Foreskin Abnormalities in Children: Conditions, Symptoms, and Treatment Options
Normal Foreskin Development: When Should the Foreskin Retract?
The foreskin is the loose skin covering the head (glans) of the penis. The foreskin cannot be retracted (pulled back from the head of the penis) in most newborns, but over time the foreskin will separate so that it is able to be retracted.
There is no need to pull the foreskin back until it naturally does so. In fact, forcing the foreskin to retract too early can result in scarring and problems in the future.
The median age for full foreskin retraction is around 10 years old, meaning half of the boys can fully retract their foreskin before this age, and the other half after 10 years old. It can happen years earlier or later, and in 99% of boys, the separation will have completed by 17 years.
Parents often worry about whether their child’s foreskin is developing normally, but there’s generally no need to retract the foreskin before it does so naturally. During early childhood, simply cleaning the area with a bath or shower is sufficient.
The below graph illustrates our understanding of the age at which the foreskin becomes retractile. Early understanding in the 1940’s (Gairdner), was not based on scientific research, like the rest of the published information that came later. There is general agreement that almost all boys can retract the foreskin at the time of puberty. This age varies between boys, and is usually between 12-16 years.
Partial Foreskin Retraction: A Normal Stage of Development
The inner layers of the foreskin gradually separate from the glans (head of the penis) over time. The separation process happens over a long time – around 50% of boys can pull the skin back before 10 years of age, and it will happen later for the other 50% of boys.
Partial retraction of the foreskin is normal during the separation process. It can sometimes happen unevenly, so it’s common to see the foreskin retract on one side more than the other. These are called preputial adhesions.
This is part of normal development, and there’s no need for concern as the foreskin will eventually retract fully as your child grows older.
Foreskin Ballooning: What is it and When Should You Be Concerned?
Ballooning occurs during urination when the foreskin fills with urine like a balloon. This is generally a normal part of development as the foreskin becomes more retractable. Most boys develop a bulge of the shaft, and the urinary stream remains normal, even if ballooning happens. Sometimes the urine stream can initially be diverted, however straightens as the stream gets stronger.
If ballooning becomes persistent causing urine trapping in the foreskin, it can become a problem. This can occur with poor urinary flow, and there might be dribbling or spraying. Sometimes the urine needs to be ‘milked’ out of the foreskin.
Urine trapping can lead to foreskin irritation and chemical dermatitis. If this occurs, dabbing the tip of the foreskin with a tissue can help to ‘wick’ the rest of the urine from inside the foreskin and can help reduce irritation.
What Is The Lump On The Penis?
This is smegma – a whitish, cheesy substance that can sometimes collect under the foreskin. It’s made up of oils, secretions and keratin, which plays a role in helping the foreskin separate from the glans.
These smegma pearls are completely normal. They will work their way up and out and help facilitate natural foreskin retraction over time.
This doesn’t need an ultrasound scan.
How to Clean the Foreskin in Children
Foreskin hygiene is important for preventing infections and irritation. For younger children, bathing is usually the best way to clean the foreskin, as the water helps soak and rinse the area. While in the bath, it’s important to let the foreskin soak properly.
For older boys, showers are also fine, but if the foreskin is still developing or if there are concerns, they can soak the foreskin in a cup of warm water while showering. There’s no need to forcibly retract the foreskin during cleaning— it does not need to be retracted for cleaning, unless it naturally already does so.
Balanitis: Infection of the Foreskin and Penis
Balanitis is an infection of the penis and foreskin, causing swelling, redness, pain, and tenderness. In some cases, there may also be discharge (pus), indicating a more severe infection.
Sometimes an infection can spread up the penis – when the entire shaft of the penis is infected, this is called balanoposthitis.
Treatment for balanitis often includes:
- Topical ointments or antibiotics prescribed by your doctor.
- Warm baths to help soothe the area.
Recurrent episodes of balanitis may be a reason to consider circumcision.
