The loose foreskin protrudes well beyond the glans of the penis (Fig. 5.1). Postnatally, the foreskin is adherent to the glans for a variable period: In many primary school-age boys, the foreskin still is partially adherent. Nevertheless, forced retraction of the foreskin by parents or doctor is not necessary since separation will occur spontaneously as childhood progresses. Any ­residual adhesions as the child approaches puberty ­separate as a result of erections and masturbation by the boy himself.

If the foreskin separates from the glans around the coronal groove before the more distal foreskin is free, secretions and desquamation of keratin can accumulate as lumpy deposits of smegma (Fig. 5.1). The characteristics of smegma are: (1) a bright yellow collection because of its high cholesterol content (similar to xanthelasma), (2) a lump covered by foreskin which is thin enough to allow the yellow colour to show through and (3) absence of inflammation or infection when the smegma is entirely contained within the congenital adhesions of the foreskin to the glans.

The diagnosis is important because this trivial condition requires no treatment but is misdiagnosed often as serious pathology, such as a ‘cyst’ or ‘tumour’ of the penis, sometimes resulting in unnecessary psychological trauma for the child and parents.

The scar at the line of resection of the foreskin lies proximal to the coronal groove. The meatus on the tip of the glans is visible as a small vertical slit (Fig. 5.1).

This is a simple manoeuvre where the fingertips of one or both hands gently squeeze the foreskin over the glans and simultaneously pull the skin down the shaft of the penis (Fig. 5.2). If the skin is not adherent and there is no phimosis, the entire glans can be exposed. It is important to replace the foreskin in the normal position as soon as the examination is complete to prevent the development of paraphimosis.

Even minor phimosis or adherence will make retraction of the foreskin difficult and, unless force is used, will prevent exposure of the entire glans.

Hence, this method of demonstrating retractability of the foreskin tends to overdiagnose phimosis. Where there is difficulty distinguishing an adherent foreskin from phimosis, the method shown in Fig. 5.3 should be used.

When the foreskin remains adherent to the glans, it may be difficult to retract in order to visualize the urethral meatus or to determine whether phimosis is present. By pulling the edges of the foreskin up with the tips of the fingers, the inner layer of the foreskin is stretched open and the glans can be seen (Fig. 5.3). If phimosis is present, the scarring of the foreskin prevents it being stretched open, and the examiner cannot see the glans. This method does not hurt the child and will separate readily the minor examples of phimosis which need no treatment from the more severe lesions requiring surgery.

Phimosis is caused by scarring of the foreskin distal to the glans and occurs as a result of (1) tearing of the foreskin from overzealous retraction, (2) chemical or physical irritation from ammoniacal dermatitis producing recurrent or chronic ulceration, and (3) infection under the foreskin (balanitis).

Mild phimosis causes no symptoms apart from a narrow urinary stream. There may be evidence of scarring around the tip of the foreskin (Fig. 5.4) which can be assessed as shown in Figs 5.2 and 5.3.

If the glans and urethral meatus can be seen, no immediate treatment is required. On occasions, topical steroid ointment may be useful in preventing further scarring before urinary obstruction occurs.

Severe phimosis with urinary obstruction is an important diagnosis to make because surgical treatment (circumcision) is needed. The scarring of the foreskin has reduced the opening of the foreskin to a pinhole. The scar surrounding the tiny opening appears as pale, unyielding tissue which cracks and fissures readily. The glans cannot be visualized at all, and there is a history of marked ballooning of the foreskin which persists after micturition has ceased (Fig. 5.4). This is the cardinal sign of phimosis because it indicates urinary obstruction requiring immediate treatment. The bladder should be palpated since distension may indicate significant subacute, or even chronic, urinary retention.