Treatment for Foreskin (aka The Intact Handbook)

By Glenn Epps

Please note that the conditions outlined in The Intact Handbook (TM) also apply to the circumcised penis. This further illuminates that circumcision, in most cases as a prophylactic or preventative measure, is not a proper method of dealing with conditions of the penis.

Lack of information and misinformation abounds respecting the anatomy, function and treatment of the structures of the male penis. At the slightest sign of "trouble" or "problem" with a males foreskin the suggested treatment is often circumcision. Circumcision is an invasive form of treatment and most radical. The Intact Handbook is here to help. If you have a foreskin related problem you'll likely find information that will allow you to avoid circumcision.

As we all become more cognizant of the structure, function and purpose of the complete structure of the male penile anatomy it is important that we make available various forms of treatment that preserve the integrity of these important structures. Circumcision should be seen as a last resort, and truly, almost all foreskin related problems DO NOT require circumcision--alternative treatment methods exist. It is these alternative treatment methods that should become the primary focus for treating various problems that a male may experience. This methodology for treatment is not new. This methodology is employed with respect to almost all medical conditions and problems.

It would be misleading to suggest that the intact penis does not befall to certain medical conditions--this is true of the circumcised penis as well. All parts of the body, whether one is male or female has the potential for befalling to various aliments or problems. It is generally accepted and expected that treatments will be conservative and that surgery is relied upon only as a last resort or where no choice exists. This principle should strongly be adhered to when we are talking about the genitals--male or female--every male and female is entitled to the benefits afforded by such structures lest there being some compelling reason that requires and necessitates surgical intervention. More and more doctors are familiarizing themselves with proper treatment methods for conditions of the penis/foreskin--if your doctor has not--perhaps you can provide him with information or seek a doctor that is up-to-date with current medical treatment methods.

The sections of The Intact Handbook provides some basic information related to some of the more common conditions and problems of the foreskin and also those conditions that have more commonly in the past resulted in treatment by way of radical surgical intervention, namely circumcision.

Attempts have been made, throughout The Intact Handbook, to use wording that is not too technical, medically or otherwise. However, there is a need to use various medical terms and terminology. Definitions to common medical terms used are provided below the Sections.

Sections:

Phimosis and/or Tight Foreskin

Restricted Foreskin Movement

General Irritation and Infection

Reddened and/or Irritated Foreskin

Redness/Swelling of the Glans

Inflammation of the Glans

Phimosis and/or Tight Foreskin:

SUGGESTIONS TO BE DONE IN CONSULTATION WITH YOUR DOCTOR

If men who have been circumcised can stretch a new foreskin (known as foreskin restoration or skin expansion), it surely must be possible for a man to stretch the opening of his foreskin to allow for retraction. Surgical intervention, and that of circumcision, should generally be considered a last resort.

BASIC POINT ON STRETCHING: Stretch without pain. If you produce pain, you may be tearing tissue, which can then scar, making matters more difficult. Stretching has to be done slowly, over time.

First, lets assume that the frenar band (essentially the tip of the foreskin) is too tight, there are no preputial adhesions, no rare pathological phimosis (usually balanitis xerotica obliterans-- lichen sclerosus et atrophicus). It should not be too difficult to stretch (dilate) the opening (lateral stretching only).

Soak the end of the penis in warm water and apply a good lubricating cream (i.e. Vaseline or another lubricant which is non-irritating ) and insert two blunt objects about a quarter inch or so within the prepuce and apply some outward pressure so-in-that the foreskin opening has pressure on it. One will need something that can apply outward pressure and not just sit or stand there holding it. Something like large tweezers that open quite widely would be good (insert closed and release), be very careful not to cause injury to any of the penile structures.

If nothing is available to do that, one may stretch it as far as possible over a lubricated short dowel (drill a hole in it for urinating) and slowly increase the size of the dowels. A good place to find doweling materials at a hobby supply store, or the local lumber shop. This may sound a bit unusual but it might be the solution for some.

Stretching should be gradual. There is no need to hurry the process, and in fact if one does try to stretch too quickly it may lead to complications and possibly complications that would then necessitate surgical intervention of some manner. It may be somewhat uncomfortable and one should be on the lookout for any splitting of the foreskin and resultant scarring. If that happens, one may have a fibrotic disease (physiological phimosis). Remember, stretching does not occur overnight. This is not a quick results program.

During the time of stretching, one should occasionally try to retract one's foreskin over the glans, but not past the corona until one is comfortable with the opening having been enlarged enough not to get 'stuck' behind the corona (paraphimosis). One should also try to ascertain, at the time of retracting to the corona, if there are any adhesions. Such adhesions might be indicative of premature retraction at an earlier age. Such adhesions (the foreskin 'fused' to the glans) may require separation by a doctor. Given that there are no major adhesions, the separating of such adhesions should not be difficult for a doctor to do.

