Are you supposed to check a boy's foreskin during a physical?

Specialties NP

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I just started work at a family clinic and I've had to do some physicals for kids and teens. Obviously, if you're giving a boy a physical you have to check for TC and a hernia, but if the boy is uncircumsized, should I also check if his foreskin moves freely? I've yet to have a patient that wasn't snipped but on the off-chance I do what's routine procedure?

Specializes in Nephrology, Cardiology, ER, ICU.

This thread got off to a rough start due to some miscommunication. I've deleted a few posts to keep it on topic.

The OP is an NP and it is within her scope of practice to do this exam.

As an APN myself, this question isn't outside the realm of being imaginable.

Specializes in ER/Tele, Med-Surg, Faculty, Urgent Care.
AAP says do not retract. Foreskins can separate anywhere between infancy and adolescence; as long as they're peeing ok there is no rush for it to separate. Matter of fact, premature retraction can cause injury/adhesions/infections which you do not want to be the cause of. My son's NP is great about this and doesn't touch if my son doesn't allow her to.

I'm in a part of the country where it's about 50/50 intact vs. circed. Unless there is a specific GU complaint a quick visual check is all you have to do for an intact member. Infants I make sure the testes are descended; adolescents I palpate the scrotum/testes and teach them about TSEs. Is it uncomfortable, maybe a little, but if they save their own life down the road it's worth it.

Anyway, back to foreskin. Leave it alone.

I graduated FNP program about 15 years ago. At that time we were taught to retract foreskin on infants during well child checks. However that is no longer recommended for reasons listed above. During sports physicals I check genitalia, you can do visual and I do scrotal checks and that is also the time I talk about testicular self exams. Along with the checks for the inguinal hernias. Just had a mom in with her son for a sports physical who had never heard of testicular cancer. She was shocked when I told her age range is about 15-35. Yeah parent stays in room during exam or I get an MA as a chaperone.

I would suggest looking at the policy where you work. They should have procedure there for the different age groups.

Specializes in Geriatrics.

OP refer to company policy or ask some colleagues during orientation.

The likelihood that there's a problem that hasn't been detected is very low (boys are pretty aware if something is not right with their member).

I feel like lots of boys would be too embarrassed to say anything if they had a problem.

Specializes in Home Health (PDN), Camp Nursing.
I feel like lots of boys would be too embarrassed to say anything if they had a problem.

Hi there LPN here so I'm out of my wheelhouse I admit but I want to contribute some food for thought.

I would hope that providers are at least asking if the for skin has retracted yet, and let boys know that it should do that. If it hasn't then let them know that it will and when it does it should move easily back and then into its original position when the member is flacid.

As a long time citizen of the internet I can tell you I have met a few men/boys on various forums who's foreskin never retracted do to phimosis and they had I un pleasurable and often painful sex because they didn't know any better. Worse yet the kid who is rushing to the Internet because his foreskin had become paraphimosed and they don't know what to do or that that could happen.

If if I took my son to be examined I would hope that a visual exam would be conducted, testicular exam,and that he be ASKED specific questions about how his member is functioning designed to assess for problems and educate. I wouldn't be happy if his foreskin was forcefully retracted.

Any my provider who asked simply "are things working on down there" I would never return to. Kids and adolescents don't know how it's supposed to work! They need someone who is comfortable talking about the body and drawing them out a bit about specific potential problems not someone who takes the 50s dad approach to sexual health.

In applaud you for asking this question, and I'm sorry the Internet can't seem to read and understand your OP, it was quite clear to me.

I wouldn't be happy if his foreskin was forcefully retracted.

I do know enough about uncircumsized boys to know to never forcibly retract. But I'm assuming that you can give it a very light tug to see if it's separated before you actually retract, right?

Specializes in Home Health (PDN), Camp Nursing.
I do know enough about uncircumsized boys to know to never forcibly retract. But I'm assuming that you can give it a very light tug to see if it's separated before you actually retract, right?

