Ballooning

There is a phase of development during which some boys may experience

"ballooning." Ballooning is the inflation of the prepuce during urination by the
pressure of urine inside. This can occur if the inner layer of the prepuce is separating
or has separated from the glans, which typically happens around three years of age,
before the prepuce has become fully retractable. Ballooning is an indication that the
normal separation of the foreskin from the glans penis has occurred. Ballooning is a
transient condition that goes away as the prepuce continues its natural growth and
development and the opening at the tip further enlarges. Babu et al. report that
ballooning does not interfere with voiding.
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Ballooning is not injurious, and it is not a
cause for concern. Ballooning is not an indication for circumcision.
The maturation of the penis may take years to complete. Each boy develops at his own
rate. The maturation of the prepuce continues beyond puberty as described below.
The appearance of the infant penis does not reflect on the appearance of the
adult penis. Sexual development after puberty causes many changes, which include
retractibility of the foreskin.

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The foreskin, or prepuce, protects the glans (head of the penis) against urine, feces and other types
of irritation agents. It also protects against infection and scarring of the urinary opening (meatus) and
protects the sensitivity of the glans.
At birth, it is unusual for the foreskin to be retractable because of the incomplete separation between
the skin layers and also the conical shape of the foreskin. Only about a 4% of the newborns have a
fully retractable foreskin and in 54% the tip of the glans may be revealed by very gentle traction.
Normally, after the age of 3 years the prepuce can be normally retracted to uncover the glans of the
penis in 90% of the boys.
The word phimosis is used to describe the narrow, nonretractable foreskin of childhood.
Phimosis can be:
Primary, referred also as physiologic, where the foreskin is narrow since birth and in most cases will
cease (90%).
Secondary, a pathologic process resulting from scarring after forceful retraction of the foreskin or as
a result of a scarring process called balanitis xerotica obliterans (BXO).
In the first years of life, keratin is produced between the foreskin and the gland, and because the
space is very narrow, balls or pearls of keratin (also called smegma) can accumulate and be visible
under the foreskin. This is a normal process and sometimes parents get worried when watching
these keratin pearls. This situation ends when occurs the complete separation between the glans
and the foreskin around 3-4 years of age.

Phimosis, note the very small opening on the tip of the prepuce and impossibility to uncover the glans
Phimosis: This is a condition in which the foreskin is tightly covering the head of the penis and
it cannot be retracted (pushed down exposing head of penis). Phimosis is uncommon and an
attempt can be made to treat with a topical medication. In general, true pathologic phimosis is
resolved through surgery. These cases that require surgery usually have a very narrow foreskin
with a small opening, or scarring after forced retractions. Sometimes the skin is possible to
retract with difficulty and its observed a compressive ring of skin, which can result in an
episode of paraphimosis if the foreskin is not put back to its original position.
In some cases of phimosis the opening of the foreskin is so narrow that the parents notice that when
the child is urinating the foreskin inflates like a balloon and after finishing keeps dripping for the time
this balloon needs to deflate. These anatomical conditions rarely resolve without surgery so they
always should be evaluated by a pediatric surgeon to decide whether or not the patient needs a
circumcision (Complete or partial resection of the foreskin).

Paraphimosis

Paraphimosis
Paraphimosis: Occurs when the narrow tip of the
foreskin (prepuce) is withdrawn behind the glans and
constricts the penile shaft, leading to swelling of the
glans. Complications of this include urinary retention,
ulceration of the glans and even ischemia and necrosis of
the skin of the glans.

Phimotic ring, a cause of
paraphimosis
This condition is very painful and is an emergency, the
foreskin must be repositioned by a pediatric surgeon as
soon as possible and sometimes is necessary to
resolve this with surgery and then the patient is
programmed for a circumcision once the swelling
disappeared after a couple of days (Doing a
circumcision in the same moment is difficult and often
leads to unaesthetic results).
Balanoposthitis: This is the term to describe the
inflammation of the glans and foreskin seen in small boys.
This occurs in around 4% of uncircumcised
boys, mostly between 2 and 5 years of age. The cause can be an infection, irritation due to long
exposure to urine and allergy to some component of the diaper. Symptoms are pain, dysuria
(pain when urinating, bleeding from the foreskin and others). The treatment is an antibiotic
cream, warm baths and proper local hygiene. In the case of associated narrow foreskin the
pediatric surgeon will recommend a circumcision in some patients with repetitive balanoposthitis
without other associated causes but phimosis.
Buried penis
Webbed Penis (Buried penis): This is the condition
where the scrotum, instead of being attached in the base of
the penis, is attached closer to the prepuce, giving the impression
of a small or buried penis. Careful examination by the
specialist will reveal the presence of a normal sized penis for the
age of the boy and the anatomic characteristics particular to this
pathology. Normal circumcision does not give good results and a
more complex procedure is performed with the objective of
giving a more normal appearance and functionality.

Balanitis xerotica obliterans
Balanitis Xerotica Obliterans (BXO): BXO is the cause of a
secondary or true phimosis, and a recognizable lesion at the tip
of the prepuce can be observed, usually in children from 5
years until adolescence. The resulting phimosis is severe and
often is not possible to visualize any part of the glan. In some
cases the scarring process can involve the glans and the
meatus as well (external opening of the urethra in the glans,
where the urine goes out). The cause of BXO is unknown and
the treatment is essentially surgical with a circumcision that
resects all the fibrotic tissue involved, though the healing
process can be longer and a higher rate of complications are
seen.