Circumcision for a tight foreskin

Publication date Sep 21, 2007

This information tells you what to expect if your son has an operation to remove his foreskin. It explains how the operation is done, how it can help, what the risks are and what will happen afterwards.

The benefits and risks described here are based on research studies and might be different in your hospital. You may want to talk about this with the doctors and nurses treating your son.

What is circumcision?

Circumcision is an operation to cut away the foreskin of the penis. The foreskin is the sleeve of loose skin that covers the end of the penis.

Circumcision may be done for medical reasons or because of social and religious beliefs. This information is only about circumcision done for medical reasons.

Why does my son need a circumcision?

Doctors don't always agree about who needs this operation.[1] It's important to ask your doctor why he or she has recommended circumcision for your son.

Most boys don't need a circumcision.[2] But here are some reasons why you and your son's doctor might consider it.[2] [3]

Your son's foreskin is scarred and narrow at the end, and he can't pull it back over the head of his penis

This can happen if your son gets a lot of infections under his foreskin. Infections can damage the delicate skin and cause scars. Because scarring makes the end of the foreskin narrow and less stretchy, your son won't be able to pull his foreskin back. Doctors call this phimosis. It's unusual in boys under 5. It's most common in boys around puberty.[4]

Scarring can be caused by a skin condition called balanitis xerotica obliterans (BXO).[5] It makes the foreskin red and swollen, and the opening becomes a stiff, white ring of scar tissue.[6] This can make it hard to pass urine.[7]

If your son has a tight foreskin, it can get scarred if he forces it back.[3]

Your son keeps getting infections and swelling around the end of his penis

Germs and urine can get trapped under the foreskin and cause infections. Your son's foreskin might be itchy and sore, and there can be an unpleasant discharge. The end of the penis may be red and swollen.[3]

Removing your son's foreskin can help prevent infections, but it isn't usually necessary. There are other treatments that can help.[8]

Your son's foreskin has been forced back over the head of his penis and got stuck

If your son has a tight foreskin and forces it over the head of his penis, there's a risk it will get stuck there. This is called paraphimosis. It needs urgent treatment. The doctor will try to reduce the swelling and apply gentle pressure to pull the foreskin back.[8] But there's a small chance that the foreskin will need to be removed.

There are some problems your son may have with his foreskin that don't usually need circumcision. Here are some examples.

Your son can't pull his foreskin back, but there are no signs of scarring

All boys are born with their foreskin stuck to their penis. The foreskin usually separates from the penis naturally and can be pulled back by the time the child is 2 or 3. In some boys this takes longer, and may not happen until after puberty. It's rare to be born with a foreskin that never goes back.[9] Most boys will eventually be able to pull their foreskin back, unless there are signs of scarring.

Your son's foreskin balloons when he passes urine

If your son can't pull his foreskin back, urine can get trapped between the foreskin and penis when he passes urine. This means, when he passes urine, his foreskin swells like a balloon. The urine leaks out later. This problem can be upsetting, but it usually goes away once your son can pull back his foreskin.

Circumcision is unlikely to prevent infections called urinary tract infections. These infections are as common in boys who are circumcised as in those who aren't.[10]

What happens during a circumcision?

The operation takes between 15 and 30 minutes. You should be able to take your son home the same day.

Your son will usually be given a general anaesthetic to make him sleep during surgery. He may also have a local anaesthetic while he is asleep to numb his penis. This stops it hurting as much afterwards.

Surgeons can remove the foreskin in several different ways. The aim is to cut away enough of the foreskin to leave the head of the penis uncovered, but keep the skin that covers the length of the penis.[5] Talk to the surgeon about how he or she will do your son's operation.

One method works like this.

The surgeon may draw a line around your son's penis to mark the amount of skin to remove.
He or she will then gently cut away the inside and outside layers of the foreskin using surgical scissors.
The blood vessels are either tied off or sealed using heat. This is called bipolar diathermy.
The edges of the foreskin left behind are carefully sewn back together in the groove behind the head of the penis. The stitches will dissolve later.
Your son may have a dressing over his penis to protect the cuts. Some surgeons put some ointment or Vaseline on the end of the penis.

