Catheterization Without Retraction

By Adrienne Carmack, M.D. board-certified urologist, in practice in Texas, and author of The Good Mommy's Guide to Her Little Boy's Penis and Marilyn Fayre Milos, R.N. Executive Director of Genital Autonomy America, California.


Catheterization Without Retraction
Canadian Family Physician. 2017 Mar; 63(3): 218–220.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5349724/

Over the past century, numerous boys born in Canada and the United States have been circumcised. (1) However, this trend is changing, with neonatal circumcision being performed less commonly than in years past. (2,3) Because of these historical practices, many physicians and nurses have limited experience treating patients with intact foreskins and engage in ill-advised procedures such as premature foreskin retraction for purposes of “hygiene” or catheterization. Premature retraction of the foreskin can lead to tearing of healthy tissue, which is painful and increases the risk of preputial scarring and infection. (4–6) We describe a method for catheterization in which premature retraction of the foreskin is not necessary.

Technique

The foreskin should first be gently manipulated to determine if the meatus can be easily visualized. Pressure used for this should be gentle to avoid tearing of tissues, similar to the amount of pressure that would be used when spreading the labia to visualize the meatus of a girl. If the natural attachments of the foreskin to the glans (head of the penis) remain, the foreskin should not be forced back to expose the meatus.

If the foreskin can be gently moved such that the glans and meatus can be seen, catheterization can be performed under direct vision using a sterile technique. The foreskin should never be retracted past the point where it has already naturally separated. (7)

If the meatus cannot be seen, the genitals can be prepared and draped in a sterile manner without retraction. The catheter can then be lubricated and gently inserted through the foreskin opening and guided into the meatus, much like an intravenous catheter is guided into a vein by feel. Gentle pressure with the thumb along the dorsal aspect and the fingers along the ventral surface of the penis can keep the catheter from slipping between the glans and inner lining of the foreskin into the preputial space (Figure 1).

When catheterization is being performed for the purpose of collecting a urine specimen, the foreskin should also not be forcibly retracted. In both boys with an intact prepuce and girls, the initial urine obtained during catheterization should be discarded, as this will contain preputial and periurethral flora. The latter urine should be saved for culture. (8)


Discussion

An understanding of the normal anatomy and development of the foreskin illustrates why the technique of catheterization without retraction is an important skill for health care practitioners. Physiologic phimosis is the normal state of young boys. (9) This finding is characterized by a closed preputial outlet with the inner mucosa of the foreskin beginning to evert through the preputial opening, which is healthy with no scarring. The glans cannot be seen without retraction. This is in contrast to pathologic phimosis, in which the glans and meatus can often be seen, as the scarred ring of the preputial orifice is held open and no mucosa is visible at the preputial outlet. (10)

In a Danish study, 8% of healthy boys aged 6 to 7 still had complete physiologic phimosis preventing visualization of the meatus, and only 23% of boys this age had fully retractable foreskins. (11) In a Japanese study, 84.3% of boys aged 6 months to 1 year had a tight ring preventing any retraction, and this decreased gradually with time to 40% at ages 1 to 2 years, 28% at ages 3 to 4 years, 20% at ages 5 to 7 years, 16% at ages 8 to 10 years, and 8.6% at ages 11 to 15 years. (12)

The term phimosis is Greek and means “a muzzling.” Physiologic phimosis simply means the foreskin cannot be retracted and the glans is “muzzled.” Ballooning during urination is a common finding and part of the normal developmental process of foreskin separation. (10) It occurs because the opening of the immature foreskin is not yet lax enough to accommodate a full urine stream or passage of the glans through it. The foreskin and glans separate naturally as the child develops, has erections, and manipulates his foreskin. When a young boy manipulates his foreskin naturally, he tends to pull his foreskin away from his body, not toward it, as is done with retraction. As he gets older and more curious, he begins to pull his foreskin toward his body as well. (10) In most boys, physiologic phimosis resolves naturally by the end of puberty. (11)

The foreskin and glans are connected by the balanopreputial lamina, a membrane similar to the synechial membrane that connects the nail bed and the fingernail. The balanopreputial lamina is sometimes called the synechia. This membrane and the small preputial opening prevent retraction in boys with normal physiologic phimosis. The attachment might be forcefully disrupted, just as the fingernail can be torn from the nail bed, but this causes pain, is unnecessary, and can lead to infection, scarring, adhesion formation, or iatrogenic phimosis. There is no functional need for the glans to be exposed, and there is a protective effect of having the foreskin attached to and covering the glans.

