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

[SydneyKidney]

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?

[Dany102]

Not cool. Not cool at all. I warn my female patients before I touch their genitals. I do the same for my male patients. That just feels like common courtesy. And the last male patient (18yo, cc STI check) I examined I had him retract his own foreskin. He knew what he was doing and I saw what I needed to see. Very sorry about your experiences.

Thank you for your comments (and concerns), Elvish. It's hard to feel slighted or wronged when you lack the proper context to refer to. As I said, I've always assumed it was part of a "normal" assessment. Not that I allow it very often, but that's an entire different ball of yarn.

This thread certainly provided me with a different point of view. I'll make sure to keep that in mind next time I see a doctor.

Dany

[sammiesmom]

Very interesting post. I'm in FNP school and appreciate all the good responses here. However, uptodate is probably what I will use first before asking this forum. Geez some people are rude here!

[WKShadowNP, DNP, APRN]

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 was wondering how far into this thread I'd find the answer, because I was going to post pretty much the same thing.

As a parent of an uncircumcised male, I had to argue with people about not retracting his foreskin. He's never had any dysruria and as a typical teenager, he is having no difficulty.

[WKShadowNP, DNP, APRN]

Very interesting post. I'm in FNP school and appreciate all the good responses here. However, uptodate is probably what I will use first before asking this forum. Geez some people are rude here!

uptodate is excellent.

I would also recommend guidelines put forth by the specialties, such as in this case, the AAP. For other systems, look at the preeminent experts for that disease or system (i.e. JNC8 for blood pressure, and so forth.)

[WKShadowNP, DNP, APRN]

Also, I found this article. Maybe it can shed further light on the issue.

The adolescent male genital examination: What's normal and what's not | Contemporary Pediatrics

However, it says to do it. I would defer to the AAP guidelines, or if the male is adolescent, allow him to do it.

[SydneyKidney]

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

[Elvish, BSN, DNP, RN, NP]

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]

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]

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.

[SydneyKidney]

[Elvish, BSN, DNP, RN, NP]

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]

Personally, I always have.