Some questions!

[colaga]

Hi,

I don't know how to start.. I mostly lurk here. I read these forums on regular basis and I have to say I have learned so much! Even though I was born in a country where infant routine circumcision is unheard of (Latvia) and now live in a country where it doesn't exist (UK), unfortunately I have to say that there still is a lot of ignorance around. I have seen women on Latvian forums arguing over whether to retract and clean little boys or not. Some women are eager their little boys circumcised because they think foreskins trap dirt.

I have done search on the internet (in Latvian) about care of infant penis and there is almost nothing. Unfortunatelly I have found some articles promoting circumcision and spreading misinformation.
I am a very busy mom of two little kiddies but I feel compelled to do something about this lack of information. I have been thinking about all this and have come up with some of questions, possibly ignorant ones.

Here it goes:

How does real phimosis manisfest itself (other than the obvious small opening).
Is it always as a result of an injury/forced retraction or can it be inherited?

Can you use soap when washing little intact boys, or is it unadvisable? For that matter, can you use soap when washing circumcised little boys?

After circumcision of an infant, for how long (approximately) are you supposed to care for it's penis by applying ointment/vaseline?
What other extra care is necessary?

Next is a totally stupid question, I am having trouble formulating it..
Say, foreskin gets infected, puss comes out, it burns to urinate. Can penis get infected, too?
Is this how some UTI's start, by microorganisms getting ito the urethra?
When you say that doctor should identify the specific pathogen of the infection, how would he do that exactly? By taking a swab from the foreskin or by testing urine?

I think I had some more questions, but I can't remember now.. I better go, now, though.

Thank you in advance!

[Quirky]

I can't answer all your questions like Frank can, but if you go to www.nocirc.org they have pamphlets on the care of both intact and circumcised penises.

I think it's best to use just plain water to wash genitals - think of how irritating soap can be! Unless things get really skanky and then use the mildest soap possible and rinse really well.

[Frankly Speaking]

Originally Posted by colaga

Unfortunatelly I have found some articles promoting circumcision and spreading misinformation.

There are people out there who want to promote infant circumcision. some of it is because they want to emulate the US and think if the US does it, it must be good. This is how circumcision was introduced into Korea during The Korean War in the early 1950's. The other reason is that there are people who get sexual excitement from anything having to do with circumcision. These people are very active on the internet and have sites that appear to provide legitimate medical information. It is not! They are designed to deceive parents into circumcising their sons with horrible stories of children who had terrible problems and painful surgery. They are totally made up stories designed to trick people.

How does real phimosis manisfest itself (other than the obvious small opening).
Is it always as a result of an injury/forced retraction or can it be inherited?

Actual pathological phimosis is extremely rare. That is phimosis that is caused by disease or injury. It is difficult to accurately diagnose pathological phimosis before puberty unless the child is having difficulty urinating. Again, very rare. Phimosis is the normal condition of boy's penises. This is developmental phimosis. Developmental phimosis is the normal human condition in infants and young boys. Pathological phimosis is never inherited. Probably the most common reason for phimosis is iatrogenic or physician caused phimosis. This is physicians who do not treat normal infections or who advise parents to retract and clean inside the foreskin. It is beyond logic why they do not provide the same medical treatment for boys infections as they do girls but we have seen several cases of that here. The reason they recommend retracting and cleaning is pure out and out ignorance and being too lazy to read their own medical society's literature.

Can you use soap when washing little intact boys, or is it unadvisable? For that matter, can you use soap when washing circumcised little boys?

It is absolutely not advised for intact boys. The inner foreskin secretes an enzyme called lysozime that is a part of the immune system. It is the same enzyme that protects the eyes from infection. As you can imagine, daily washing of the eyes with soap and water would actually cause infections, not prevent them. The same is true of the penis. Washing inside the foreskin would also change the pH level that is required for optimal health just the same as washing out the urethra would cause infections. It's best to just leave it alone. The penis is self maintaining for children just like the eyes are self maintaining.

There is not much of a way to avoid getting soap on the penis of a circumcised boy. In a newly circumcised child, I can imagine even water would be painful not to mention soap. In an older circumcision, there is little reason to use soap on the glans and it may even contribute to meatal stenosis. Mothers should be careful to completely rinse the glans and remnant foreskin as remaining soap can be very irritating and can cause the child considerable discomfort.

