Phimosis in 9year old

[proudmomof4]

Just to get this clear upfront: I have 3 boys all of whom are intact. As we are German, this was the normal thing to do (not some "crunchy" decision I had to defend). My 2 younger sons were born while we lived in the U. S. (Michigan) - even though that area seems to have (had?) a high circ rate, it wasn't an issue with our children as they were born at home, and at the ped's office I simply played the "Germans don't circumcise" card. (I was horrified at the sight of a friend's baby during a diaper change so I made it a point at the pediatric office to state that my son's genitals were to be left alone!)

My now 9y old son has phimosis, and has never been retractable. I guess that there aren't any adhesions because he's been ballooning for years now. However, the foreskin opening is about as big as a pinhead, no change within the last 5 years or so (that's when I first was aware that this is a real phimosis).
I've read many posts here on MDC during the last years and first decided to just wait. As I said, in Germany it's not routine to circumcise newborns or babies but I've read about a lot of toddlers who were circumcised because of phimosis.

According to what seems to be the official stance on phimosis for German urologists, circumcision is the cure to prevent infections when the boy grows older (my son definitely can't clean himself under his foreskin), avoid tears of the foreskin (during masturbation or sexual intercourse), prevent paraphimosis (no chance with my son, so far the opening is way to small for that!) and to prevent kidney damage ("urination against resistance").

I've also read about triple incision as an alternative to circumcision which seems like a less invasive surgery but still - this is more than "just a piece of skin".

I feel strongly about circumcision as a human right issue and therefore am opposed to RIC - but the kidney part worries me. Any ideas where to look for information?

[Fellow Traveler]

Originally Posted by proudmomof4

Just to get this clear upfront: I have 3 boys all of whom are intact. As we are German, this was the normal thing to do (not some "crunchy" decision I had to defend). My 2 younger sons were born while we lived in the U. S. (Michigan) - even though that area seems to have (had?) a high circ rate, it wasn't an issue with our children as they were born at home, and at the ped's office I simply played the "Germans don't circumcise" card. (I was horrified at the sight of a friend's baby during a diaper change so I made it a point at the pediatric office to state that my son's genitals were to be left alone!)

My now 9y old son has phimosis, and has never been retractable. I guess that there aren't any adhesions because he's been ballooning for years now. However, the foreskin opening is about as big as a pinhead, no change within the last 5 years or so (that's when I first was aware that this is a real phimosis).
I've read many posts here on MDC during the last years and first decided to just wait. As I said, in Germany it's not routine to circumcise newborns or babies but I've read about a lot of toddlers who were circumcised because of phimosis.

According to what seems to be the official stance on phimosis for German urologists, circumcision is the cure to prevent infections when the boy grows older (my son definitely can't clean himself under his foreskin), avoid tears of the foreskin (during masturbation or sexual intercourse), prevent paraphimosis (no chance with my son, so far the opening is way to small for that!) and to prevent kidney damage ("urination against resistance").

I've also read about triple incision as an alternative to circumcision which seems like a less invasive surgery but still - this is more than "just a piece of skin".

I feel strongly about circumcision as a human right issue and therefore am opposed to RIC - but the kidney part worries me. Any ideas where to look for information?

I think your son is still too young to worry about this. However, keep in mind there are other approaches available. For example, you might start with a steroid cream. Or, the least invasive surgical option, would be prepuceplasty as shown here: http://www.biomedcentral.com/1471-2490/8/6/

But again I think it's too soon but there are options.

[MyBoysBlue]

If the average age of retraction is 10 years old, there will be some boys who retract after 10 and others before 10. I'd say still too soon to worry.

I've also herar that the steriod cream usually works really well but it won't help unless your son has hit puberty and his hormones can take over after the cream is stopped. Otherwise once the cream is no longer being used the preputial sphinter will just tighten back up.

[BlessedMommy2006]

Much too soon to worry about it. Some boys don't retract until puberty. If it isn't retractable, nothing can get underneath, so no need to clean.

If he's not having problems with it and is peeing fine, I would say to leave it be.

[chaoticzenmom]

I'm not sure it's "not a reason to worry." My 10yo is not retractable, but it's because his skin is still fused, not because the opening isn't big enough. If he's still only opened the size of a pinprick, that doesn't sound like nothing to me. Even my 1yo, who's opening was pinprick size has had an obvious change in the size of the opening. I realize that all are different, but the OP is saying that her son's foreskin is no longer fused, but it's just the opening that is the problem. It also sounds like she's aware of what's in the range of normal.

OP, I'd ask about using a steroid cream and see what happens. Then, I'd opt for the non-circumcision route if that doesn't work. Is there a way to see if his kidneys are being affected? Did your Dr. give you these options? Has the Dr. looked at this or have you just been reading and preparing for the visit? Your German Dr. should have a pretty good idea about what is normal and have respect for the fact that you don't want circumcision if at all possible.

Is your son complaining about this? Has he had infections? If his kidneys were being affected, I'd think he'd have recurrent kidney infections.

