Does Your Baby Need a Circumcision?

A tight foreskin can often prompt parents to think their baby needs a circumcision – but this is not always the case.

Dr Sharryn Gardener

Don’t worry – it’s vanishingly likely that your baby boy needs a circumcision, despite well-intentioned advice from dad, uncle or grandad who may have had one at their age.

You look and the little wee-hole is barely visible, it all swells up like a balloon even before any wee comes out. You’re reasonably convinced they must need one too.

All babies have their foreskin fully stuck down at the start to the head of the penis. Sometime between then and being effectively an adult man it needs to become loose and be able to come back. For some babies this will be within the first year, for some boys it will be during puberty. The important thing is that it honestly doesn’t matter. Even if it is not loose after puberty there are other options as it makes things painful.

You might have noticed that (some – actually almost all) boys can play with their foreskins helping this natural process along a bit.

So when you look at the teeny tiny hole at the tip of the penis and watch it balloon up, this is normal – as long as the flow after the balloon fills is good and it’s not painful or a big effort to start the wee. The big balloon only happens because the hole on the inside at the tip of the head of the penis is bigger than the one at the tip of the foreskin. This means that the foreskin swells up until the pressure becomes high enough to come out at the tip of the foreskin. The foreskin is designed for the adult head of the penis to grow into so there’s literally loads of space.

When a doctor looks to see if they need a circumcision they won’t pull the foreskin back (OUCH – it’s really delicate and pulling it back is painful and completely unnecessary). They may pull it gently forwards to demonstrate where the head of the penis will later expand into it.

The foreskin would almost always sort itself with time. If they think it is really tight or there is pain there is a really effective treatment available, The humble steroid cream (usually Eumovate – sometimes Hydrocortisone). You may have heard that we should be really careful using steroids as they can thin the skin (and the foreskin is already very thin delicate skin). It makes skin go thin. 

That’s exactly what we want it to do here!

We are stealing that later growth to open the hole slightly and relieve any symptoms or anxiety about it. You just massage a tiny bit into the area around the foreskin morning and night for up to 6 weeks. In fairness it often opens up enough after a few weeks that you don’t need the full 6 weeks. Usually your doctor will plan to see you again at 6-8 weeks to see how it went. Most boys will be fine by then. Some may relapse and need a bit more of the cream later. Most it will be quickly forgotten.

If even a longer course of steroids is not effective, more surgical options may be considered (after checking that your son has definitely applied the cream first!).

The only definite indication for a circumcision is something called BXO – weird name, huh? It’s marginally better than it’s real name or Balanitis Xerotica Obliterans! It isn’t totally understood how it happens – it’s thought to be partly an autoimmune condition (the body fights itself). Anyway, it is white scaly patches that start as spots and then group together in patches. It cracks and bleeds and then scars to form a hard lump. It’s really itchy and can cause pain and burning (girls get something similar as flat white patches called Lichen Planus). By the time it is diagnosed the hard lump can make it really difficult to pass urine and boys will often struggle to start their urinary stream. They will have really struggled on while it has got worse and worse. It can be a relative emergency if this is the case.

Steroids are still the first line treatment but most boys with this will need surgery. 

Even then they may not need a circumcision!

There is another option (not for all affected boys called preputioplasty – a fancy name for using an operation to open up the hole more than the steroids managed. Boys at this age will not fully appreciate what they need their foreskin’s for later so where possible if the foreskin can be ‘saved’ it should be to allow them to decide for themselves later if they wish to have it removed. It is completely irreversible.