Michel Beauge, M.D. (faculty of medicine, Saint-Antoine University in Paris), in his paper working with young men with tight foreskins, uses therapeutic masturbation procedures of which he has reported a terrific success rate.

If one has generally masturbated by stroking the glans through the foreskin in the usual way, but pulls the skin toward the tip of the penis rather than that of pulling it back toward the pubis, one's foreskin may well be similar to that of many of Dr. Beauge's patients, i.e., the presence of a long tubular foreskin as seen in infants (this is normal in infants) and a tighter opening due to it never having been stretched during normal masturbatory experiences.

In his report it is noted that, "Some boys roll the penis between two palms or between one hand and another surface. It is usual in these cases for the raphe on the underside of the penis not to be in the midline but more or less displaced to one side or even spiral; the preputial orifice is often displaced." Further, "It is of course essential that the preputial opening be stretched round the circumference of the fully erect glans. This technique meets the requirements of the kinesitherapy of soft tissues, gradual stretching. In some cases I have recommended instrumental dilation with the use of a dilator in patients who agree to this procedure, or I have advised the introduction of two fingers into the opening of the foreskin to stretch it." Also, "Thus the boy can progressively expand his foreskin until the diameter is equal to that of the erect glans, allowing him subsequently to proceed to sexual intercourse without risk of paraphimosis."

People tend to want quick results, but again stretching should be done slowly and with patience. If the conventional stretching methods are not working well (give them time) one may want to approach their doctor to prescribe Temovate (clobetasol propionate cream 0.05%) If you are using such cream, apply the cream sparingly on the narrowest portion of the foreskin as one gently retracts on a daily basis. Then, after a few days, one can use the erect penis (the glans itself) as a dilator (or other methods mentioned), gently stretching the foreskin, but not past the point of pain, because that could introduce tearing. It is recommended that the cream not be used for more than two weeks at a time because of systemic side effects of cortisone-like substances.

NOTE: Using a topical steroid (0.05% betamethasone cream) has been shown to have excellent results in the treatment of phimosis. [Z. Colubovic, D. Milanovic, V. Vukadivovic, I. Radic and S. Perovic, The Conservative Treatment Of Phimosis In Boys, British Journal Of Urology, 1996; Vol. 78: pages 786-788.] It should be emphasized that there should be great hesitancy of a doctor to diagnosis phimosis, particularly in young boys. However, if so diagnosed, there are very effective treatments which do not require circumcision. In any event, z-plasty (prepuital plasty) will preserve most of the foreskin if surgery is required. Prepuital plasty (where a small incision is made vertically, then closed horizontally so as to widen the opening) is a particularly effective means of dealing with many of the problems for which circumcision is often employed. In an alternative only a small portion of the tip of the foreskin need be removed (in most cases) to resolve phimosis thereby successfully leaving almost all of the foreskin intact.

Sometimes stretching alone does not always work. The frenulum should be considered in an exam. For example, a short frenulum may restrict the ability of the foreskin to retract partially and even in some cases fully. It should be noted again, men's penises vary greatly. It should be remembered that the degree of retractability varies from man to man; this is all normal. What is not normal is for men to experience pain during normal sexual activities. For more information on conditions related to the frenulum see the section "Restrictive Foreskin" in the Intact Handbook.

If there are adhesions found after successful stretching one may advise (seek) his physician that he would like to try the EMLA (Eutectic Mixture of Local Anaesthetics) cream inserted in the foreskin and left there for about an hour and then the adhesions separated. Many doctors are quick to recommend circumcision at the first sign of adhesions. Some physicians recommend against this at any age so again, it would be extremely beneficial to find a foreskin friendly doctor knowledgeable about the natural penis (difficult to find in North America) and any of the rare problems that may occur would be most helpful.

You should keep in mind that if stretching achieves the desired result you may need to employ a regular method of stretching if you find that tightening begins to occur.

OTHER INFORMATION

Sometimes what happens is that the foreskin will tighten either around the head of the penis or in most cases behind the glans (head of the penis). No need to worry. DO NOT PANIC! If this ever happens, just grasp the head of your penis in your fingers and apply constant pressure. This pressure will force the blood out of the glans (head) and you should then be able to slip the foreskin back over the head. One might want to get a lubricant, like KY, and smear it all around the area where the foreskin is lodged and the rest of the glans. If left alone, or if taken to a doctor, circumcision is likely as many doctors still do not understand that there are good reasons for trying to preserve the penile structures, particularly the foreskin.

Consider an alternative to soap; certainly this is not always necessary but it is something to consider. Alkali in soap is the leading cause of irritation that looks like infection. (balanitis (among the circumcised and intact) and balanoposthitis). It causes non-specific dermatitis. Intact (and circumcised) children should be taught to wash their penises with water -- omit the soap. If in a bath, wash the intact penis (one that has naturally retracted) first so the water is clean and there will be no soap residue. Otherwise, one may wish to shop around and find a soap that is alkali-free.