Urinary Tract Infections (UTIs) Related to Foreskin Issues
Boys with foreskin abnormalities may have a higher risk of developing urinary tract infections (UTIs). Certain conditions of the renal system, such as vesico-ureteric reflux (where urine flows backward into the kidneys), can also increase this risk.
In some cases, circumcision may help lower the risk of UTIs in boys with these conditions, as it reduces the risk of bacteria being trapped under the foreskin.
Phimosis: When the Foreskin Doesn’t Retract
Phimosis occurs when the foreskin does not retract, which can be either normal (physiological) or abnormal (pathological).
Physiological Phimosis: This is normal in younger boys – it just means that separation hasn’t yet occurred. The foreskin naturally becomes more retractable over time, with the median age for full retraction being around 10 years. Forcing the foreskin to retract too early can lead to scarring and problems in the future.
Pathological Phimosis: This can occur when there is scarring of the foreskin, making it too tight to retract. A condition known as BXO (Balanitis Xerotica Obliterans) can develop, usually between the ages of 7-10. BXO causes thickening and scarring of the foreskin, making retraction difficult or impossible. In such cases, circumcision is often the recommended treatment.
When to Seek Medical Attention for Foreskin Abnormalities
While many foreskin conditions resolve on their own with time, there are cases where medical attention is necessary. You should seek medical advice if:
- Your child’s foreskin is causing persistent pain or irritation.
- There is a severe infection, such as recurrent balanitis or discharge.
- Ballooning persists with poor urinary flow.
- Symptoms of a UTI appear, such as fever, pain during urination, or foul-smelling urine.
- There is scarring or thickening of the foreskin which is stopping retraction
If your child experiences any of these symptoms, contact your paediatrician or urologist for further evaluation.
For more information about surgical options like circumcision, visit our Circumcision for Children page.
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FAQs About Hyrdocele in Children
What is hydrocele repair surgery?
Hydrocele repair surgery is a day procedure where fluid around the testicle is drained, and the opening in the abdominal wall is closed with dissolvable sutures. It’s similar to inguinal hernia repair, and it’s performed under general anaesthetic.
How long does hydrocele surgery take?
The surgery itself takes about 15-20 minutes. Including the time for anaesthetic administration and recovery, you can expect your child to be away from you for around an hour.
Will my child need surgery on both sides?
Most of the time, surgery is only performed on the affected side. If there’s no visible swelling on the other side, there’s usually no need for additional procedures. Your surgeon will assess this during the examination.
What are the risks of hydrocele surgery?
Hydrocele repair is a straightforward procedure, but as with any surgery, there are some potential risks. These include recurrence of the hydrocele, infection, and in rare cases, injury to nearby structures like the testicle or vas deferens.
How long does recovery take after hydrocele surgery?
Most children recover quickly after hydrocele surgery. Your child can return home within 1-2 hours after the procedure and resume normal activities, like bathing, the day after surgery. They can return to school within 5-7 days and sports after 2-3 weeks.
What should I expect after hydrocele surgery?
After surgery, it’s common to notice some swelling and bruising around the wound. Your child will have a waterproof dressing that can be removed after a week. Pain is usually mild and can be managed with paracetamol or ibuprofen for a few days.
When should I seek medical attention after surgery?
You should seek medical attention if your child experiences any of the following symptoms after surgery:
- You should seek medical attention if your child experiences any of the following symptoms after surgery:
- Persistent pain that doesn’t improve with medication.
- Increased swelling or a new bulge in the groin.
- Fever over 38.2°C.
- Vomiting or trouble feeding.
- Discharge or bleeding from the wound that doesn’t stop with gentle pressure.
- No bowel movements for 3 days after surgery.
Is swelling normal after hydrocele surgery?
Yes, some swelling is normal after hydrocele surgery. However, if the swelling is accompanied by pain, tenderness, or vomiting, you should contact your surgeon or family doctor. If your child is unwell, you may need to go to the emergency department.
How do I care for the wound after hydrocele surgery?
The wound will be covered with a waterproof dressing, which can be removed after a week in the bath or shower. Swelling and firmness under the wound are part of the normal healing process, and the scar will fade over time.