Phimosis or tight foreskin is common and depending on severity may be physiological or otherwise. It must not be confused with redundant foreskin which may be normal. Foreskin retractility in the older child and adult is important for functional and hygienic issues. A too tight foreskin increases risk the of balanitis, ballooning, spraying stream etc. and may become a progressive condition. Penile cancer, while rare, almost always develops in uncircumcised patients probably secondary to local chronic irritation.
Phimosis may be managed by prepucoplasty or circumcision though in my view circumcision is the more definite and satisfactory procedure
Preputial adhesions, where the inside of the prepuce attaches to the glans, are physiological in utero and the first couple of life and thereafter should gradually spontaneously separate. Failure to do so may result in retained smegma and infections. Management by separation of these adhesions is a very minor general anaesthetic procedure
Any operation should be undertaken only by appropriately trained and qualified surgeons. Therefore we believe religious circumcisions should be performed in a theatre environment as in any other circumcision.
Retractile and undescended testes
Undescended testes are uncommon affecting approx 2% of the population. Because of the less favourable temperature conditions the undescended testis is less likely to develop normally particularly with regard to spermatogenesis and is more exposed to trauma. Torsion is also a recognised complication of a truly undescended testis. Management is recommended in the form of an orchidopexy; in this procedure the testis and spermatic cord are mobilised up to the internal inguinal ring and, provided adequate length is achieved, the testis is then fixed in the scrotum.
Retractile testes are far more common and physiological for the first few years of life. The degree of retractility gradually reduces as the child gets older. Retractility is enhanced in excited or upset children, examination is therefore difficult. Children are often best examined in the bath. As long as the testis rests in the scrotum then this is unlikely to become a significant clinical issue. If in doubt the child should be referred for a urological opinion.
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