After circumcision of an infant, for how long (approximately) are you supposed to care for it's penis by applying ointment/vaseline?
What other extra care is necessary?

The jury is still out on this issue. In the older, tight circumcisions, Vaseline should be applied every day for about 10 days. However, the newer style of loose circumcisions are different and it is not known at this point how long the vaseline should be applied if at all. It seems that it should be applied at least for the first year and maybe longer and that may not even be enough. have heard from several mothers that even with Vaseline applied several times a day, the foreskin remnant starts re-adhering in just a few hours and I know one mother who is still battling adhesions on her almost 4 year old son. It seems that the most common sense approach is to go ahead and let the foreskin readhere just making sure that the scar line is not involved in the adhesion and let it release several years later at it's normal time.

Next is a totally stupid question, I am having trouble formulating it..
Say, foreskin gets infected, puss comes out, it burns to urinate. Can penis get infected, too?

Not likely. The infection would be a dermal infection on the skin surface and it is doubtful that any mother would let it go long enough to eat through the skin to get to the internal structure of the penis. The child would be showing extreme symptoms and would be in very much pain.

Is this how some UTI's start, by microorganisms getting ito the urethra?

No. In boys, the urethra is too long for the infection to travel up the urethra to the bladder. Since urine is sterile, it will flush out infection. However, it is a different story with girls. They have a significantly shorter urethra and the bacteria can travel up this short path to the bladder where it will take up residence. This is exactly why girls have 450% more UTIs than boys.

When you say that doctor should identify the specific pathogen of the infection, how would he do that exactly? By taking a swab from the foreskin or by testing urine?

Yes. The doctor will swab around the end of the foreskin with a cotton tipped swab to pick up bacteria and will then transfer the collected bacteria to a growing medium. It is then allowed to reproduce in this medium for a couple of days to get enough of the bacteria to observe under a microscope. The specific bacteria is then identified by sight through the microscope. Bacteria is just like mammals . . . They all look different.

Infections are relatively rare and coupled with the circumcisionn rate in the US, the vast majority of physicians here have so little experience with this that they can not accurately diagnose from symptoms alone. In other words, without a culture, they are simply guessing. This also means they are guessing about which antibiotic will effect a cure as not all antibiotics will destroy all bacteria. Because of this, US mothers should always insist on a culture for accurate diagnosis and proper and quick treatment.




Frank

[hummingbear]

note on

In response to Franks comment "No. In boys, the urethra is too long for the infection to travel up the urethra to the bladder. Since urine is sterile, it will flush out infection."

Just a note here:
Boys under six months do have a greater risk of UTI's because their urethra is still quite short. Urinary reflux (not related to circumcision) can increase the chances too. (edited to add the comment of my sister's urologist that reflux is not actually a causality for UTIs)

Ann

[colaga]

Thank you Quirky, I have intact penis care links saved under "Favorites", I just was wondering about why exactly is soap unadvisable.

Frank, thank you so much for your thorough reply, where would we all be without you? But I have more questions! :


Who "invented" that all boys must be able to retract their foreskins by age 5? Is that basically because some doctor (Gardener was it?) followed boys for the first five years of their life and then stopped doing his research?

Might you have any good links with statistics where it shows at what age what percent of boys are able to retract?

Are there any alternative ways of treating pathological phimosis (non-circumcision)?
So, pathological phimosis is basically a foreskin that's grown together tightly at the end that is going to be simply imposible to retract?
Can a boy have a patological phimosis but have his foreskin already separated away from the glans (I hope I am making some sense)?

What would be the post op care of the penis in a boy that has been circumcised aged 5-10 or is it pretty much the same (vaseline for as long as necessary)? Might it be possible to perform the circumcision in a more precise way because the child's penis is more developed?
But adhesions are still possible, right?

How did the mothers ever care for their circuimcised infants in ancient times to prevent adhesions? Especially if just the hang-over was amputated, not the entire prepuce?

What would happen if an intact man never ever washed himself? Is there any possibility that infection could flare up because of buildup of smegma or remnants of urine, or is it completely out of the question?
Can dirt ever get trapped inside foreskin, I suppose like dirt could get trapped inside the eye?

-
Why is it some intact men may tear their frenulum in their first sexual experience?

I keep reading on this board that girls get the same streph or staph infections just as boys do (in the foreskin). Where exactly do girls have these infections? Sorry, this sounds so terribly ignorant.. Might they happen virtually anywhere, or are they more common in some specific areas?

