between pathological and physiological phimosis (nonseparation).[9],[10]

Although circumcision is considered to be a simple procedure devoid of much morbidity, it is associated with many complications like hemorrhage, edema, infection, meatal stenosis, urethral fistulae, unsightly scars, penile curvature, shortness of shaft skin, and partial, or total penile loss.

Preputial skin has been used as a graft in many procedures such as urethroplasty for hypospadias or strictures, the reconstruction of skin defects of various sizes caused from trauma, acute burn, release of burn contractures,[11] and syndactyly repair.[12] The advantages of using preputial skin as a graft donor site include minimal donor site morbidity, low tendency to contract, and hairless skin.

In view of the various studies including the present one and the versatile use of preputial skin as a graft, it is suggested that circumcision should be avoided as far as possible especially for nonseparation of prepuce in early childhood. Alternatives to circumcision such as a topical steroid such as betamethasone valerate 0.05% applied to the tip of the phimotic prepuce;[13] use of EMLA cream (eutectic mixture of lignocaine and prilocaine) to separate adhesions in the outpatient clinic;[14] dorsal relieving incision operation;[15] and retraction under GA alone[16] were found to be less invasive and had less postoperative complications. These procedures along with local hygiene will help preserve preputial skin for further use if required.

   Acknowledgments Top

Authors thank the Indian Council of Medical Research, New Delhi, for providing financial assistance for carrying out the study.

   References Top

1.Kayaba H, Tamura H, Kitajima S, Fujiwara Y, Kato T, Kato T. Analysis of shape and retractibility of the prepuce in 603 Japanese boys. J Urol 1996;156:1813-5.  Back to cited text no. 1  [PUBMED]  
2.Deibert GA. The separation of the prepuce in the human penis. Anat Rec 1933;57:387-99.  Back to cited text no. 2    
3.Gairdner D. The fate of the foreskin. Br Med J 1949;2:1433-7.  Back to cited text no. 3  [PUBMED]  
4.Øster J. Further fate of the foreskin. Arch Dis Child 1968;43:200-3.   Back to cited text no. 4    
5.Wright JE. Further to "the further fate of the foreskin". Med J Aust 1994;160:134-5.  Back to cited text no. 5    
6.Rickwood AMK, Walker J. Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence? Ann Royal Coll Surg Engl 1989;71:275-7.  Back to cited text no. 6    
7.Shankar KR, Rickwood AMK. The incidence of phimosis in boys. BJU Int 1999;84:101-2.  Back to cited text no. 7    
8.Sahin F, Beyazova U, Aktürk A. Attitudes and practices regarding circumcision in Turkey. Child: Care, Health and Development 2003;29:275-80.  Back to cited text no. 8    
9.Dewan PA. Treating phimosis, Med J Aust 2003;178:148-50.  Back to cited text no. 9    
10.Quaba O, Mackinley GA. Changing trends in a decade of circumcision in Scotland. J Pediatr Surg 2004;39:1037-9.  Back to cited text no. 10    
11.Yildirim S, Akan M, Ak φz T, Tangolu B. The preputium: An overlooked skin graft donor site. Ann Plast Surg 2001;46:630-4.  Back to cited text no. 11    
12.Fontenot C, Ortenberg J, Faust D. Hypospadiac or intact foreskin graft for syndactyly repair. J Pediatr Surg 1999;34:1826-8.  Back to cited text no. 12    
13.Ashfield JE, Nickel KR, Seimens DR, MacNeily KA, Nickel JC. Treatment of phimosis with topical steroids in 194 children. J Urol 2003;169:1106-8.  Back to cited text no. 13    
14.MacKinlay GA. Save the prepuce. Painless separation of preputial adhesions in the outpatient clinic. BMJ 1988;297:90-1.  Back to cited text no. 14    
15.Cooper GG, Thompson GJ L, Raine PAM. Therapeutic retraction of the foreskin in childhood. BMJ 1983;286:186-7.  Back to cited text no. 15    
16.Saxena AK, Schaarschmidt K, Reich A, Willital GH. Non-retractile foreskin: A single center 13 -year experience. Int Surg 2000;85:180-3.  Back to cited text no. 16    


[Table - 1]

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