Foreskin 101: How to deal with your baby boy's business

When Catherine Groves’* four-year-old son, Will*, started complaining that it hurt when he went pee, she did what any sensible mom would do—she had her husband go into the bathroom to have a look. After gently pulling back Will’s foreskin, Dad saw that his penis looked red and inflamed, so he took him to a walk-in clinic.

It turns out Will had a minor infection that was easily treated with an antifungal hydrocortisone-cream. The doctor visit also revealed that Will’s foreskin had separated from his penis—up until that point, Groves wasn’t sure if it had yet. “We hadn’t really been checking,” she says.

This was Groves’ (and her son’s) uncomfortable introduction to foreskin care. “It’s not that it’s a really complicated thing, but if you’ve never dealt with it, you don’t know what to do,” says Groves, adding that her husband is circumcised, so, like her, he’s a stranger to caring for foreskin.

Indeed, the loose skin that covers and protects the head of the penis can cause parents a lot of anxiety, says Peter Metcalfe, a paediatric urologist at Stollery Children’s Hospital in Edmonton. They worry about retraction, proper cleaning and whether they’re doing the right things, he says. Part of the problem is a knowledge gap. More and more parents are choosing to leave their baby boys’ foreskin alone—in 1970s Canada, an estimated 48 percent of boys were circumcised; today, the rate has dropped to 32 percent and will likely keep heading south. But if dad is circumcised—or even if your doctor is—there are a lot of blanks that need filling in.

The Canadian Paediatric Society (CPS) recently put out a few position statements on male circumcision. Last September, it reviewed its stance on routine circumcision, noting that the benefits aren’t widespread enough to endorse it as a standard procedure for all newborn males. In the same statement, the CPS urged doctors to ensure that parents of uncircumcised newborn boys know how to properly care for their son’s penis when they leave the hospital (granted, even if they do get a lesson, chances are strong the knowledge will evaporate somewhere into the postpartum haze). But it will take time to educate a generation of circumcised dads and doctors.

“It’s a huge generational change,” explains Metcalfe. “The pendulum has swung in the other direction.” And though it may make newbie parents apprehensive, caring for a boy’s foreskin is straightforward, and infections are extremely rare, says Metcalfe. “It’s a pretty low-maintenance little organ.”

Here are the answers to all questions you may be too shy to ask.

How do I care for my baby's uncircumcised penis when he's a baby?

The advice Groves received from her family doctor when Will was a newborn—“Don’t worry about it for now”—was spot-on. “In an uncircumcised, otherwise healthy baby, there’s really no special care that’s required at all,” says Michael Dickinson, a paediatrician at Miramichi Regional Hospital in New Brunswick. “I tell parents to forget about it and ignore it, at least through the baby stage.” During that time, regular bathing and gentle washing on the outside is all that’s needed.

When will my son's foreskin retract?

Some time between the ages of two and five, the connective tissue between the foreskin and the head of the penis begins to dissolve and the foreskin opening widens. By age five, most boys (85 to 90 percent) will be able to pull back their foreskin, though full retraction can take until puberty or later in one to two percent, says Metcalfe.

“Where some people get into trouble is they try to force the foreskin back when it’s not ready to be retracted,” says Dickinson. It’s important parents leave it be and let their son discover retraction on his own (which often happens in the tub, since the penis is a favourite bath toy). You may notice it, but Dickinson says it’s not something parents need to be checking or talking to their kid about. If you have a concern, ask your doctor to check it at your kid’s next exam.

Once his foreskin pulls back, what’s the best way to clean the penis?

After retraction, you can talk to your kid about proper washing if he’s interested and responsible—but Dickinson says to be careful not to force him into a hygiene routine before he’s ready. If your boy can barely dress himself, it’s a lot to expect him to clean his penis. In those cases, just sitting in the tub and letting water wash around it should be enough to keep it clean, says Dickinson.

Once he’s washing behind his ears and everywhere else, encourage your kid to retract his foreskin and clean away any obvious smegma—oil and dead skin cells (it looks pasty and whitish) that collect under there—and then put the foreskin back in place. “Most foreskin will naturally return to the non-retracted position, but there is a small risk that it can get stuck in the retracted position and might need an ER visit to carefully release it,” says Dickinson. A mild soap can be helpful if there is a lot of smegma (just be sure the soap is completely rinsed off), though if it causes irritation, water will usually suffice.

