The most common problems that affect the foreskin in childhood are a tight foreskin and recurrent infections.
The foreskin is not fully developed at birth and continues to develop during childhood. By about 5 years of age, however, most boys can pull the foreskin back over the head of the penis. There are 2 principle reasons why there might be difficulty doing this: a narrow opening (known as a phimosis) and attachments between the inside of the foreskin and the underlying head of the penis (referred to as prepucial adhesions). Difficulty in pulling the foreskin back can lead to problems with hygiene and cause infections underneath the foreskin – so-called balanitis.
If a child has a tight foreskin but this is not causing any symptoms then it is perfectly reasonable to wait and see if the problem will get better by itself. If, however, they are suffering from repeated infections then usually some intervention is required. Sometimes treatment with topical steroid ointment will resolve the problem but in other cases a small operation might be needed. Boys with prepucial adhesions may simply require these separated under a short general anaesthetic but if the problem is a phimosis then a circumcision is normally appropriate.
SWELLINGS IN THE SCROTUM
The most common childhood swelling in the scrotum is a hydrocoele. A hydrocoele is a collection of fluid in the space in front of the testicle.
In younger children, it usually forms because of a small persistent channel between the abdomen and the scrotum. This is known as a persistent processus vaginalis or PPV for short. This channel allows a small amount of fluid to track downwards and build up in front of the testicle. Sometimes the swelling will come and go and may be more noticeable when the child is crying or straining. In very young children the PPV may close spontaneously and therefore no treatment is normally indicated until they are 2 years of age. At this point an operation is offered to locate and tie-off the PPV to prevent the fluid tracking downwards and causing the scrotal swelling. This is called a ligation of PPV and is performed through a small incision in the groin as a daycase procedure under a general anaesthetic.
In older children, a persistent processus vaginalis is not usually the problem but hydrocoeles can still occur due to a fluid build up in the space in front of the testicle. These are usually dealt with by an operation through the scrotum to drain the fluid out and then disrupt the hydrocoele sac that contains the fluid.
The testicles form within the abdomen during the early part of foetal development and then migrate through the inguinal canal to reach the scrotum by the time of birth. If this descent does not occur properly then the testis is referred to as an undescended testis. The testis can stop descending at any point along its path although most commonly they reach the inguinal canal in the groin.
About 4% of babies will be born with an undescended testis but further descent can occur within the first year of life. By the age of 1, a little under 1% of boys will still have a testis which is absent from the scrotum. At this stage further descent is unlikely. The scrotum provides the best environment for the testis to develop fully and so an operation is offered to bring the testicle down which is referred to as an orchidopexy. The exact nature of the operation depends on where the testis is located but for most boys the operation is done through a small incision in the groin and is performed as a daycase under general anaesthetic.