How can circumcision help my son?

If your son's foreskin was so tight it got uncomfortable, this operation should make his penis feel better.[3]

If your son's penis got red and swollen, he had infections under his foreskin, or he had problems passing urine, these should happen less often after the operation. But we don't know how much circumcision will help, as there are no good studies to tell us. Boys without a foreskin can still get infections and swelling around the end of their penis.[11] [12]

If your son had the skin condition BXO in his foreskin, it should go after a circumcision.

What are the risks of circumcision?

All operations have risks, and your doctor should talk to you about the risks of circumcision.

Anaesthetics can have side effects. These are more likely with a general anaesthetic. Your son may have an allergic reaction to the anaesthetic or get breathing or heart problems. These problems are serious but very rare. If your son has any allergies, tell the doctor.

It's difficult to say how often problems happen with circumcision, because there isn't much good research to tell us. It's important to discuss with your doctor how often problems happen in your hospital.

One study we looked at found that between 2 and 10 boys in 100 had problems, either during or after their operation.[13]

Problems that happen straight away

Your son's penis may bleed heavily during or after the operation. Occasionally, blood can build up under the cuts and cause a bruise called a haematoma. This may go away by itself, or your son may need another operation to drain off the blood.[13] [14]

Your son may get an infection in the wound on his penis or at the opening he passes urine through. Most infections go away on their own or with antibiotics. Sometimes infections cause open sores (ulcers) on the end of the penis.[13]

Circumcision can damage your son's urethra. This is the tube that carries urine from the bladder and out of the body through the penis. This problem is very rare, but if it happens your son may need another operation to mend the tube.[5]

Problems that can happen later

The opening at the tip of the penis can become scarred and narrow. This makes it difficult for your son to pass urine and can cause infections. Your son might dribble or spray urine. The stream may leave his penis at an angle. This problem can happen if your son's foreskin was stuck to the end of his penis and had to be pulled off during surgery. This can damage the opening and cause scarring. It sometimes happens later because the top of the penis is irritated by clothes or because it's washed too much.[14]

Your son may not be happy with how his penis looks. The surgeon may have cut away the foreskin too far down the penis. This means that when the ends of the foreskin are sewn up behind the head of the penis, the skin that runs along the penis will be tight and overstretched. This can look unusual, and your son's penis may be slightly bent and uncomfortable when it's erect.

Sometimes, too little of the foreskin is taken away and it's left looking baggy. This won't cause any problems, but your son may not like how it looks. Circumcision can also leave a bumpy scar which doesn't look nice. If this happens, your son may be able to have another operation to make his penis look better.

Occasionally, the foreskin left behind can stick back onto the head of your son's penis. This makes the sleeve of skin over the penis tight, and it will hurt when your son has an erection.[15]

Some parents worry that circumcision will affect their child's future sex life. But, as long as nothing goes wrong, there's no evidence to show that the penis is less sensitive or erections more difficult after a circumcision.[16]

Problems that are rare, but serious

It's possible, but very unlikely, that your son's penis will be damaged during the operation. The skin may be cut or burned by the tool the surgeon uses to seal up the blood vessels. If the foreskin is stuck to the head of the penis, pulling it off can cause damage. Ver y rarely, part or all of the penis has to be removed.[17] This will probably never have happened in your hospital, but you may want to talk to the surgeon about the risk.

It's incredibly unlikely that your son will die after this operation, but in order to tell you about all the possible risks we have included it here. The chances of serious bleeding or a reaction to the anaesthetic mean all operations have this risk.

What will happen if I choose not to have my son circumcised?

If your son's foreskin won't go back because it's scarred, it probably won't get any better without treatment. But creams and other types of surgery may work, and are worth trying first.

If your son can't pull his foreskin back but there are no signs of scarring, it may be best to wait and see if it will go back naturally. It's very rare for boys to be born with a foreskin that never goes back.

