A few weeks ago, Joey, a healthy 3 year old boy, was brought into my office by his dad. Joey was potty training, and his dad noted that Joey’s urine stream went almost straight up, so that he had to sit Joey on the toilet and push his penis down into the toilet to keep the urine from spraying all over the bathroom. Surprisingly, Joey’s parents never saw him urinate while they were changing his diapers, so this was a new experience for them. I suspected the problem had been there since birth, but was never noticed until his parents saw his abnormal urine stream. This is one of many penile anomalies seen in newborns, some common and some uncommon (for a discussion of common scrotal problems, see this article elsewhere in The Pulse).
I instantly recognized Joey’s problem as meatal (me-ATE-al) stenosis, or a narrowing of the opening (meatus) of the urethra at the tip of the penis. Sometimes this occurs when inflammation at the meatus causes scarring, and the opening narrows or has a web-like formation covering it. In other cases, the babies are born with this narrowing. There is usually no pain associated with this condition, but it may take longer to urinate, and the stream is usually deflected in some way: up, down, or sideways. It is a relatively rare condition.
Occasionally, a steroid cream can be used to decrease the inflammation at the meatus and open it up, but if the problem is identified later, like in Joey’s case above, then surgery is usually performed to widen the meatal opening. However, it is a relatively simple procedure with very good outcomes.
Hypospadias is a congenital condition (one the baby is born with) in which the meatus is displaced somewhere other than the center of the tip of the penis. The opening is most commonly on the bottom of the penis, but can be on top, or rarely off to the side. This is obvious at birth, once the foreskin is retracted. It is often not noticed until the circumcision is about to be performed. But it is important NOT to circumcise these boys as circumcision makes surgical repair more difficult.
To urinate normally and have normal sexual function, most cases need to be repaired surgically. However, in very mild cases, no treatment is needed.
Some baby boys are born with the penis curved downward, a condition called chordee. This is due to a problem during penile development in the womb. Less commonly, the penis can be curved upwards or to the side. The vast majority of chordee cases occur with hypospadias: about 25% of the cases of hypospadias will also have chordee. Less frequently, chordee or penile curvature is seen with meatal stenosis, and they also can occur on their own.
Like the other two problems, chordee and other penile curvatures need to be corrected surgically.
Many parents bring their sons in to the doctor worried that the penis is very small. Usually, the problem is not the penis size, but the fact that it is “buried” in the surrounding skin. This is also referred to as a “trapped” or “concealed” penis. In these cases, the length of the penis is normal, but the penis is restricted and trapped, either at birth by the fat pad or soon after birth by scarred skin after a traumatic circumcision.
Again, surgical correction is the only treatment, but this is a simple procedure that results in great relief and satisfaction of the parents.
The prepuce is another name for foreskin, the part of the skin that covers the glans or head of the penis, and is the part that is cut off in a circumcision. Phimosis is a condition in which the prepuce cannot be retracted to reveal the glans. At birth, this is called physiologic phimosis and is actually normal, as almost all boys are born with foreskin that is not retractable, but by 3 years of age, 90% of foreskins are retractable.
But phimosis is a problem when the foreskin is forcibly retracted and then becomes “stuck” in this position, and acts like a tourniquet on the penis. This is called pathologic phimosis, causing severe pain, swelling, and ultimately damage to the penis. For this reason, parents of uncircumcised babies should not retract the foreskin until a health care provider instructs them to do so.
Most cases of problematic phimosis can be resolved by a pediatric urologist without the need for surgery. And physiologic phimosis is not a problem, and requires no treatment.
When examining an uncircumcised baby in my office, I ask the parents if they know how to care for an uncircumcised penis. Sometimes, they look surprised by my question, and say that their boy was, in fact, circumcised. In these cases, the remaining foreskin covers the entire glans, and can be easily retracted to reveal a circumcised penis. This is called redundant foreskin.
Depending on the amount of foreskin left, the options are to do nothing and let the child “grow into” the redundant foreskin, or to re-circumcise the child. However, a re-circumcision usually requires a pediatric urologist performing the procedure in an operating room, with all the attendant risks and costs. So a thorough discussion with the pediatric urologist is warranted before taking this step.