[intactDS]

As far as my understanding goes, the purpose of the foreskin retracting is not so you can clean under it, but rather it is something that I doubt your nine year old son is old enough to be anywhere near ready to be concerned about. The fact that a retractable foreskin useful in the context of penile hygiene is a coincidence of evolution; a process, I believe, that has never taken a person's personal hygiene routine into consideration. Particularly in a boy your son's age, the penis will take care of itself.

I also want to say that my parents visited a pediatric surgeon when they were concerned about my then 8 or 9 year-old brother's "pinhole opening" and were advised not to worry about it. He's my older brother, and this is something my mother told me about happening. She said the surgeon was pretty dismissive of the need for circumcision. This happened in the states. I have NO idea if my brother ever became fully retractable, but I do know he never had any issues which required penile surgery at any point.

[glongley]

I would not be worrying yourself about this unless he literally is only able to pass drops of urine or something like that. There is no evidence that ballooning causes pressure on the kidneys. (See: http://www.cirp.org/library/normal/babu1/) And don't get yourself freaked out about calling it "phimosis" - it is not some kind of dread diagnosis. In the absence of scar tissue or other pathological changes, it just means "foreskin not retractable yet," which is a totally normal phenomenon in a 9 year old. (See more on normal foreskin development at: http://www.cirp.org/library/normal/) As another poster said, the average age at full retractability is about 10 years old, meaning while some may be fully retractable at birth, others may not be fully retractable till they're 20. Cleaning underneath is not an issue, as the urine is sterile and will wash the inside out regularly if he is ballooning.

The thing to understand is that TWO things need to happen for the foreskin to become easily retractable: 1) the inner foreskin has to separate from the glans, and 2) the normally tight outlet of the young child must become more elastic, which happens naturally as the child develops into an adult (http://www.cirp.org/library/anatomy/lakshmanan/). The two progress simultaneously, but one may occur before the other. Your son's foreskin is separated, but the outlet has not yet become elastic. Not to worry however, give it time, and it will, however! This is just his body's own unique process, which is to be trusted and respected.

My son did not retract AT ALL till he was 8 years old. All he had was a pin head size opening, like you described for your son. This never really caused him any trouble, except for sometimes peeing in funny directions. Then when he was 8, all of a sudden the opening which had seemed so small, and so resistent, started becoming looser and looser, and almost overnight he became completely and easily retractable. So it really does take care of itself!

Gillian

[BlessedMommy2006]

Here is some additional info to reassure you that your son is 100% normal and requires no medical intervention:

http://www.mothering.com/10-0-0/html...rcson103.shtml

Protect Your Uncircumcised Son
Expert Medical Advice for Parents By Paul M. Fleiss

"Your son's foreskin balloons when he urinates. He needs to be circumcised or else he will suffer kidney damage.

Ballooning of the foreskin during urination is a normal and temporary condition in some boys. It results in no discomfort and is usually a source of great delight for little boys. Ballooning comes as a surprise only to those adults who have no experience with this phase of penile development. It certainly does not cause kidney damage; it has nothing to do with the kidneys. Ballooning disappears as the foreskin and glans separate and the opening of the foreskin increases in diameter. It requires no treatment.

[MCatLvrMom2A&X]

Not something I would worry about until puberty was well established.

Remember the tip of the foreskin is a sphincter just like the anus when not is use it closes down to keep stuff out. Once your ds's body is ready it will loosen up like an adult. Steroid cream should only be used after puberty is established because the effects once stopped will wear off.

If this is bothering your ds then talk to him about stretching exercises he can do to encourage the process. Making sure to tell him not to force anything because he could get his foreskin stuck behind the glans, paraphimosis. That would be a bad thing but not impossible to fix without circing.

Have you seen this thread http://www.mothering.com/discussions...d.php?t=764732

Having a none retractable foreskin does not present a health issue if it did then all boys would have problems since most are not retractable until they are 10.5 years old.

Like I mentioned before until puberty hits there is no way to diagnose a true phimosis. What you ds has is considered normal phimosis though that name is misleading since he dosnt have a problem.

[proudmomof4]

Thanks for all your responses so far - I have a meeting to lead this morning but I'll be back later to read all the links.
Thanks again for your support!

[Night_Nurse]

I don't have any links handy but I do know some boys don't start retracting until well into their teens. Kind of like some girls get their menstral period as early as 10 but some don't until they are 15 or 16. It's a wide range, but all are normal - same with retraction. As others have stated, as long as he's urinating, I wouldn't worry about it. The ballooning is normal, too. You may want to mention to your son that if his foreskin ever becomes painful during an erection he can mention it to you or your partner but otherwise, I just wouldn't worry. If it ever came to it, I'd recommend investigating steroid creams, stretching exercises or a dorsal slit before I'd go for a full circ.

I don't think you should spend much time worrying over kidney problems. Does your son have a history of kidney infections or some congenital kidney defect? That's really the only reason you might want to see a urologist - to treat kidney problems but not for a circumcision.

