Several conditions can be seen in uncircumcised boys; some are benign and only require reassurance to patients and parents, and others are complications that require intervention.

Benign conditions — Benign conditions that do not usually require intervention, but only reassurance, include:

●Physiologic phimosis

●Preputial cysts due to smegma

●Transient ballooning of the foreskin

Physiologic phimosis — As discussed previously, physiologic phimosis is present in almost all newborn males. Although the spontaneous resolution of physiologic phimosis is high, the rate is variable so it is not possible to set an age by which the foreskin should be normally retractile. School-age boys without a fully retractible foreskin and their parents should be counseled that there is normally a wide range of retractibility rate, and over time, there is a very high likelihood physiologic phimosis will spontaneously resolve. The clinician should also reinforce proper preputial hygiene; patients and/or parents can be taught to perform gentle stretch exercises. A four- to eight-week course of topical corticosteroids (eg, 0.05% betamethasone cream) applied directly to the preputial outlet twice daily speeds up the natural process of obtaining foreskin retractility. 

Smegma and preputial cysts — Desquamated epithelial cells that are trapped under the foreskin are referred to as smegma. In boys without a fully retractible foreskin, smegma may form white lumps under the foreskin, often referred to as preputial cysts. Preputial cysts are benign and usually are located around the corona. They aid in the process of separation between the foreskin and the glans penis, and are extruded once the foreskin becomes more retractible.

Foreskin ballooning — Transient ballooning of the foreskin during voiding is usually benign. However, if urinary retention can only be resolved after applying manual pressure, the parent or care provider should seek medical attention. In all other cases, parents should be assured this is a benign condition that will resolve over time as there is increasing retractibility of the foreskin.

Pathologic conditions — Complications of the foreskin that typically require intervention include:

●Pathologic phimosis

●Paraphimosis

●Recurrent urinary tract infections (UTIs)

●Severe/recurrent balanoposthitis

●Balanitis xerotica obliterans (BXO)

●Frenulum breve

Pathologic phimosis — Pathologic phimosis is defined as foreskin that is truly nonretractable secondary to distal scarring of the prepuce, such as that which occurs with preputial fibrosis due to trauma, infection, and/or inflammation. A fibrotic preputial ring (cicatrix) may form from scarring due to forcible retraction or following episodes of balanoposthitis. Cicatrix may also occur from scarring after circumcision. 

Symptoms of pathologic phimosis include:

●Secondary nonretractability of the foreskin after retractibility at an earlier age

●Irritation or bleeding from the preputial orifice

●Dysuria

●Painful erection

●Recurrent balanoposthitis

●Chronic urinary retention with ballooning that is only resolved with manual compression

Pathologic phimosis increases the risk of other foreskin complications including paraphimosis, recurrent urinary tract infections, recurrent/severe balanoposthitis, and BXO.

When pathologic phimosis is present, pediatric urologic consultation should be sought. Several options exist for treatment of pathologic phimosis, and families should never be counseled that their child "needs" a circumcision without considering more conservative interventions.

●Stretching exercises of the prepuce have been reported to have some success in treating pathologic phimosis. In one study that compared stretching and topical corticosteroids with a control group with stretching alone, 60 of 90 children in the control group responded with resolution of phimosis using a protocol of retraction as far back as the appearance of stricture for one minute, performed four times daily for one to three months.

●Topical corticosteroids, usually administered concomitantly with routine stretching exercises, are effective in most boys with pathologic phimosis. Betamethasone cream (0.05%) is the topical agent most frequently used; other agents include 0.01 to 0.5% triamcinolone and 0.05% fluticasonepropionate.

In two case series, the daily application of 0.05% betamethasone cream for at least four weeks resulted in complete resolution of phimosis in over 90 percent of patients.

•In one study of 137 boys (median age 5.4), the administration of topical corticosteroid applied twice a day, and stretching exercises, which were started five days after the initial application, resulted in a 90 percent rate of retractable foreskin. In this study, half of the patients had a phimotic but retractable prepuce, one-third had a nonretractable phimotic ring, and one-third had a pinpoint opening. There were no differences in the response rate among the three groups.

•In another study of 247 boys referred for surgical treatment for phimosis (mean age 7.6 years), the protocol of betamethasone cream applied twice a day for 15 days and then once a day for 15 more days, and stretching exercises started seven days after the first application of betamethasone, resulted in a 77 percent resolution rate after one protocol cycle, and an additional 20 percent of patients had resolution after a second course. There were no differences in response rate based on the phimosis grade; grade 1: fully nonretractable, grade 2: partial or complete exposure of the glans with a lacerated foreskin, and grade 3: phimotic ring.

●Although rarely used, alternative surgical procedures to circumcision include preputioplasty (surgical release of the scarred tissue), preputial balloon dilation, and various prepuce preserving plastic surgical procedures designed to widen the preputial ring.

●Circumcision. 

In our practice, we initially treat pathologic phimosis with 0.05% betamethasonecream applied twice a day directly on and around the phimotic ring for six weeks, and stretching exercises (gentle retraction of the foreskin) performed several times a day. In patients who fail topical corticosteroid therapy, surgical options are presented to the patient/family, and the choice of intervention is based on the clinical findings and the patient/family preference.

From Up To Date: Care of the uncircumcised penis in infants and children