I’m reprinting a letter that my friend Cindy had to write to her son’s pediatrician. This is because, as the parent of an intact son, you can never, ever relax your attention. Not even for an instant. The medical school graduates of the last 15 years or so just have no idea how to deal. And I thought this letter summed up nicely how it is sometimes that we the parents do far far more research about the choices we make for our children than those we pay to provide those services do.
I’d appreciate it if you passed this blog along to any parent of any intact boy you know, so that their parents can be as informed, and as strong, as Cindy was.
Dear Dr. W:
On 18 July 2011 you provided care during the 6-month well child visit for my son. I found you to be warm, caring, and helpful, and I want to thank you for the professionalism you showed during the visit.
There was one aspect of the visit that concerns me. My son is intact, and during the check of his genital area, you attempted to manipulate his foreskin backwards towards the shaft while asking, “Are there any adhesions?” This was despite my holding my son’s penis with my fingers and repeating, “No retraction!” three times or more. We had already discussed the fact that my son’s urine stream flows straight and freely prior to the genital exam. It was distressing to me to realize that if I had not been so attentive, my son could have suffered unintentional pain and harm from his doctor. I am writing to share information that may be used to ensure the best quality care for all intact male patients of XYZ Pediatrics. I look forward to developing a mutually supportive, evidence-based care plan for my son.
In virtually all intact male infants, the foreskin is adhered to the glans by way of synechiae, which are the normal physiological attach points of the foreskin to the glans in the infant. This attachment is similar to the way that the fingernail is adhered to the nail bed, or the way a kitten’s eyes are fused shut at birth. In virtually all males, the synechiae will naturally desquamate over time, and the foreskin will naturally separate from the glans. There is no specific age by which desquamation should or must occur, and wide variation exists from toddlerhood to the teenage years. In a very small percentage of adults, the foreskin never becomes retractable; if this occurs and if the adult male would prefer a retractable foreskin, non-surgical alternatives exist to loosen the synechiae and induce retraction. However, because virtually all males will become retractable by adulthood, the risks of routine premature retraction or manipulation of the fused foreskin of all boys outweigh any possible benefit to the very small percentage of males who would not have otherwise become retractable on their own with time and who would prefer to be.
Premature retraction or manipulation of any kind of the fused foreskin backward toward the shaft of the penis can cause tearing of the synechiae. This tearing apart of the tissues causes pain, opens a wound, can introduce pathological bacteria into the delicate area between the foreskin and the glans, and can cause the development of scar tissue and true adhesions. Adhesions are a pathological consequence of forced premature retraction or manipulation of the fused foreskin, when scar tissue adheres the foreskin to the glans at the site of tissue damage. The infant foreskin that has not been manipulated or retracted does not have adhesions, only synechiae, and there is no reason for anyone, including a medical provider, to check for their presence.
Virtually all intact male infants also exhibit physiologic phimosis, where the preputial orifice acts as a tightly closed sphincter at all times except during urination. This is a normal, protective mechanism of the foreskin.. As the child matures, the preputial orifice will gradually stretch to accommodate retraction. Forced premature foreskin retraction or manipulation can create small tears at the preputial orifice. These tears can create scar tissue and lead to true pathological phimosis later.
I have enclosed a copy of current guidelines for proper care of the intact penis from the American Academy of Pediatrics and the American Academy of Family Physicians. I have also included several educational documents. I would appreciate if this topic could be reviewed and shared with all doctors and practitioners at XYZ Pediatrics.
I would be happy to discuss this topic with you. I can be reached on my cell at ###. Thank you again for the care you continue to provide to my children.
Encl: 1. “Care of the Uncircumcised Penis” from AAP; http://www.growingchildpediatrics.com/pdf/UncircumcisedPenis.pdf
2. “Circumcision” from FamilyDoctor.org, AAFP; http://familydoctor.org/online/famdocen/home/men/reproductive/042.printerview.html
3. “The Development of Retractile Foreskin in the Child and Adolescent” from Doctors Opposing Circumcision; http://www.doctorsopposingcircumcision.org/pdf/2008-03retractileforeskinleaflet.pdf
4. “Short Warnings About Forcible Foreskin Retraction” from Doctors Opposing Circumcision
5. “Only Clean What Is Seen” from Kindred, Aug 2008; http://www.kindredcommunity.com/articles/only-clean-what-is-seen-reversing-the-epidemic-of-forcible-foreskin-retractions/p/1253
cc: (Office Manager)