Resources for HCP

[mommyminer]

I am a nurse-midwifery student and intactivist. I'm listening to my male GU lecture. Instructor states most boys are retractable by 3-4 with adhesions sometimes lasting till 6. I know from this wonderful forum that this isn't true. I don't have time to look for a resource that will back up my claim when I present him with the truth.

Also, I work with residents from Iowa City (labor and birth RN). I educate all of them about NOT retracting EVER. Yes -- they are taught to retract to visualize the glans I refer them to the AAP, but I encounter the question about hypospadias often. Can someone take me through the issues surrounding the foreskin and hypospadias.

On a side note, my nephew had hypospadias.... circ'ed with surgery at 3 months and almost died..... by the time he was returned to the ER, he had a hemoglobin of 4 and required 2 blood transfusions. He was also retracted so forcibly when examined by the GU specialist that his foreskin lay in two flaps at the base of his penis That's how it healed. Broke my heart!

Lets keep educating! People like us are creating a paradigm shift in this country.

[vachi73]

Gosh, I am sorry to hear about your nephew. I hope that he recovered, as much as could be, and is healthy and happy now. That had to be terrifying!

Good for you for educating!! Regarding retractibility, I think I read stats recently at www.cirp.org that were something like, 40% retractible at age 10, 90% at age 16, 99% at 18. Does that seem right anyone else? I was struck by it because I have four boys under 7, and none is even close to retractible. In fact, my second son (almost 5) is probably closer/more retractible than my oldest (6). Somehow, I was thinking that it should've happened by 8, but the stats that I saw made me think that there's NO REASON to be concerned until such time as he is 16-18 and has a problem with pain, etc. Certainly not at age 6!

From cirp.org (http://www.cirp.org/library/hygiene/):

When does the foreskin become retractable?
There is no "right" time for the foreskin to become retractable. Two things must happen before the foreskin becomes retractable and each usually takes many years.1

1.The fusion between the glans penis and the inner surface of the foreskin must become separate.

2.The narrow tip that prevents retraction must become large enough in diameter to permit retraction.

The time varies widely from individual to individual. Complete separation of the foreskin from the glans may not occur until after puberty.1 20 About 44 percent of boys have a fully retractable prepuce by age 10, by age 16, 90 percent, by age 18, 99 percent.1

(emphasis mine)

Visualizing the glans/meatus drives me NUTS. Why?? Do they look at a girl's urethral opening?? Seems to me, if the baby is making urine that can be seen/felt in a diaper, what's the problem?? Makes me want to tell my friends and family to have birthing center births and run away home ASAP! It also makes me feel vehemently against allowing residents/students anywhere near a newborn, and that's not exactly a good thing either (how else can they learn??)

Thank goodness you are out there educating!!!!!

Hypospadias occur when the urethra does not fuse closed (and form a complete tube) during fetal development. It can vary widely, and be as simple as having an "off-center" opening at the tip of the penis (which is, IMO, almost always of no consequence, assuming urine comes out) to having the urethra completely open along the bottom side of the penis. In those extreme cases, if you flipped the penis "up" you would see the entire length urethra open. Intermediate cases can have small openings along the "bottom" of the penis, and those openings go to the urethra -- so when the baby urinates, urine dribbles out of every hole along the route, so to speak. It can be messy for boys learning to urinate while standing up, as you might imagine.

In the U.S., babies with moderate to severe hypospadias usually are NOT circ'd at birth, but ARE when the repair is done, usually around 6 months. Usually, the foreskin is used to close the urethra and/or to improve the cosmetic outcome. I do not know how this issue would be handled in a family who wanted to circ for religious reasons.

In Europe, there are other methods to correct hypospadias that DO NOT involve circumcision. I believe that there is/was an expert in this in the Baltimore, MD area, but I'm not sure now.

I only know this because I was completely OCD about circ issues before my twins were born, and asked around here for help. In addition to being completely terrified of retraction and/or circ w/o our consent, I was afraid about hypospadias. This is somewhat hilarious in retrospect ... I didn't even know if I was having boys, girls, or one of each ... why wasn't I worried about other health issues??

(to cut myself some slack, I had a *terrible*, very stressful pregnancy, and more high-res/detailed ultrasounds than I care to discuss/remember, and I guess I believed -- perhaps incorrectly -- that a congenital issue with the heart or kidneys or ??? would've already been diagnosed. This is not rational! )

ETA: Link to where I asked this question before --> http://www.mothering.com/discussions...867&highlight=

HTH! Keep up the good work!

[eepster]

Originally Posted by mommyminer

Yes -- they are taught to retract to visualize the glans I refer them to the AAP, but I encounter the question about hypospadias often. Can someone take me through the issues surrounding the foreskin and hypospadias.