Having a tight foreskin may make it difficult for your son to keep his penis clean, and germs can build up and cause infections and swelling. It may also be difficult for your son to pass urine. However, these problems can be treated without having the foreskin removed.

Circumcision is done more often than necessary. About 6 in 100 boys are circumcised for medical reasons each year, but studies show that only 2 in 100 really need it.[1] [18] [19]

What other treatments are available?

Circumcision is the only way to remove the foreskin. But creams and other operations can help with a tight foreskin, and may help with one that's scarred.[20] We don't know for certain how well these other treatments work, because there aren't any good studies to tell us.

There are creams you can put on the end of your son's penis each day. They thin and soften the foreskin so it's easier to pull back. Studies show that between 7 and 9 in 10 boys who use a strong steroid cream for four weeks to six weeks can then pull back their foreskin.[21] [22] [23] [24] It's possible that your son's foreskin will become tight again once he stops using the cream. If this happens, he may need a circumcision.
A surgeon may be able to loosen your son's foreskin by making one, or a few, small slits in it to stretch it, rather than removing it completely. The slits are sewn up afterwards. This operation can help if your son gets infections under his foreskin, but it's less likely to work if his foreskin is scarred.[25] [26]
If parts of your son's foreskin stay stuck to his penis, the skin can be separated with a minor operation using a local anaesthetic.
Antibiotic creams and tablets can help with infections under the foreskin.
If your son has a tight foreskin without any scarring, gently stretching the foreskin by hand may make it go back. But if your son's foreskin is forced back, it may tear and scar.[27]

What can I expect after my son's circumcision?

Your son can probably come home the same day. The doctor or nurse will want to make sure your son is able to urinate normally before he leaves hospital. Urinating may hurt the first time, but it should be fine after that.

Your son's penis will probably look raw, bruised and slightly swollen for about a week. If your son had a lot of infections under his foreskin, it may also have a covering of scabs. Encourage him not to pick at these.

Your son's penis will feel numb and tingly at first, and may hurt and feel uncomfortable for three or four days. Paracetamol tablets will help with the pain. You shoul dn't give your son aspirin as it can be dangerous for children.

A clear, sticky fluid may ooze out of your son's wound for a few days. This is normal. If the fluid is a whitish yellow colour or smells, it may be a sign of infection. This can be treated with antibiotics.

If your son had a lot of discomfort from infections before the operation, he will feel relieved afterwards. Some boys say their penis feels strange at first.

Within a week, life should start to get back to normal and your son should be able to go back to school.

If your son has a medical problem with his foreskin, it may be difficult to avoid the operation. But if you can, it might be best to wait until he's older so he can be part of the decision. Some men say they wish they hadn't been circumcised as a child. A small number of men have had an operation to make a new foreskin, but this is very rare.

One study found that a small number of boys were shy and unwilling to undress in front of schoolmates after circumcision because their penis looked different.[27] But the boys in the study didn't show signs of more serious psychological problems.