If these options have been non-responsive, surgical intervention maybe necessary. Once again one should seek out a doctor who has knowledge of the penis and not just circumcised penises. Circumcision need not be performed. A procedure, which a well-informed doctor ought to know about, called a Z-plasty will almost certainly alleviate the problems that are non-responsive to less invasive treatments. A Z-plasty (the stitched up incision take the form of a z) removes essentially no tissue and allows a 'widening' of the foreskin. This is an invasive surgery, less radical than a circumcision, and should be sought if less conservative measures are not successful.

Restrictive Foreskin Movement:

SUGGESTIONS TO BE DONE IN CONSULTATION WITH YOUR DOCTOR

Depending on exactly the brevity (shortness) of the frenulum or its attachment to the glans, may result in various methods of treatment. Most treatments are very simple surgical procedures which do not ablate (remove) the foreskin or the frenulum. The type of surgical procedure will depend on the manner in which the frenulum is causing a restriction of movement. Generally, most or all of the frenulum can be saved and need not be removed to correct the brevity, so be clear that you and your doctor are fully aware of what exactly is going to be done. Remember, that the frenulum is considered the most sensitive part of the penis; ensure you seek out a knowledgeable medical doctor.

You should also keep in mind that the frenulum can be stretched and if stretching relieves any breve condition that may exist you should make sure that you continue to stretch the frenulum or you may find that it becomes rather taut again.

General Irritation and Infection:

SUGGESTIONS TO BE DONE IN CONSULTATION WITH YOUR DOCTOR

Apply some lotrimin lotion on the foreskin to ease the inflammation. The help restore the natural bacterial/flora balance ensure that the boy eats food that contains lactobacillus and other helpful bacteria, if he is not allergic. These might include live culture yogurt, or any juice with lactobacillus added.

If the condition arises during the antibiotic treatment one may want to increase the frequency of bathing (i.e., once a day) using warm water to gently wash the genitals.

This is a temporary imbalance for which circumcision most certainly is not needed.

Ammonia Dermatitis:

SUGGESTIONS TO BE DONE IN CONSULTATION WITH YOUR DOCTOR

May be alleviated by treating the diapers with an antiseptic (mercuric chloride) which inhibits the ammonia-producing bacterium. Frequent diaper changes can also help alleviate this problem.

Infants skin can be very sensitive and react to a number of agents. Alkali in hand soap's can be the cause of irritation. Simply bathing with warm water may alleviate the irritation--with patients and time the redness will disappear. Alkali in laundry detergents may be the source of irritation particularly if one is using cloth diapers. You may want to find both a bathing soap and a laundry soap which is alkali free.

Surprisingly the diaper itself may be the agent causing irritation; switching of brands may eliminate irritation.

Other things to watch for are reactions to bubble bath soaps, reactions to chlorine, this maybe particularly evident if you take your child to public swimming pools. Certainly not all the problems will affect your son, whether circumcised or not, but in some cases these are do have a bearing on children and in many cases also that of females as well.

Often when the foreskin reddens it shows that it is doing is job of protecting the glans. Meatal ulceration (the opening at the tip of the penis) is seen in 30% of circumcised boys. This can be a most painful condition and lead to meatal stenosis and in many cases requiring surgical intervention to enlarge the urinary opening. Meatal ulceration is almost non-existent in intact boys. Meatal ulceration is considered a complication of circumcision but of which is hardly ever told to parents by doctors.

Note: Ammonia Dermatitis and Eczema are quite frequently found with the circumcised penis. The problems are more particularly exacerbated by the exposed glans. Remember, the foreskin is essentially like a protective glove. We often wear gloves to protect our hands when dealing with cleaning solutions (ammonia, Javex) and to protect against abrasion, i.e. raking grass/leaves.

Balanitis:

SUGGESTIONS TO BE DONE IN CONSULTATION WITH YOUR DOCTOR

Balanitis may be treated by bathing in hot water and local washing; a saline solution might be advisable. One can get this from a pharmacy or make it yourself with 4 teaspoons of salt in 1 liter of clean water Application of an emollient cream may also help ease this condition.

One should BOIL their undergarments for at least 20 minutes then wash them and rinse them three or more times. There have been cases where the problem was washpowder on the underpants which irritated the penis and gave the impression of an infection. After this one might want to make sure that they are using a laundry detergent which is not harsh and alkali free.

In some cases broad spectrum oral antibiotic is required as the problem can be 'inside' rather than 'outside' the person. But depending on the cause one may need injected penicillin if there are certain specific problems.

One may also want to ensure that they are not "over-bathing." Constant washing of the irritated area can sometimes cause further irritation.

Note: In most cases balanitis is that of Nonspecific Dermatitis (NSD) and is treated with emollient cream and the restriction of soap usage and that 90% of all cases respond well to this very simple treatment.

Balanoposthitis:

SUGGESTIONS TO BE DONE IN CONSULTATION WITH YOUR DOCTOR

Sample cultures should be taken to identify any offending organism(s) and then by appropriately treated with antibiotics.

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