This has become the regular washing routine for Kerrianne Kusch’s two oldest boys, ages six and four. “We’re pretty open about it. They know when they shower to roll back their foreskin and clean,” says the mom of three boys, adding, “but they need a lot of reminding.” Her husband is also uncircumcised, so he knows the drill and helps educate the boys.

I’ve heard some horror stories. Just how common are infections in the penis or foreskin?

Dickinson sees a lot of babies and toddlers with red or inflamed skin on their penis or foreskin, usually from diaper irritation. Parents often assume it’s an infection, but it’s usually just chafed skin in need of petroleum jelly. In his experience, true infections—typically caused by an abrasion or break in the skin (a self-inflicted scratch, or a tear caused by a parent’s too-vigorous cleaning or by forcing the foreskin back) on a child still in diapers—are extremely rare. In older boys, an infection can start with a tear or abrasion as well, but that’s even less common since the source of infection (bacteria in a dirty diaper) has been removed.

In toilet-trained boys, infection can also be caused by a buildup of smegma trapped under foreskin that has yet to retract. The smegma attracts bacteria, and it all eventually ruptures (like a pimple), often solving the problem. It has the added bonus of loosening the foreskin, helping it to retract. While infections are uncommon, they’re impossible to miss and should be seen by a doctor. The penis becomes red, swollen and tender—“It looks like a sausage,” says Dickinson—and even wearing underpants or walking can hurt. Infections usually clear up with topical ointment or oral antibiotics.

Should I worry that my kid’s foreskin hasn’t retracted?

The CPS says normal foreskin may not pull back until puberty. Something to watch for, though, is phimosis, which occurs in neonate and teen boys when an overly tight foreskin prevents retraction. Most boys have some degree of phimosis at birth, but it gradually resolves as the foreskin loosens. Phimosis is rare and isn’t really a concern unless the tightness bothers your boy, it interferes with peeing or the foreskin doesn’t retract by puberty—Dickinson recommends seeing your doctor if this is the case. A prescribed cortisone cream works about 80 percent of the time to help loosen the foreskin. If it doesn’t, or if the foreskin is so tight it blocks urine, Dickinson will refer the family to a paediatric urologist who will decide on more definitive action, such as a delayed circumcision.

What if my kid needs to be circumcised when he’s older?

The bad stories get around, but circumcision later in life is actually quite rare, affecting about one percent of boys, Dickinson says.

It happened to Lauren West’s* son, Sam*, whose foreskin was extremely tight from birth. It was so remarkably tight, in fact, that West’s doctor warned her when Sam was just six months that it could cause problems with urination, including a “ballooning” effect (where the foreskin fills with pee because its opening is so small it impedes the flow). Though Sam was still in diapers and West never saw any ballooning, she took a proactive approach with cortisone cream. After a couple of years of using the cream with no lasting results (his foreskin would tighten right back up when she stopped using it), Sam got a terrible infection.

“His penis swelled up like crazy. He couldn’t even walk,” recalls West. “That was the last straw for me. I didn’t want to deal with infection after infection, and I didn’t want to risk giving it more time and then having to circumcise him even later.” Her urologist fast-tracked Sam, now four, for circumcision at age three.

While delayed circumcision is uncommon, it can be the only solution for boys with recurrent infections or phimosis that doesn’t respond to cortisone cream—though doctors seem conflicted on whether it’s necessary for tight foreskin unless it’s causing the kid distress, as many cases eventually resolve.

Another extremely rare condition (it affects less than one percent of boys, says Metcalfe, though some doctors believe it’s underdiagnosed) that can result in surgery is lichen sclerosus, which is when an atypical scar forms on the tip of the foreskin. Doctors aren’t sure what causes the scar (hence “atypical”)—it’s not bacterial, and it’s not due to poor hygiene. It’s usually sore and doesn’t improve on its own, so circumcision is the most common treatment.

I should relax, shouldn’t I?

Yes. Most boys will sail through childhood without any issues. Over time, as circumcision of newborns becomes even less common, that extra skin will no longer cause such anxiety. “I think there could be information given right at birth, just so you’re aware from the start,” says Groves. She believes doctors should take the lead, looking for retraction at checkups and talking parents through their concerns. And parents, for their part, shouldn’t be too shy to talk about it either. It’s just skin, after all.

* names have been changed

Are there any symptoms that mean my son's penis might be infected or have another issue?

Not sure if your boy’s foreskin is just irritated or needs medical attention? Call a doctor if genital tenderness is accompanied by one of the following symptoms:

- Fever - Pain when urinating - Redness or swelling - Obvious discharge or pus - The foreskin retracting and becoming stuck behind the head of the penis

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