In boys at birth the foreskin is usually largely adherent to the underlying glans penis. This is part of the reason that the foreskin is not retractable at that age. Adhesions gradually separate during childhood and will always be completely gone by puberty. Separation occurs by a process of desquamation which in some boys can lead to significant build ups of keratin debris (or smegma) in places beneath the foreskin. This presents as a firm whitish lump between the foreskin and the glans, which may look similar to a sebaceous cyst. As adhesions continue to separate then these smegma collections or cysts will discharge spontaneously. Sometime this will be noted as white material in the nappy or pants. It is not indicative of Thrush.
In a very small number of boys adhesions may be symptomatic, often this is when they are markedly asymmetric and attempted retraction will pull on the glans. Lysis of adhesions can be performed but does require a general anaesthetic. Steroid application is useful for an unretractable foreskin when the preputial opening is small but it does not speed up the lysis of adhesions so is not useful when it is clear that an inability to retract the foreskin fully is due to adhesions alone.
In the vast majority of boys with preputial adhesions and / or a smegma cyst reassurance that these will resolve spontaneously is all that is required.
FM, LS, JB Sept 22
Who to refer:
Only those boys with preputial adhesions or smegma cysts with significant irritative symptoms or there is diagnostic uncertainty.
Who not to refer:
- Boys with preputial adhesions or smegma cysts unless these are associated with significant irritative symptoms or there is diagnostic uncertainty.
How to refer:
- Please refer via SCI Gateway
Referral Priority
- A child preputial adhesion or a smegma cyst will be triaged as a routine referral.
Surgical Priority
Options for Management in Primary care
- Simple reassurance regarding the natural history of preputial adhesions.