I will end this with a big apology.
I feel so terribly guilty pestering you all (especially Frank) with my various questions.. I do try to do my own research whenever I can find time for it, but it's difficult with two little ones, one of which is teething and learning to stand and hold balance.
It is so incredibly frustrating seeing people (and doctors!) give wrong advice to mothers of intact boys, but not be able to confidently argue back that they are mistaken or have wrong/outdated information.

I appreciate your answers so much!

[colaga]

Hummingbear, sorry, just saw your post, we must have been writing at the same time..

So in small babies UTI's can start because of an infection in the foreskin?

[Frankly Speaking]

Originally Posted by colaga

Frank, thank you so much for your thorough reply, where would we all be without you? But I have more questions! :


Who "invented" that all boys must be able to retract their foreskins by age 5? Is that basically because some doctor (Gardener was it?) followed boys for the first five years of their life and then stopped doing his research?

There have been about a half dozen studies I am aware of and their results are as variable as boys age of retraction so the jury is still out on that question. They range from 2/3 being retractile at 3 years old to 70% not being retractile until puberty or later. It seems that every doctor has only seen the former and forgets that 1/3 should not be retractile. Many even miss that and think a child should be retractile from a few weeks after birth. Definitely not true!

Might you have any good links with statistics where it shows at what age what percent of boys are able to retract?

Go to www.cirp.org and search for "Retraction" and you should easily find all of the studies. Just don't expect a hard and fast answer.

Are there any alternative ways of treating pathological phimosis (non-circumcision)?

As long as it has not gone so far that it is obstructing the urine flow, it can be treated with betamethesone, a steroid skin relaxer. Baring that, the foreskin opening can be enlarged with small incision called a "Z-plasty." However, you must realize that this is a completely over blown issue. At most, the true incidence of pathological phimosis requiring surgical treatment is about 1/18,000 intact boys.

So, pathological phimosis is basically a foreskin that's grown together tightly at the end that is going to be simply imposible to retract?

Actually, pathological phimosis is the result of injury either from bacteria or from physical injury. The foreskin opening of young boys is not elastic but becomes elastic later. Phimosis is where this tissue has been replaced with scar tissue so that it will not become elastic later. This scar tissue is a build up over a long period of time as would happen with an untreated infection or from repeated trauma as would happen with daily retraction and cleaning.

Can a boy have a patological phimosis but have his foreskin already separated away from the glans (I hope I am making some sense)?

Yes, the loosening of the preputial sphincter and disolving and separation of the epithelial layer are two separate events.

What would be the post op care of the penis in a boy that has been circumcised aged 5-10 or is it pretty much the same (vaseline for as long as necessary)? Might it be possible to perform the circumcision in a more precise way because the child's penis is more developed?
But adhesions are still possible, right?

Some vaseline or other occlusive treatment may be used but generally, the organ is large enough and well developed enough that the surgeon will know how much of hte foreskin to remove so that there is little risk of adhesions. The child's penis is going to be extremely tender because basically, an internal organ has been put outside the body as in the organ being turned inside out. The sensitivity will be extreme for several weeks to several months and there will be significant sensitivity for a year or more. Adhesions are possible but very unlikely.

How did the mothers ever care for their circuimcised infants in ancient times to prevent adhesions? Especially if just the hang-over was amputated, not the entire prepuce?

Initially, only the part that extended past the tip of the glans was cut off and the part that covered the glans remained. Therefore, the natural bond was not disturbed nor was the frenulum. As the child aged, the remnant foreskin would pull away to expose the glans. Most likely, until the early 20th century, there was a significant death risk as well as a significant infection rate as we see at the current day circumcision "schools" in Africa today.

What would happen if an intact man never ever washed himself? Is there any possibility that infection could flare up because of buildup of smegma or remnants of urine, or is it completely out of the question?

There is little or no research I am aware of for this. However, I have heard of men whose hygiene habits are less than culturally acceptable who seemed to have no problems and I think homeless men who live on the street would be in this category and they seem to have no problems. I would think the rate of infection would be similar to eye infections or maybe less since the eyes are more exposed to everyday dirt. I also know of one 32 year old man who is the father of two children who has never retracted his foreskin and has never had any problems. This would lead me to believe that what we think of as hygiene is a highly overblown issue.