Because the foreskin protects the glans penis and urethral meatus, premature exposure of the glans, as occurs after circumcision, commonly leads to meatal stenosis, in which a substantial part of the circulatory system in the glans penis is damaged (the frenular artery), and the glans tissue is exposed, denuded, and inflamed, which can lead to ulceration and subsequent scarring of the urethral opening. This inflammation and ulceration are caused by disruption of the normal attachment between the glans and foreskin, the absence of the protective foreskin, interruption in the normal circulatory system, or blisters from ammonia burns. (13–15) The blisters and ulceration at the opening of the urethra are caused by contact of urine-soaked diapers with the urethral meatus, which is no longer protected by the foreskin.

Retracting the foreskin of a prepubescent boy with physiologic phimosis, although still a common recommendation by many health care practitioners, has been shown to increase problems such as scarring and infection. These might result in iatrogenic pathologic phimosis and lead to a higher likelihood of circumcision being performed at a later date. (16)  If the prepuce is unable to retract, there is nothing to clean under. The foreskin should not be retracted for cleaning until the foreskin has naturally separated and the child can do this himself. In fact, the owner of the foreskin should be the first person to retract his foreskin. Forceful retraction causes microtears that can lead to pathologic phimosis. (10)

An additional danger of premature retraction is paraphimosis, a condition in which the retracted foreskin becomes stuck behind the glans penis, cutting off circulation and leading to ischemia and possibly penile gangrene if not treated promptly. Retracting the foreskin and cleansing with soap, commonly believed to be important for proper hygiene, not only exposes the child to the risks of premature foreskin retraction, but also to the risks of infection such as balanitis, which has been shown to be associated with the use of soap on the delicate mucosal tissues of the male genitalia. (17) Soap dries out mucosal tissue and should never be used on the glans or inner foreskin. The foreskin should be left alone until it demonstrates the ability to retract. (10) Once this is possible, foreskin care is simple: retract (gently and only to the extent possible), rinse, replace. Warm water and fingertips adequately clean the tissue.

Besides false beliefs about hygiene, one of the main reasons boys are subject to premature foreskin retraction is that many health care professionals believe that the foreskin must be retracted to obtain a clean specimen for urine culture. Fortunately, this is not the case. With proper technique, as described above, urine specimens can be obtained from boys with intact foreskins without exposing these patients to the risks of premature foreskin retraction. Although the focus of this article is on a technique for catheterization, it must be remembered that catheterization is an intervention that carries risks. The risks of catheterization include discomfort and introduction of bacteria into the urinary tract, which could lead to infection. Indications for catheterization include the need to monitor urine output for medical management, emptying the bladder in patients who are unable to do so, introducing contrast material for imaging procedures such as a voiding cystourethrogram, and obtaining a urine specimen for analysis in patients who are unable to provide one.

If a patient can reliably void into a collection container, catheterization for monitoring urine output can be avoided. Patients who cannot empty their bladders have the options of clean intermittent catheterization, indwelling urethral catheterization, and suprapubic catheter placement. Other options for collection of a urine specimen for analysis and culture include a midstream voided sample and suprapubic aspiration, and these should be considered when determining the optimal approach for specimen collection.8 Suprapubic aspiration is significantly more painful than urethral catheterization in premature male infants (P < .001). (18) Contamination is possible with catheterized samples as it is with voided samples.19 This suggests that catheterization for urine specimen culture should be reserved for those patients who are unable to provide a voided specimen into a clean container, and suprapubic catheterization should only be used if previous efforts to obtain a specimen have resulted in contamination.

