Saturday, 6 June 2015

How do we deal with the messy bits? (Easter egg - Balanitis and foreskins in children)

In case you hadn't noticed, in the UK there is now a NICE guideline for everything.  It feels like a new ones come out so frequently that it is impossible to keep up.  That is despite the fact that  I can now ignore anything not relevant to children.   On top of that we get NHS England alerts, journal updates, e-bulletins and local guidelines.   It goes on.

So why are there still things that are surrounded in confusion that don’t need to be?  I think that the answer has to be that many of them are seemingly too minor and don’t belong to a bigger topic.   A good example of this is little boys’ foreskins.  It seems to me that there are misunderstandings that could easily be cleared up and yet no UK national guideline has done so.

At some point in my medical training I remember being taught that uncircumcised penises should easily retract by about 3-4 years old and that they should be kept clean.  Balanitis was seen as a marker of poor hygiene and so more cleaning was the presumed solution.  Foreskins that were ‘non-retractile’ were considered abnormal and if there was recurrent balanitis or ballooning, the child should be considered for circumcision.  We now believe that all of this is untrue.  It is quite normal for the foreskin of a boy to remain adhered to the glans until they hit puberty, whenever that may be.  Ballooning is within normal limits and balanitis is often due to unnecessary attempts to retract or clean under a foreskin.

So I know that I was taught something that later turned out to be untrue and I know that many clinicians in both primary and secondary care haven’t heard the good news.  Why?  I think it is because it only needs two boxes worth of information, so no-one gets round to it.  Well, here they are:

In case you were wondering what t’interweb has to tell people, I've saved you the bother.  On the first two pages of a Google search I found:
  • Four patient forums, starting each time with a parent who had been told by a doctor to ‘encourage’ their toddler’s foreskin to retract so that it could be cleaned underneath.
  • Four medical sites advocating retraction as being desirable in a baby or toddler.
  • Three sites quoting the expectation that foreskins should retract by the age of 3-4.
  • Seven sites recommending that the foreskin of a child should not be forcibly retracted but stopping short of suggesting that it should just be left alone.
  • Four sites unambiguously recommended that the foreskin of a child should be left alone completely other than to wash externally.

I was pleased to see that Australian websites were frequently up to date and unambiguous about leaving well alone.

Increasingly the guidelines available online are providing clearer advice about foreskins and the message is this:

So, since it is unlikely that there will be a foreskin summit any time soon, you might want to spread the word yourself.

Meanwhile, if you have any messy bits that you think could be covered in two or three boxes, please post your suggestions below and I'll do my best to deal with them

Edward Snelson
President of the Sir Lancelot Spratt Association

Disclaimer:  Don't worry.  Be happy.

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