Can dirt ever get trapped inside foreskin, I suppose like dirt could get trapped inside the eye?

I think "trapped" is probably not an appropriate word. That indicates that it can get in but not be removeable and that is certainly not the case. In a retractile man, cleaning inside the foreskin is very easy. You just grasp the foreskin between the forefinger and thumb and pull toward the body. After that, cleaning is the same for a circumcised man or an intact man. Normally, the foreskin protects the glans and inner mucosal foreskin with the tight band around the tip that pretty much barrs anything from getting in just as the vaginal sphincter bars anything from gettinginto the vagina. Can dirt get trapped inside the vagina?

Why is it some intact men may tear their frenulum in their first sexual experience?

Why is it that some women tear their hymen with their first sexual experience? Same reason!

I keep reading on this board that girls get the same streph or staph infections just as boys do (in the foreskin). Where exactly do girls have these infections? Sorry, this sounds so terribly ignorant.. Might they happen virtually anywhere, or are they more common in some specific areas?

These infections can be anywhere on the body especially when there is an injury that compromises the protective skin system. The tender mucosal genital areas are probably slightly more susceptible. This would include the inside of the vulvar area (inner surfaces of the labia majora, the labia minora, clitoris, clitoral hood and around the vaginal sphincter as well as possible inside the vagina) and the glans and inner foreskin area of boys.

I will end this with a big apology.
I feel so terribly guilty pestering you all (especially Frank) with my various questions..

Questions like yours are exactly why we are here and you are educating some simply for the fact that you are asking questions they have not thought of. By all means, keep going!

It is so incredibly frustrating seeing people (and doctors!) give wrong advice to mothers of intact boys, but not be able to confidently argue back that they are mistaken or have wrong/outdated information.

I appreciate your answers so much!

The frustrating thing is that we pay these people incredible amounts of money with the false belief that they are well trained and that we can trust the health and well being of our families to them. It is also frustrating when we present well documented information and they blow it off like we are some kind of meddling idiots.




Frank

[PuppyFluffer]

Frank, your statement about drs blowing off questioning patients is so true. It is very sad!

Thanks for all the great info.

[hummingbear]

Originally Posted by colaga

Hummingbear, sorry, just saw your post, we must have been writing at the same time..

So in small babies UTI's can start because of an infection in the foreskin?

Hi Colaga,

I am not an expert here, so I don't have an answer to your specific question about infections in the foreskin possibly starting a UTI. UTI's can start in very young babies from bacteria entering the foreskin opening and travelling upwards. (when boys are infants the urethra is short enough for progression of bacteria to cause UTIs, the urethra grows long enough by ae 6 months that the occurance of UTIs is reduced) I don't know much about foreskin infections: I suppose if the infection is on an "internal" surface (meaning either on the skin at the tip or on the skin facing the glans) that it could also travel upwards.

Anyone else?

[colaga]

I have thought of one more foreskin related question.
This is following my discussion with a urologist.. He claims that if the foreskin is not retracted in young boys then a type of "glue" will form under there and it will become completely impossible to separate the glans form the prepuce. It's a bunch of crap, but how do you debunk this sort of statement? Where has this absurd idea come from?

[boingo82]

Originally Posted by colaga

I have thought of one more foreskin related question.
This is following my discussion with a urologist.. He claims that if the foreskin is not retracted in young boys then a type of "glue" will form under there and it will become completely impossible to separate the glans form the prepuce. It's a bunch of crap, but how do you debunk this sort of statement? Where has this absurd idea come from?

He has it backwards -
in babies and young boys the foreskin is attached to the glans by the same type of membrane that keeps your nails on your fingers. If you leave it alone, it eventually dissolves and the foreskin becomes retractile.

If you do what he is advocating (retract in young boys) you are forcibly pulling that apart causing small rips and tears in the foreskin and the glans, similar to if your toenail/fingernail got ripped off. Now, you have open wounds touching open wounds and they can heal together permanently, with scar tissue, which isn't stretchy at all. This is what they call "iatrogenic phimosis" - that is, phimosis (when the foreskin won't retract) CAUSED BY medical care.

[Frankly Speaking]

Here's what I suspect:

I suspect he has been forcibly retracting young boys, probably from a few weeks old to a couple of months, breaking the natural adhesions and then when the mother does not continue to forcibly retract on a daily basis, the natural adhesions reform and this is the glue he is talking about.