Conclusion

In boys with intact prepuces and physiologic phimosis, catheterization without retraction minimizes potential long-term problems and is an effective technique. Understanding how to catheterize without direct vision of the meatus and discarding the initial urine if culture is desired allow this procedure to be performed with high validity and minimal risk of iatrogenic problems for the child.

References

1. Weiss H, Polonsky J, Bailey R, Hankins C, Halperin D, Schmid G. Male circumcision. Global trends and determinants of prevalence, safety and acceptability. Geneva, Switz: World Health Organization, Joint United Nations Programme on HIV/AIDS; 2007.

2. Maeda JL, Chari R, Elixhauser A. Circumcisions performed in U.S. community hospitals, 2009. Rockville, MD: Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality; 2012. Available from: www.hcup-us.ahrq.gov/reports/statbriefs/sb126.jsp. Accessed 2015 Jun 15.

3. Fetus and Newborn Committee, Canadian Paediatric Society Neonatal circumcision revisited. CMAJ. 1996;154(6):769–80. [PMC free article] [PubMed]

4. Kaplan GW, McAleer . Structural abnormalities of the genitourinary tract. In: Mac-Donald MG, Mullett MD, Seshia MMK, editors. Avery’s neonatology. Pathophysiology and management of the newborn. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005. p. 1088.

5. Roberton NRC. Care of the normal term newborn baby. In: Rennie JM, Roberton NRC, editors. Textbook of neonatology. 3rd ed. Edinburgh, UK: Churchill Livingstone; 1999. pp. 378–9.

6. American Academy of Pediatrics . Newborns: care of the uncircumcised penis. Guidelines for parents [pamphlet] Elk Grove Village, IL: American Academy of Pediatrics; 1984.

7. Lacroix LE, Vunda A, Bajwa NM, Galetto-Lacour A, Gervaix A. Catheterization of the urethra in male children [video] N Engl J Med. 2010;363(14):e19. [PubMed]

8. Schaeffer AJ, Schaeffer EM. Infections of the urinary tract. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell-Walshurology. 9th ed. Philadelphia, PA: Saunders-Elsevier; 2007. pp. 238–9.

9. Smeulders N, Wilcox DT. Urology. Disorders of the kidney and urinary tract. In: Rennie J, editor. Rennie & Roberton’s textbook of neonatology. 5th ed. London, UK: Churchill Livingstone–Elsevier; 2012. p. 949.

10. McGregor TB, Pike JG, Leonard MP. Pathologic and physiologic phimosis. Approach to the phimotic foreskin. Can Fam Physician. 2007;53:445–8. [PMC free article] [PubMed]

11. Oster J. Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child. 1968;43(228):200–3. [PMC free article] [PubMed]

12. Kayaba H, Tamura H, Kitajima S, Fujiwara Y, Kato T, Kato T. Analysis of shape and retractability of the prepuce in 603 Japanese boys. J Urol. 1996;156(5):1813–5. [PubMed]

13. Canning DA, Nguyen MT. Evaluation of the pediatric urology patient. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell-Walsh urology. 9th ed. Philadelphia, PA: Saunders-Elsevier; 2007. p. 3215.

14. Elder JS. Abnormalities of the genitalia in boys and their surgical management. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell-Walsh urology. 9th ed. Philadelphia, PA: Saunders-Elsevier; 2007. p. 3749.

15. McGrath K. The frenular delta. A new preputial structure. In: Denniston GC, Hodges FM, Milos MF, editors. Understanding circumcision. A multi-disciplinary approach to a multidimensional problem. New York, NY: Springer; 2001. pp. 199–206.