If the hypospadia is major enough to be a concern, then the foreskin itself will not be fully formed, and it will be obvious without retracting. It is called a hooded foreskin.

He was also retracted so forcibly when examined by the GU specialist that his foreskin lay in two flaps at the base of his penis That's how it healed. Broke my heart!

That probably wasn't caused by the Dr retracting, that would just be the way it was incompletely formed to begin with. In severe hypospadia, the foreskin isn't attached to the glans and there is no sphincter at the end, so it is loose already and moving it doesn't constitute forcible retraction.

[PlainandTall]

eepster- I think the damage of forceful retraction is twofold - there is the issue of damaging the preputial sphincter at the tip ... and there are the natural adhesions of the connecting layer between the foreskin and glans present at birth. Even with a hooded foreskin, I think it's possible to forcefully tear the adhesions to the point of doing damage/trauma. So yes and no... I do think the "two flaps" was likely the form the anatomy took when the adhesions from birth were no longer holding the atypical hooded foreskin in place.

To the OP- I think it IS true that *most* boys are retractable by that age, and it's not a problem for people to know that as long as they don't turn that into a presumption that *all* boys should be retractable by that age.

You should visit the CIRP (www.cirp.org) website and spend some time just reading- they have various catagories on issues like normal anatomy and development, complications of surgery, and foreskin problems and how they can be treated. Whenever possible they publish the actual journal articles and if not- you can get the citation and hopefully as a HCP you can get them.

[MCatLvrMom2A&X]

Somehow, I was thinking that it should've happened by 8, but the stats that I saw made me think that there's NO REASON to be concerned until such time as he is 16-18 and has a problem with pain, etc. Certainly not at age 6!

Yep until he is well into puberty and having issues that is when something can be done in the form stretching with or without the use of steroid cream.

[Zenbuoyant]

There is an excellent online educational workshop series called, "The Intact Boy". This course counts towards a Health Care Provider's yearly CEUs.

I'll send the link to you via PM.. The site has the registration's monetary information, which I think is forbidden to post on the open forum. Better safe than sorry.

I hope this is the kind of educational resource you seek.

[mommyminer]

Eepster - this was caused by the uro. I was the L&D RN at the birth and know he wasn't born that way. He didn't have a severe hypo. When I asked her what happened, she said the urologist in Peoria (IL) did it. His foreskin literally laid in two flaps at the base of his penis He's over 3 now, alive and healthy.

I have lurked on these boards for years, and I have written papers about circ. I am familiar with cirp. I've been so engrossed with school, work, mothering, etc that I haven't had as much time the last year to educate myself on these boards. When I am lucky enough to have parents make the wise decision to leave their son intact, I always refer them here.

I'm amazed if only 40% of boys are retractable by 10 that the myth of retractability by 3-4 still persists.... but this is America.

Thanks everyone for your responses.

[eepster]

Originally Posted by mommyminer

Eepster - this was caused by the uro. I was the L&D RN at the birth and know he wasn't born that way. He didn't have a severe hypo. When I asked her what happened, she said the urologist in Peoria (IL) did it. His foreskin literally laid in two flaps at the base of his penis He's over 3 now, alive and healthy.

If it was mild enough that the foreskin was properly developed, then why did they do surgery? Was the hypospadia discovered when he went to be circ'd? Possibly the Dr had begun the circ and already made the dorsal slit when he noticed the hypospadia and decided to abort the surgery since hypospedia is a contraindication for cic.

[hakunangovi]

Originally Posted by eepster

If it was mild enough that the foreskin was properly developed, then why did they do surgery?

This is what confounds me - With a mild hypospadias I would have thought it far more advantageous to leave the foreskin intact. No surgery would be required and the boy/man could go through life without the hypospadias being noticable at all.

[mommyminer]

They were going to circ irregardless. She was educated (by me), but they decided to circ anyway. Even before she was pg, she told me that she would circ. The uretheral opening is checked before circing on every baby (it's considered standard of care), b/c if the baby has hypospadias, then the circ isn't performed. The foreskin is used in the corrective surgery.

[eepster]

Originally Posted by mommyminer

The uretheral opening is checked before circing on every baby (it's considered standard of care), b/c if the baby has hypospadias, then the circ isn't performed. The foreskin is used in the corrective surgery.

I know that they are supposed to check it before starting, but simple forceful retraction happens frequently, and does not normally leave the foreskin in flaps. The consequences of it that we see on this board are temporary irritation, infection and paraphimosis. If the foreskin was properly formed at birth, but then in flaps after the Dr examined it, it sounds like cutting went on. The fore skin is amazingly stretchy, and doesn't tear easily. I have to wonder if they started the circ before they noticed the hypospadia and just never told your sister about the mistake.