I have this overwhelming compulsion to make comments about how ignorant Latvian urologists are but I also have to keep reminding myself that American urologists are little different. At least, you would think latvian medical professionals would have far more experience than the Americans.



Frank

[cloak]

Should I be worried?

I've been reading along and now I have questions too. My intact son's first pediatrician told me to gently retract the foreskin with each diaper change (this was before I knew better). He said it was like a new rubberband and the more you stretched it the stretchier it would become until it would retract all the way. He said that it could take several years and not to force it. Long story short, my son is almost three and his foreskin was fairly easy to "stretch" out so it's been fully retractable for awhile now. Once it was retractable I stopped messing with it and later learned that you're not supposed to do anything to it anyway.

Should I be worried about scar tissue? It doesn't seem like he has any problems and while I don't retract it all the way anymore, I sometimes pull it back a little to look at the head when DS is complaining that it's bothering him. I'm thinking that there was only one time where it was stretched too far and might of torn the skin a bit. That was when he was still pretty young, probably less than 1 year.

Is there anything I should do now, after the fact, to prevent problems in the future?

[Frankly Speaking]

It's impossible to know at this time if there will be any long term effects and only time will tell. We can't know when your son would have been naturally retractile so there is no way of knowing if there was any potential damage to the preputial ring or if the natural adhesions have reformed.

The only thing you can do now is to let nature take it's course and see what happens. I would not be surprised if the preputial ring becomes non-elastic again and years from now becomes elastic again. That would be the normal course of events. It would also be the normal course of events for the natural adhesions to form again and also break down later.

The best thing you can do is stop doing anything. Your son will discover on his own when he can retract comfortably and easily and will do so at that time. There is no maintenance required for anything inside the foreskin any more than there is maintenance required inside the eye lids. When he becomes a teen, you may want to inquire if he can comfortably retract his foreskin, explaining the poor information you got and why he may have a problem. If there is a problem, it is easily resolved usually with no medication at all or if he wants to speed up the process, there is a steroid ointment that will facilitate the process and will get it down to a few weeks.




Frank

[cloak]

Thanks, Frank!

[colaga]

More Q!

I have a question, so I might as well continue this thread..

What kind of antibiotics are usually used to treat strep infections and what kind of medication should be given for a staph infection?
What exactly is a yeast infection? What kind of bacteria?

[Quirky]

I don't know about types of antibiotics, but I can tell you about yeast. Yeast is caused by an overgrowth of the yeast cells (a type of fungus) that we have living on us all the time; when our microflora get out of balance, for example because of a course of antibiotics that kill off the beneficial bacteria, the yeast overgrowth causes irritation. It's treated with an antiyeast medication, diet changes, and/or probiotics (beneficial bacteria) such as those found in yogurt, kefir, and other fermented/cultured foods.

[Frankly Speaking]

Originally Posted by colaga

I have a question, so I might as well continue this thread..

What kind of antibiotics are usually used to treat strep infections and what kind of medication should be given for a staph infection?
What exactly is a yeast infection? What kind of bacteria?

This may surprise you but I intentionally keep myself uneducated about medications. That's because I have to be very careful in giving advice about them so that I don't cross the line of practicing medicine without a license. If you have ever noticed, I say whatever medication the physician prescribes. I say bring the name of the medication here and then I will investigate it to be sure that it is appropriate for the diagnosis and that there are no serious contra-indications or side effects. There is also the factor that new meds are being introduced and it would be practically impossible for me to keep up with all of them. There is also the factor that bacteria are in a constant state of flux as with the Multi Resistant Staph Aureus (sp?) or MRSA antibiotic resistant staph and meds that worked just a couple of years ago may no longer be effective in some locales. This is something only a local doctor would know.

Quirky has given an excellent description of yeast infections. There are yeast meds available over the counter that just a few years ago were only available by prescription. They appear to be very effective.



Frank

[colaga]

But strep and staph infections are treated with different antibiotics, right? What will cure strep won't cure staph, is that at least so?
When you say that sometimes doctor will give a "broad spectrum antibiotic", what exactly do you mean by that?

Thanks so much Quirky! I am wondering though, can you tell me more about anti-yeast medication? How exactly does it work?

[Quirky]

Anti-yeast medicines are anti-fungals....like the creams used for vaginal yeast infections and athlete's foot/jock itch (also fungal infections). There are also pill forms like Diflucan which tackle yeast.