In all honesty I wouldn't. For two reasons. Many parents of uncircumcised boys have read horror stories of a provider forcefully retracting and would be very concerned. Secondly I honestly I would be afraid of being accused of abuse, especially since the medical community is not unified in exactly how the exams would occur.

In in young boys it really doesn't matter the position of the foreskin so long as urine can pass. In pre adolescents I would say the question "does your foreskin go back?" Is a good start. If they look at you like your crazy you get to educate if they say yes you can simply ask them to show you. If no and they are older than you can address the potential for adhesions or phimosis. Which I would think would include verifying the status of the foreskin with a gental pull back.

I would let the interview do most of the exam under normal conditions. I hate to say it but society is crazy panicked right now about molestation, and a witch hunt can brew up anyplace these days.

all that being said I am probably one of the least qualified to give advice on NP practice in this thread, from an educational standpoint.

Maybe np's can share how they do an genital urinary exam on a boy or man in a routine physical. I bet there are a variety of

Approaches. What are the criteria if any for pulling back forskin .

I'm curious to hear what some of the other approaches are, but here's how me and the other NP at the clinic I work at do for boys from 8 to 18:

1. With one hand, pull down the front of the boy's waistband.

2. Make a mental note of the tanner stage of their genital development and pubic hair growth.

3. With the hand not holding the waist band, quickly feel each testicle (to make sure they've descended in younger boys and to make sure there are no masses in older boys).

4. If the boy is there for a sports physical, do a hernia check.

5. If the boy is uncircumcised, test how far their foreskin can retract VERY GENTLY (so it isn't harmed if it can't retract)

6. Release waistband.

This should take less then 5 seconds (10, if you have to check for hernia/phimosis). As a female NP, no matter what you do, the boy is going to get embarrassed, so you just have to do things in a way that minimizes embarrassment. If you ask them a bunch of questions and spend time talking about their genitals before you actually do the exam, they are going to get infinitely more embarrassed than if you finish examining member/testicles before they even realize what you're doing and just treat it like any other part of their body.

Don't just ask him if he has any foreskin problems, if he does, there's a pretty good chance he either doesn't know or is too embarrassed to say something.

Specializes in Community, OB, Nursery.

Nobody needs to be retracting the foreskin except the child himself. This is the AAP's position statement as well. If he's old enough to tell you whether or not it goes back he's old enough to do it himself if you deem it necessary.

Even if it's retractable, other people doing so can unwittingly retract too far and cause pain or injury. Microtears make great portals of infection and as a parent of an intact son (and soon-to-be NP) I would be less than thrilled with you if you did this to my son. If the boy retracts himself, a) he's got some control over what's already an uncomfortable situation; and b) he will stop before retracting too far.

I'm curious to hear what some of the other approaches are, but here's how me and the other NP at the clinic I work at do for boys from 8 to 18:

1. With one hand, pull down the front of the boy's waistband.

2. Make a mental note of the tanner stage of their genital development and pubic hair growth.

3. With the hand not holding the waist band, quickly feel each testicle (to make sure they've descended in younger boys and to make sure there are no masses in older boys).

4. If the boy is there for a sports physical, do a hernia check.

5. If the boy is uncircumcised, test how far their foreskin can retract VERY GENTLY (so it isn't harmed if it can't retract)

6. Release waistband.

This should take less then 5 seconds (10, if you have to check for hernia/phimosis). As a female NP, no matter what you do, the boy is going to get embarrassed, so you just have to do things in a way that minimizes embarrassment. If you ask them a bunch of questions and spend time talking about their genitals before you actually do the exam, they are going to get infinitely more embarrassed than if you finish examining member/testicles before they even realize what you're doing and just treat it like any other part of their body.

Don't just ask him if he has any foreskin problems, if he does, there's a pretty good chance he either doesn't know or is too embarrassed to say something.

Anyone do anything differently?

Specializes in Community, OB, Nursery.

Well...providers aren't really supposed to be even lightly tugging to see if it will retract.

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