16. Metcalfe PD, Elyas R. Foreskin management. Survey of Canadian pediatric urologists. Can Fam Physician. 2010;56:e290–5. Available from: www.cfp.ca/content/56/8/e290.full.pdf+html. Accessed 2017 Feb 2. [PMC free article] [PubMed]

17. Birley HD, Walker MM, Luzzi GA, Bell R, Taylor-Robinson D, Byrne M, et al. Clinical features and management of recurrent balanitis; association with atopy and genital washing. Genitourin Med. 1993;69(5):400–3. [PMC free article] [PubMed]

18. Badiee Z, Sadeghnia A, Zarean N. Suprapubic bladder aspiration or urethral catheterization: which is more painful in uncircumcised male newborns? Int J Prev Med. 2014;5(9):1125–30. [PMC free article] [PubMed]

19. Lau AY, Wong SN, Yip KT, Fong KW, Li SP, Que TL. A comparative study on bacterial cultures of urine samples obtained by clean-void technique versus urethral catheterization. Acta Paediatr. 2007;96(3):432–6. [PubMed]


Related Reading

Urine Samples and Catheter Insertion for Intact Boys: http://www.drmomma.org/2011/12/urine-samples-and-catheter-insertion.html

Using a Catheter Without Retraction: My Nurse Did It, and So Can Yours! http://www.savingsons.org/2013/01/using-catheter-without-retraction-my.html

How the Foreskin Protects Against UTIs: http://www.drmomma.org/2009/12/how-foreskin-protects-against-uti.html

UTI and Circumcision Resources: http://www.savingsons.org/2014/11/uti-resource-page.html




YEAST Q&A

Yeast Q&A

QUESTION: Can yeast be passed back and forth between adults, and cause a problem for an intact man? 

ANSWER: 

Yes -- anything flora/microorganism related easily goes back and forth from one partner to another. However, this is not limited to intact adults. There are many 'yeasty' non-intact men who also pass yeast 'infections' back and forth between themselves and their partner. 

Yeast lives naturally on all humans, on all mammals, and everywhere in nature. It is normal (and even healthy) to have some. The problems becomes when yeast spores overgrow. This is easier done on some people than others, depending on a variety of factors (diet being one, and how someone baths/showers/or cares for their body is another). 

Many people are under the mistaken belief that they should use soap on the genitals to decrease yeast - this is counter productive and tends to disrupt flora. Or, it could be that things were disrupted from a young age when parents used soap on a child, or a child eats a hearty amount of processed (and sugary) non-foods. A child may grow up thinking they "smell" if they don't use soap -- but this is solely because the flora of the genitals became disrupted in the first place. In their healthy, natural, clean state (i.e. washed regularly with simply warm water), the human genitals are able to maintain their own balance. 

Babies who are in diapers also have the perfect environment for yeast to flourish -- warm, moist, with a sugar-rich diet (human milk or a substitute - necessary and very important for human infant brain and body growth, but with the potential to nourish yeast as well). A youngster can get into a cycle of feeding yeast (processed, sugary foods and drinks), supporting the habitat in which it grows, and then well-meaning parents do things to try and over clean (soaps, scrubs), or apply things to the diaper area that they hear of in parenting threads (cornstarch, powders, flour, lotion, essential oils, human milk, etc.), and make the situation worse. Thankfully, these cycles are easy to break free from, but it takes the willingness to step back and be more hands-off while the body rebalances. 


Some simple ways to make the body less likely to experience yeast overgrowth: 

1) Showers under warm water only (no soap, not even 'natural' soap on the genitals).

2) Warm baths in epsom salt (and a little boron salt if desired - another anti-fungal natural mineral) -- 2 cups plain epsom salt (no perfumes or oils added), 2 Tablespoons boron (Borax is the most commonly sold refined brand of natural boron).

3) Air dry - go underwear free at home when it is practical to do so (if you live in a private place, even being in the sunshine nude is healing for the body, and sunlight plus fresh air aids the skin and genitals in rebalancing microflora).

4) Use only 100% cotton underwear of your chosen type - not too tight against the skin; not those with lining that is non-breathable.

5) Increase whole food plants in the diet (and items like garlic, lemons, onions, ginger root, turmeric root, black seed oil, d-mannose powder, apple cider vinegar, also help to re-balance gut and genital flora). Smoothies or juicing vegetables and fruits makes this easy.

6) Decrease processed non-food items and sugary items as much as possible. Dairy is also another culprit for many who have gut (intestinal) and yeast disturbances - switching to a nut-milk is one alternative, for example.

