Odd AAP Advice on Penile Development and Care

Adding to my post on ethics, I want to continue with the recommendations from the technical report on non-therapeutic male child circumcision issued by the AAP Task Force:

  • Parents are entitled to factually correct, nonbiased information about circumcision that should be provided before conception and early in pregnancy, when parents are most likely to be weighing the option of circumcision of a male child.
  • Parents of newborn boys should be instructed in the care of the penis, regardless of whether the newborn has been circumcised or not.

Notice the past tense in the second point. Parents should be instructed in the care of the penis before they decide to circumcise. My anecdotal experience suggests some number of parents circumcise in part because they don’t understand how to care for a normal penis. However small this number probably is, if parents shouldn’t be ignorant, the AAP should recommend education before the decision, not after. Some parents may leave their son his choice if they’re educated in how simple and non-scary it is to care for a normal, intact penis.

It should also provide factually correct information. From “Care of the Circumcised Versus Uncircumcised (sic) Penis” (Pg. 763):

Parents of newborn boys should be instructed in the care of the penis at the time of discharge from the newborn hospital stay, regardless of whether they choose circumcision or not. The circumcised penis should be washed gently without any aggressive pulling back of the skin.24 The noncircumcised (sic) penis should be washed with soap and water. Most adhesions present at birth spontaneously resolve by age 2 to 4 months, and the foreskin should not be forcibly retracted. When these adhesions disappear physiologically (which occurs at an individual pace), the foreskin can be easily retracted, and the whole penis washed with soap and water.25

No, they should be instructed about care before discharge. Even if we ignore the obvious point that a circumcision would likely already have been performed by that point, are parents not responsible for any care for their son while in the hospital? Unless a hospital is doing it wrong, they don’t just keep the child until parents are discharged and then say “here you go”.

More importantly, that paragraph contains factually incorrect information. The Task Force states that most adhesions present at birth spontaneously resolve by age 2 to 4 months, which is ridiculous. It’s also unsupported by their source. From footnote 25, Caring for the uncircumcised penis: what parents (and you) need to know by Cynthia J. Camille, FNP, CPNP, Ramsay L. Kuo, MD, and John S. Wiener, MD:

Penile growth, along with intermittent erection, aids in the process that eventually completely separates the prepuce from the glans to form the preputial space (Figure 1). This process begins late in gestation and proceeds at varying rates during childhood; therefore, the age when the prepuce is completely retractable also varies.2,3 Complete retraction past the corona is possible in at least 90% of boys by 5 years of age. In contrast, some boys will not have complete separation of the prepuce circumferentially beyond the corona until accelerated penile growth occurs at puberty.

Even if “90% by age 5” is correct (some evidence at this link suggests it might be an overestimate), that differs significantly from “by age 2 to 4 months”. This is a recipe for incorrect diagnoses of phimosis and forced retraction, leading to unnecessary circumcision for non-existent medical necessity.

If we look at source 24, the AAP’s Caring For Your Son’s Penis, it states:

The Uncircumcised Penis

In the first few months, you should simply clean and bathe your baby’s uncircumcised penis with soap and water, like the rest of the diaper area. Initially, the foreskin is connected by tissue to the glans, or head, of the penis, so you shouldn’t try to retract it. No cleansing of the penis with cotton swabs or antiseptics is necessary, but you should watch your baby urinate occasionally to make sure that the hole in the foreskin is large enough to permit a normal stream. If the stream consistently is no more than a trickle, or if your baby seems to have some discomfort while urinating, consult your pediatrician.

The doctor will tell you when the foreskin has separated and can be retracted safely. This will not be for several months or years, and should never be forced; if you were to force the foreskin to retract before it is ready, you could cause painful bleeding and tears in the skin. After this separation occurs, retract the foreskin occasionally to gently cleanse the end of the penis underneath.

The Task Force provided no obvious evidence to support its “by age 2 to 4 months” claim. Either they didn’t correctly source the claim they made, or they’ve allowed at least one mistake to enter the document. Neither generates much confidence in the overall process.

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