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

SydneyKidney · Aug 31, 2016

I talked to the other NPs at the practice and they all say they retract.

Elvish, BSN, DNP, RN, NP · Aug 31, 2016

I talked to the other NPs at the practice and they all say they retract.

There are lots of people in the US that mistakenly think you're supposed to retract. Folks from other parts of the world where foreskin is more common than it is here do not retract during exams. We're a bit behind the times. AAP clearly says not to, so I would go with AAP guidelines.

YoutubeTheNP · Sep 1, 2016

I think I'm beating a dead horse when I say this, but I always ask myself before I do something what benefit will it provide? For example;

I listen to heart sounds to determine any MRG

I listen to the Lungs for adventitious sounds

I palpate lymph nodes to detect any unusual LAD

See where I am going?

I wouldn't routinely check the foreskin of an asymptomatic member. What is the point, what are you looking for?

If you can answer the question above than by all means do whatever assessment you need to do, but you shouldn't do it just to do it.

Get2theChoppa · Sep 12, 2016

I'm in NP school, and I did a peds rotation last quarter with a pediatrician who was very adamant that students do a genital check on males and females. For girls, it was for hygiene purposes because there was a decent amount of girls who would wipe the wrong way and get UTIs. For boys, he said we must look for an undescended testicle at all annual physicals, and to continue until 18 years of age. It is also for Tanner staging purposes which is documented in the chart.

Personally, as a forensic nurse, I do not see anything wrong with performing a genital exam, so long as you explain it to the patient and parent. They can always decline, and then you document that.

Elvish, BSN, DNP, RN, NP · Oct 1, 2016

If this is an American text, I am not surprised to find advice like this. Countries that do not routinely circ do not advise providers to check under a foreskin to see if cleaning is adequate. NO special cleaning is needed! A visual exam is really all that's necessary. Just as we don't tell parents to clean inside little girls' lady partss, we should not be doing this. Part of the reason young boys end up needing circumcision later on for 'repeated infections' is improper care, meaning they are being messed with too much. Just leave it alone!

This is what other English-speaking countries have to say about routine foreskin care. Please note that they mention only the boy himself retracting to clean. There is no mention of healthcare providers doing this.

Foreskin care | kidshealth (Paediatric Society of New Zealand)

Tight foreskin (phimosis and paraphimosis) - NHS Choices (UK's National Health Service)

Foreskin care | Better Health Channel (Urological Society of Australia/NZ)

NurseKatetheGreat · Oct 1, 2016

Personally, I always have.

CourtneyBz · Jun 1, 2017

If the boy is at least 10 years old, I gently check, stopping if there's even slight resistance. I wouldn't even try to retract gently if the boy is any younger than that.

Biker53 · Aug 30, 2017

I don't fault the NP's who are doing their job as best they can while trying to minimize the embarrassment of their teenage boy patients, but I am at a loss as to what their parents are thinking in sending them to have such an exam by women. Do they not realize how embarrassing it is for these boys, embarrassment that would be greatly lessened if they sent the boys to a male provider for physicals post-puberty?

My kids had a male pediatrician but when our daughter hit puberty we switched her over to a female NP for her physicals and routine care so as to spare her the embarrassment of being examined by a man during those sensitive years. It astounds me that parents don't think of their son's embarrassment.

Elvish, BSN, DNP, RN, NP · Sep 2, 2017

I don't fault the NP's who are doing their job as best they can while trying to minimize the embarrassment of their teenage boy patients, but I am at a loss as to what their parents are thinking in sending them to have such an exam by women. Do they not realize how embarrassing it is for these boys, embarrassment that would be greatly lessened if they sent the boys to a male provider for physicals post-puberty?
My kids had a male pediatrician but when our daughter hit puberty we switched her over to a female NP for her physicals and routine care so as to spare her the embarrassment of being examined by a man during those sensitive years. It astounds me that parents don't think of their son's embarrassment.

Fair point.

My son, for his part, prefers a female provider. When he started hitting puberty I asked him if he wanted me to take him to a guy instead, and he said no. He likes/trusts his NP and for him that seems to be more important than her XX chromosomes. Ditto when he started having mental health issues (puberty + coming out to us = bumpy couple of years) - asked if he wanted to see a male or a female counselor and he said wanted to see a female. No hesitation.

Some things are not going to be easy no matter who's doing them. I am female and have a female NP do my yearly stuff and it's still no fun, despite 20+ years of having them and birthing 2 kids.

Biker53 · Sep 2, 2017

Elvish, you did it the way I would hope all parents would handle it. You gave your son a choice, and he chose what he was comfortable with. Our daughter was very shy and my wife just knew moving her to a female NP was the way to go. Our son was also shy and though he stayed with the male pediatrician he was still pretty embarrassed on account the doctor had a female in the room assisting during a physical I brought him to. Puberty can be a tough time for kids.

Goldenfox · Sep 30, 2017

Totally depends. I rarely see boys in clinic who have foreskin. The younger ones that do usually have some smegma. The older ones not so much. Thats all. I don't do anything to cause embarrassment; but I have found that most of them are not embarrassed at all. In fact, they typically freely volunteer information as long as their parent is not in the room.

I ask if they have any difficulty with urinating or any itching or burning. I don't retract. I've never had reason to. I ask them if they have any issues doing so. All that I really look for is scrotal development and the secondary developmental characteristics so I can document the Tanner stuff.

I do ask blunt questions about sexual activity if they are teens because I've sometimes heard shocking stories that have led me to do STD testing on them.

SydneyKidney · Sep 30, 2017

Wow, I forget all about this post.

So, I asked a friend of mine (who's a pediatric urologist, and probably the smartest woman I know) about this topic, and she said that she recommends retraction should be regularly checked during physicals, BUT not until the boy is 12 years old, and even then, the retraction should be incredibly gentle. Following this advice, I've actually discovered foreskin and/or hygiene problems in several patients that they either were too embarrassed to mention, or didn't even know they had.