During the school holidays, parents are taking the opportunity to schedule health care appointments for their children.

This includes fathers bringing their sons to see the urologists. This week, we address the issues relating to circumcision of children.

Dear Dr G,

I am a concern father who has two boys. My elder one is now 9 years old and the younger one is only seven.

When my older boy was born, I accepted the proposal of the pediatrician to let him undergo a circumcision.

Although the operation was uneventful, my son began to have a band that bridged across the penile shaft and glans.

This is very unsightly. The doctor said it was a common complication and might need a revision operation in the future.

Because of his brother’s experience, I did not subject my second son through the operation. I am rather anxious, as his foreskin is still not retractable.

My questions to you are: Is the bridge on the penis going to be problematic for my son in the future? And is the foreskin non-retractable normal for a seven year old?

Please advice.

Desperate father.

When a child is born, the adherence of the foreskin to the glans penis is completely physiological, as the foreskin and the underlying glans initially developed as one.

The bonded membrane acts like a protection for the inner lining of the glans until the detachment becomes spontaneous between three and 10 years old.

When left alone, the separation occurs naturally. If the retraction is induced by force, this can cause pain, inflammation and scarring.

In the normal circumstance, the foreskin is relatively long at birth; as the penis grows, the apparent length of the foreskin lessens.

In some children, the redundant foreskin may trap some residual urine and cause infection.

Although physicians will advise parents to retract the skin as much as possible for hygiene purposes, such maneuver should be carried out gently, perhaps with the aid of a lubricant or under anesthesia.

If the retraction can be done thoroughly, circumcision may not even be necessary.

In many culture and religions, the ritual of circumcision is performed during neonatal period.

For non-religious reasons, many parents believe the circumcised penis is more hygienic and require minimal maintenance.

However, many would not expect the “premature” forceful retraction prior to the cutting of skin could induce a complication called penile adhesion or skin bridges.

This usually appears as skin flap from the penile shaft attached to coronal margin and result in permanent attachment that cannot be separated on its own.

A recent study performed by Van Howe, published in British Journal of Urology reported that 30% of circumcisions performed on boys under the age of three result in skin bridges.

The researchers postulated the tearing of the bonded membranes from the overlaying glans often induce a raw surface, that may be in contact with dirt, talcum powder and stool that are trapped in the nappies.

The result of such combinations will cause unsightly post-operative outcomes.

Other causes of penile adhesion may be due to excess of residual foreskin following the newborn circumcision.

It is noted most skin bridges caused by the post operative adhesion will resolve within 24 months, some may persist all the way to adult lives.

Although this will not cause any impairment in the sexual and reproductive functions of the penis, revision or redo circumcision may be necessary for cosmetic reasons.

When it comes to non-religious and non-medical elective circumcisions in children, there really is no right or wrong decisions.

Sometimes, doing nothing is really not the worse thing, as nature often finds its way to resolve problems, even when it comes to penises.

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