Forcible retraction of the foreskin

Forcible retraction of the foreskin, sometimes called premature retraction, in infants or young children can damage the glans and mucous inner tissue of the foreskin. Doctors or parents who may be unfamiliar with the foreskin can often forcibly retract it, unaware that it can be damaging.
At birth, the foreskin is fused to the glans. Over time, separation occurs naturally. Infants are sometimes diagnosed as having pathological phimosis, which some authors consider to be erroneous. In order to perform circumcision the foreskin must be retracted by force, ripping it away from the glans when performed on infants.
Biology of the infant foreskin
It has been widely recognized by the medical profession for most of the 20th century that normal male infants have foreskins which are incompletely separated from the epithelium of the glans. The foreskin cannot be retracted without tearing the fusion which exists between the inner foreskin and the glans penis. According to McGregor et al (2005), many physicians have difficulties distinguishing between this normal physiological non-retractile foreskin and pathological phimosis.
At birth, the foreskin is usually still fused with the glans. As childhood progresses the foreskin and the glans gradually separate, a process that may not be complete until the age of 17. A Danish survey (2005) reported that average age of first foreskin retraction is 10.4 years. Marques et al (2005) reported that 99% of boys can retract their foreskins by age 14.
About 2% of males have a non-retractable foreskin throughout life, although this does not necessarily mean it is a pathological phimosis.
Prevalence and consequences
Forcible retraction may lead to bleeding, scarring, pathological phimosis or paraphimosis, and often pain. The Canadian Pediatric Society poses the question of whether increased urinary tract infection and balanitis rates in uncircumcised male infants may be caused by forced premature retraction.
Forcible retraction happens in a variety of occasions. Most well known is the forcible retraction by doctors. Spilsbury et al (2003) suggest that doctors may be likely to confuse congenital (and normal) infant phimosis and the fused glans and foreskin with pathological phimosis. Forcible retraction may also be done by carers. Osborn et al (1981) reported that mothers are often advised by their doctors to retract the child's foreskin.
Camille et al (2002), in their guidance for parents, state that "he foreskin should never be forcibly retracted, as this can cause pain and bleeding and may result in scarring and trouble with natural retraction."
Therapeutic forcible retraction
Several doctors proposed forcible retraction as treatment for a number of penile problems in the 1980s and again in 1997. This procedure is controversial and may be outmoded.
Cooper et al (1983) urged therapeutic retraction as an "alternative to circumcision" and reported resolution of a number of problems, including balanoposthitis, dysuria, and phimosis through retraction under anaesthesia. Griffiths & Freeman (1984) reported the use of topical anaesthetic for forcible retraction, reporting:
:"The procedure we describe is safe, simple, relatively atraumatic, cheap, and easily repeated if adhesions recur. Only 4 boys (2.5%) came to circumcision and can be regarded as failures. Between March, 1973 and November, 1980 we treated 161 patients in this way, achieving complete separation in 150 and partial separations in 11. Complications were severe trauma in 9 and slight discomfort in 15. 2 mothers fainted. Apart from the 4 failures, the procedure had to be repeated in 4 children and paraphimosis was recorded in 1."
MacKinlay (1988) reported on breaking the adhesions between foreskin and glans, which rendered the foreskin non-retractile, with topical anaesthetic, thus achieving full retractibility "without the necessity of circumcision". Iwamuro et al (1997) have reported similar results in treating older children "without further operation."
Osborn et al (1981), however, say "he office practice of freeing adhesions and subsequent retraction of the foreskin is unnecessary." Simpson & Barraclough (1998) state that "o attempt should be made to retract a foreskin in a child unless significant separation of the subpreputial adhesions has occurred. Failure to observe this basic rule may result in tearing with subsequent fibrosis and consequent true phimosis. ..."
Recommendations of paediatric societies
The American Academy of Pediatrics caution parents not to retract their son's foreskin, but suggest that once he reaches puberty, he should retract and gently wash with soap and water. The Royal Australasian College of Physicians as well as the Canadian Paediatric Society emphasize that the infant foreskin should be left alone and requires no special care.

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