[Ron_Low]

Originally Posted by proudmomof4

My now 9y old son has phimosis, and has never been retractable. I guess that there aren't any adhesions because he's been ballooning for years now. However, the foreskin opening is about as big as a pinhead, no change within the last 5 years or so (that's when I first was aware that this is a real phimosis)....According to what seems to be the official stance on phimosis for German urologists, circumcision is the cure to prevent infections when the boy grows older (my son definitely can't clean himself under his foreskin), avoid tears of the foreskin (during masturbation or sexual intercourse), prevent paraphimosis (no chance with my son, so far the opening is way to small for that!) and to prevent kidney damage ("urination against resistance").

The surgical remedy is NOT circumcision, but rather one of the non-amputative preputialplasties.

However, surgery should never be considered until 6 months of stretching has failed. You'll need Betamethasone ointment which in the US we must get from a doctor.

And unless your child has actual symptoms like you describe today, treating phimosis is not appropriate until after puberty.

[mntnmom]

Also remember, as a sphincter, the opening is not always the same size. Just like the anus, it opens up when it needs to let something out. So a pinhole opening at rest, likely opens up just fine during urination. So pressure on the kidneys is likely not an issue. My boys are not that old yet, and I know even German boys get circ'd occasionally, but I agree that your son seems to be in the range of normal still. As long as he's urinating fine, I wouldn't even think about surgical options for a few more years.
How are the doctors regarding circ' where you are now?

[Stardust27]

Hi Andrea!

I agree with what the others said - your son ist most likely completely normal, just on the later side with foreskin retraction. As long as he can pee without problems (and ballooning in itself is not a problem) he's fine. If there would be enough resistance to urination to damage the bladder or kidneys, it would be obvious, he would have to really strain to get the pee out.

If you - and he! - want to, you can try steroid cream and gentle stretching. If it works, you can stop worrying. If it doesn't, well, just wait a few more years.

If you like, check out this link: http://www.phimose-info.de/component...ileinfo/id,24/ . You'll find a German guide for parents (downloadable 41 page PDF) about the foreskin with a lot of information. You might find other useful stuff on that site, too.

Stardust

[proudmomof4]

I spent quite some reading time on the phimose-info.de before I posted my question here. The information there took away some of my worries but all the other sites on pediatric urology in German that I could find played the "phimosis after the age of ... needs to be fixed by circumcision" tune. So, I'm still a little clueless about how to find a "foreskin friendly" urologist in Germany.

I haven't seen a doctor here in Suzhou. The English-speaking pediatricians here often take pride in their training in - you guessed right - the U. S., so maybe not my best option.

"I don't think you should spend much time worrying over kidney problems. Does your son have a history of kidney infections or some congenital kidney defect? That's really the only reason you might want to see a urologist - to treat kidney problems but not for a circumcision."
Night_Nurse

To my knowledge, my son has never had a bladder or kidney infection. Having gone through some UTIs myself I'm very sure I would know if he had - ouch!
I was just troubled by this kidney thing because it sounded as if an untreated phimosis would inevitably cause kidney problems later on which sounded painful and dangerous.

So, from what I hear from most posts a good start would be to see our pediatrician in Germany (we'll go on a home visit in the summer) and get a steroid cream - then we can work from there.

[FernG]

The only problem with the steroid creams is that they don't cause lasting change until after the puberty hormones have kicked in. It sounds like your son is still young for that treatment.

[Stardust27]

I spent quite some reading time on the phimose-info.de before I posted my question here.

The information there took away some of my worries but all the other sites on pediatric urology in German that I could find played the "phimosis after the age of ... needs to be fixed by circumcision" tune.

Yes, unfortunately, that is still the official mainstream view of phimosis in the German medical community. Doctors are slow changing their ideas all over the world, it seems...

So, I'm still a little clueless about how to find a "foreskin friendly" urologist in Germany.

We usually recommend using this search engine for the region you're in and then phoning them asking for their approach to phimosis treatment: http://www.helpster.de/aerzte/

You can also contact the local "Ärztekammer".

For a prescription of a steroid cream, you probably won't need an urologist. A ped should be able to do this, too.

To my knowledge, my son has never had a bladder or kidney infection. Having gone through some UTIs myself I'm very sure I would know if he had - ouch!
I was just troubled by this kidney thing because it sounded as if an untreated phimosis would inevitably cause kidney problems later on which sounded painful and dangerous.

He's been born with his foreskin like this, right? So why should his tight foreskin suddenly become a problem and start to harm him at 3, 6 or 9 years old? Where's the logic in that? And why is everyone quoting different age limits? Hmmm...

So, from what I hear from most posts a good start would be to see our pediatrician in Germany (we'll go on a home visit in the summer) and get a steroid cream - then we can work from there.

Good plan!

Concerning the steroid creams, I like this German study. There used to be an link to the original document (http://www.medreports.de/medpdf/Rev12_04.pdf), but it has unfortunately been removed during a website update:
http://www.phimose-info.de/medizinis...be-5272-26.php


If you have any Germany-specific questions, feel free to ask in the forum of phimose-info.de.


Stardust

[tutucrazy]

Phimosis is an entirely phony diagnosis unless your son has finished puberty. Please read this and the links provided:

http://www.mothering.com/discussions...phony+phimosis