References

Farshi Z, Atkinson KR, Squire R. A study of clinical opinion and practice regarding circumcision. Archives of Disease in Childhood. 2000; 83: 393-396.
British Association of Paediatric Surgeons, The Royal College of Nursing, The Royal College of Paediatrics and Child Health, et al. Statement on male circumcision. Royal College of Surgeons of England. London, UK; 2001.
Rickwood AM. Medical indications for circumcision. British Journal of Urology. 1999; 83(s1):45-51.
Rickwood AM, Hemalatha V, Batcup G, et al. Phimosis in boys. British Journal of Urology. 1980; 52:147-150.
Stringer MD, Oldham KT, Howard ER (editors). Pediatric surgery and urology: long-term outcomes. WB Saunders, Philadelphia, U.S.A.; 1998.
Edwards S. Balanitis and balanoposthitis: a review. Genitourinary Medicine. 1996; 72: 155-159.
Clark C, Huntley JS, Munro FD, et al. Managing the paediatric foreskin. Practitioner. 2004; 248: 888-899.
Davenport M. ABC of general surgery in children: problems with the penis and prepuce. BMJ. 1996; 312: 299-301.
Gairdner D. The fate of the foreskin: a study of circumcision. BMJ. 1949; 2: 1433-1437.
Van Howe RS. Effect of confounding in the association between circumcision status and urinary tract infection. Journal of Infection. 2005; 51: 59-68.
Herzog LW, Alvarez SR. The frequency of foreskin problems in uncircumcised children. American Journal of Diseases of Children. 1986; 140: 254-256.
Fergusson DM, Lawton JM, Shannon FT. Neonatal circumcision and penile problems: an 8-year longitudinal study. Pediatrics. 1988; 81: 537-541.
Williams N, Kapila L. Complications of circumcision. British Journal of Surgery. 1993; 80: 1231-1236.
Griffiths DM, Atwell JD, Freeman NV. A prospective survey of the indications and morbidity of circumcision in children. European Urology. 1985; 11: 184-187.
Kaplan GW. Complications of circumcision. Urologic Clinics of North America. 1983; 10:543-549.
Senkul T, Iseri C, Sen B, et al. Circumcision in adults: effect on sexual function. Urology. 2004; 63: 155-158.
Sherman J, Borer JG, Horowitz M, et al. Circumcision: successful glanular reconstruction and survival following traumatic amputation. Journal of Urology. 1996; 156: 842-844.
Shankar KR, Rickwood AM. The incidence of phimosis in boys. BJU International. 1999; 84: 101-102.
Rickwood AM, Kenny SE, Donnell SC. Towards evidence based circumcision of English boys: survey of trends in practice. BMJ. 2000; 321:792-793.
Huntley JS, Bourne MC, Munro FD, et al. Troubles with the foreskin: one hundred consecutive referrals to paediatric surgeons. Journal of the Royal Society of Medicine. 2003; 96: 449-451.
Golubovic Z, Milanovic D, Vukadinovic V, et al. The conservative treatment of phimosis in boys. British Journal of Urology. 1996; 78: 786-788.
Orsola A, Caffaratti J, Garat JM. Conservative treatment of phimosis in children using a topical steroid. Urology. 2000; 56: 307-310.
Webster TM, Leonard MP. Topical steroid therapy for phimosis. Canadian Journal of Urology. 2002; 9: 1492-1495.
Wright JE. The treatment of childhood phimosis with topical steroid. Australian and New Zealand Journal of Surgery. 1994; 64: 327-328.
Cuckow PM, Rix G, Mouriquand PD. Preputial plasty: a good alternative to circumcision. Journal of Pediatric Surgery. 1994; 29: 561-563.
de Castella H. Prepuceplasty: an alternative to circumcision. Annals of the Royal College of Surgeons of England. 1994; 76: 257-258.
Stenram A, Malmfors G, Okmian L. Circumcision for phimosis: indications and results. Acta Paediatrica Scandinavica. 1986; 75: 321-323.

Glossary

general anaesthetic: You may have a type of medicine called a general anaesthetic when you have surgery. It is given to make you unconscious so you don't feel pain when you have surgery.
local anaesthetic: Local anaesthetic is a painkiller for one area of the body. You usually get it as an injection. It makes that area numb. An example is the lidocaine you may get when your dentist fills a cavity.
allergic reaction: You have an allergic reaction when your overreacts to a substance that is normally harmless. You can be allergic to particles in the air you are breathing, like pollen (which causes hay fever) or to chemicals on your skin, like detergents (which can cause a rash). People can also have an allergic reaction to drugs, like penicillin.
haematoma: A haematoma is a collection of blood in any part of your body. The blood has usually clotted or dried.
antibiotics: These medicines are used to help the fight infection. There are a number of different types of antibiotics that work in different ways to get rid of bacteria, parasites and other infectious agents. Antibiotics do not work against viruses.

This information does not replace medical advice. If you are concerned you might have a medical problem please ask your Boots pharmacy team in your local Boots store, or see your doctor.

Circumcision for a tight foreskin