Phimosis: when is circumcision necessary?

Phimosis in infants. What is it exactly?

Initially, it is a physiological phenomenon: it is when the ring at the top of the foreskin is too narrow. At birth, the foreskin of little boys completely covers the glans. Decalculation is not possible. We can see the opening of the urethral canal but nothing more. This is normal, there is no need to worry. In fact, the foreskin sticks to the glans by preputial adhesions.

These will come off spontaneously on their own in the vast majority of cases, during childhood, sometimes even until adolescence. The adhesions are released under the effect of secretions coming from the bottom of the groove of the preputial ring. By exteriorizing, they separate the mucous membrane of the glans from that of the foreskin. Most often, they result from the absence of cracking in the little boy. Up to 3-4 years, the presence of simple phimosis is not pathological. Around 2 years old, we can say that half of the boys can be retracted. However, if this is not the case with your child yet, there is no point in forcibly retracting it. Rarely, preputial adhesions require forced release by a doctor or surgeon, performed with a local anesthetic such as EMLA and / or laughing gas such as MEOPA.

When do we speak of pathological phimosis?

Pathological phimosis is due to episodes of inflammation or to forced retracting causing small cracks which heal in the form of retractions. So we are talking about pathological phimosis in infants and children when the preputial ring is narrow, thick and fibrous. This phimosis can be the cause of complications such as balano-posthitis infections. These result in a foreskin subject to inflammation. There is also a purulent discharge. Another type of complication: retention of urine under the foreskin. It may be a few drops or a larger amount under the expanding foreskin. This then gives the penis a buried appearance.

Pathological phimosis: is circumcision compulsory?

It is quite rare that it is necessary to have recourse to circumcision. In general, we start with a local treatment: the application of corticosteroids, once or twice a day for two months. When scalping becomes possible thanks to the ointment, parents should not hesitate to do it regularly. If the child is taller, he must also be removed with each urination in order to maintain the width of the preputial ring. And for good reason, it can tighten again, once the treatment is finished. Nevertheless, corticosteroids can treat 80% of pathological phimosis. In some cases, when the tissues are flexible enough, it is possible to perform an enlargement of the preputial ring leaving the foreskin in place.

Circumcision, which only concerns the remaining 20%, is much less systematic than ten years ago and that is a good thing. The forced cut-outs form small cracks which heal in the form of retraction, ”explains Professor Georges Audry, head of department in pediatric and neonatal visceral surgery at Trousseau hospital. Surgery is mainly reserved for phimosis having resisted local treatments, but also in certain special cases: when there is a sclero-atrophic lichen (dermatological disease with whitish and thickened areas), when there is significant sub-preputial retention in infants, or after several infections that have caused the very stiff fabrics.

Circumcision: a measure of hygiene?

In the United States, circumcision is almost automatic in the maternity ward. Nearly 55% of children are believed to be circumcised at birth. For religious reasons, Hispanics of the Catholic faith are those who practice it the least. This procedure is recommended by the American Academy of Pediatrics (AAP). According to her, it would be healthier for young boys to be circumcised. For his part, Georges Audry recalls that circumcision remains a surgical act, not without risk: ” parents must weigh the pros and cons when it is considered for hygienic purposes and without medical indication ”.

Circumcision, sexuality and HIV

In adulthood, is sexuality different for circumcised men? It seems so. According to Professor Audry, circumcision would decrease the frequency of premature ejaculations in men affected by this phenomenon. A point confirmed by sexologist Gérard Leleu: “in fact, when the glans is no longer covered by its mucous membrane, it is exposed to the outside and to the friction of the underwear. As a result, it becomes epidermis, more exactly it keratinizes and becomes less sensitive to various forms of arousal. The man can therefore better control his ejaculatory reflex, which is rather beneficial for the woman ”. Moreover, in circumcised men, the risk of breaking the frenulum during intercourse is lower. And for good reason, “when the glans is stripped, the frenulum solidifies”. Another benefit mentioned by Georges Audry: HIV prevention in highly endemic countries. In 2007, WHO and UNAIDS also integrated circumcision into their program of measures to curb the spread of AIDS in sub-Saharan Africa and in high-risk areas.

What if Baby doesn’t have a foreskin (hypospadias)?

Sometimes little boys are born without or with a small foreskin. This is called a hypospadias. The orifice of the canal is not in place, resulting in a curvature of the penis. ” In that case, do not remove the foreskin for religious reasons, because the remaining skin will be useful to the surgeon to repair this anomaly ”, advises Professor Georges Audry. As an alternative, some, especially within the Jewish community, just take an injection on the sex of the child in order to “make him bleed” and consider him as circumcised “, specifies Patrick Banon, researcher and specialist in religions. .

Therapeutic circumcision: what risks of complications?

Note that all surgery is performed under general anesthesia, and no surgical procedure is trivial, including on the foreskin. There are several immediate complications like bleeding or infection. In the case of plastic enlargement, the most common risk is recurrence of phimosis, especially if the cracking is not regular. In the event of circumcision, even correctly performed, the most notable complication is stenosis of the meatus, that is to say a narrowing of the orifice. This can also occur several years after the operation. Finally, when circumcision is not performed in a medical environment, and poorly performed, it can lead to amputation of the glans or a fistula (sores) in the urethra.

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