This is not my area of expert but I have treated many cases in the past. The treatment for phimosis (the opening of the prepuce is very narrow)or para phimosis is usually circumcision but conservative treatment including widening the opening of the prepuce can also be done

Important to distinguish between physiological and pathological phimosis. If on very gentle retraction the inner prepuce starts to " flower out" then likely physiological and should be treated conservatively unless further problems. If on gentle retraction there is a tight cicatricial ring then pathological phimosis should be considered and the possibility of BXO. There are obviously many other possible pathologies depending on the examination.

phimosis inyounger children does not usually require any treatment and the foreskin will become retractile as the child continues to grow. In some cases I have used local(on the foreskin) steroid cream every night for few weeks with simultaneouly streching of foreskin over the glans while in warm bath. Only very little quantity of steroid cream / ointment should be used and that too om the foreskin only. I have good resultswithin 3 months or so . o nly a very few children actually requires any surgical intervention.

I agree with the comments of previous colleagues. I would only add that in case of physiological phymosis the parents should be taught to be very gentle in handling the prepuce in a 1-year-old child. The prepuce of such a child is very delicate and it can be damaged by the maneuvers used to open it. The continuous contact with the urines in the nappy with a damaged prepuce may itself lead to a "iatrogenic" phymosis.

The natural history of the prepuce is one thing we do know about, thanks to a number of (much cited) papers. The one most often used is Gairdner's 1949 paper - the fate of the foreskin. He used a probe to separate adhesions around the age of three - thus his figures are not a true reflection of the natural history. This is perhaps where the expectation of a fully retractable foreskin at age 3 comes from.

The studies below show gradual and variable figures. We must also remember that full retractability is a function of two things - a preputial opening large enough for the glans, and a lack of glanular adhesions to the inner prepuce. Thorvaldsen has a mean age of 10.4 years, Oster's cohort had a 48% chance of some preputial adhesions at this age.

Perhaps more accurate are the figures of authors such as Oster (1969 - Danish schoolboys), Thorvaldsen (2005 - Danish again, this article in Danish), Ko (2007 - Taiwanese boys), Kayaba (1996 - Japanese boys), Agarwal (2005 - Indian boys), and Morales Concepcion (2002 Spanish article).

In the clinic, ballooning is the complaint from the parents which make them feel that the child has a 'problem'. In fact, practitioners many times refer these children for circumcision. Convincing the parents that the child does not require surgery is an uphill task.

From a different viewpoint, foreskin preservation is discussed extensively of late. In this context, Preputioplasty instead of circumcision, where foreskin preservation is possible, has been proposed.

As Dr Jones & Dr Saad pointed out, the physiological & pathological phimosis need to be distinguished to base an acceptable treatment plan.

Question is sometimes foreskin stretching/adhesiolysis done to 'open up' the foreskin - is it an acceptable method ? Objections stem from the possible turn to pathological phimosis due to 'aggressive' stretch and resultant fibrosis.

When there is no evidence of infection, a simple dilatation of the prepuce (or 'open up' as mentioned) using 2% lignocaine jelly will suffice. It should not be too forceful. Patients who have persistent symptoms. like itching, redness of prepuce or dysuria after such dilatation may need circumcision.

At one year re-assuarance after ruling out pathological phimosis (as detailed by previous contributors). Ballooning per se is not an indication for intervention. Local steroid is quite useful in this situation and if compliance is adequate.

In my experience, dilatation of prepuce is effective. Circumcision should be indicated when the dilatation was uneffective.

quote "Question is sometimes foreskin stretching/adhesiolysis done to 'open up' the foreskin - is it an acceptable method ? Objections stem from the possible turn to pathological phimosis due to 'aggressive' stretch and resultant fibrosis. "

Conservative treatment as mentioned up by colleague,Before circumcision be sure that the child have no HYPOSPADIA.

laboratory  investigations is important to exclude any bleeding tendency as PTT, CBC, bleeding and clotting times,  then proceed for circumcission by dissection method after  exclusion of hypospadias or epispadias. As regarding to group of parents not prefer circumcission, it is better to do dorsal preputial slit incision only as dilatation of the prepuce ends with resentosis and may BXO occur.

Too young for BXO, the child probably only has a physiological phimosis. However needs to be seen to exclude the uncommon condition known as congenital mega prepuce, which usually requires a surgical reconstruction.

Many of the problems/complications that are proclaimed in the literature in an intact male infant are in fact caused by the improper care of the intact penis. Many erroneously believe that the foreskin should be forcibly retracted for cleaning. This interrupts the body's normal protection mechanisms and introduces bacteria causing an infection, thus creating a self-fulfilling prophecy that intact males are more prone to infection. When left alone this is not the case however. The foreskin, early on in development is fused to the head of the penis and should not be retracted for any reason. Over the course of several years separation occurs. A first retraction can occur any time from infancy to around 18 years old. The average is around 10 years old but often can be well into puberty. Until retraction has occurred naturally for the first time there should be no cleaning under the foreskin. Only the boy himself should do this. Anyone else attempting to retract could force it and injure the boy and cause damage to a sensitive area.

As for phimosis, this is one of the most common reasons given for the circumcision of children past infancy but if one looks at the anatomy and physiology of the situation it becomes clear that this is a normal part of the physiological development rather than a pathological problem.

As long as the urine can leave the body ballooning is not an issue. The opening is purposely smaller to protect the glans penis. Many intact boys are teenagers before they can retract for the first time. No intervention is necessary. It may become an issue later on if there is pain but until late adolescence it is completley normal for intact boys to be unable to retract.