7) Clotrimazole on the outside of the genitals when there is external yeast overgrowth. If internal in the vagina, use treatment options that are 7 days in length vs. the 1-3 day treatment options that tend to leave behind some of the stronger yeast spores to regrow. Clotrimazole will be cheapest at your local store pharmacy aisle in any generic version they stock.

8) Calmoseptine on the outside when yeast causes raw skin, redness, rash, chaffing, irritation -- this is also antifungal and healing for the skin. It can also be used preventatively (say when traveling, or when swimming in a chlorine pool or bacteria filled lake). Using Calmoseptine FIRST, before clotrimazole is applied for the first time, is the best course of action to most rapidly heal a yeast related rash on babies, children, or adults. The skin needs to be on its way to healing first, preventing further issues, before 'treatment' starts with clotrimazole for the fastest, most effective remedy. Apply Calmoseptine first, ideally after an epsom salt bath. Wait 4-6 hours, and then continue with the course of suggestions above and clotrimazole. Doing so allows exterior yeast issues to be remedied within 24-48 hours. Internal yeast overgrowth, or that which recurs often, is more complex and requires more of the above changes and/or treatments to remedy. Calmoseptine can be found behind the counter at most pharmacies (call to ask which pharmacy has a tube in stock near you), or on Amazon. No prescription is needed. 


further resources on caring for your intact child

an intact living community

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a mainstream group for those raising boys today








May the Foreskin Be With You! Star Wars - Intact Style!

By Erin Dutra
Director, Intact Rhode Island



I have to admit, I have never actually watched an entire Star Wars movie, but my husband is an avid Star Wars fan, so naturally our kids are too. Over the past few years of making Star Wars Halloween costumes and planning Star Wars birthday parties, I've grown familiar with the characters and become a little more into it than I ever would have expected. I find some of the characters cute - (have you seen an ewok? Adorable!) -  and I become a little excited when I see a Yoda shirt or R2-D2 lunchbox in the store.

My son was born on Star Wars Weekend (an event I only know because of my husband: "May the 4th be with you!" and "Revenge of the 5th"). So in honor of my son's birthday, I decided to create a fun, pro-intact meme that fit with the Star Wars theme to share on Facebook. My original idea was, "Your little Jedi needs his whole lightsaber" ...and then several other ideas started to surface. Soon, I was cracking myself up with witty slogans - I may not be a true Star Wars fan, but I'm clearly a true nerd!

Once I had a handful of graphics created, I could not choose just one for my son's birthday, so I declared the entire week leading up to May the 4th "Intact Rhode Island's Star Wars WEEK." It has been so much fun seeing the response these graphics (and the accompanying informative links) have received. Over the course of the past week they have reached tens of thousands of individuals on Facebook and Pinterest, and have been shared by hundreds. Clearly, there are a lot of Star Wars fans out there, and many of them support leaving babies intact!

I think it's awesome that so many people, who may not otherwise be interested in learning about the benefits of remaining intact and the detriments of circumcision, will be intrigued by fun Star Wars images popping up in their newsfeed and will discover some important information in the process.









Learn more from Erin and her Star Wars Fun Family at Intact Rhode Island.

If you have an Intact Star Wars themed photo you'd like to share, send to SavingSons@gmail.com and we'll include it here as well. ツ

May the Foreskin Be With You

via SOS' WA chapter, Intact Washington

My face when someone says they are circumcising...
Baby Yoda • IntactBaby.org/research

Baby Yoda via IntactBaby.org

When you tell them to research the foreskin, and then watch them discover the truth about circumcision.
Baby Yoda • IntactBaby.org/research

via SOS' MI chapter, Intact Michigan

"May the FORESKIN be with you!"
~Ginger's little sweetie of Intact Wyoming

Christina's cutie, of Intact Iowa, plays in the May 4th sun in his Rumpkinz May the foreskin be with you cloth custom!

Mandi of Intact Michigan writes,
"I tried snapping a picture while my son was awake, but this little guy is a mover and a shaker, so I had to wait until he passed out. May the foreskin be with you!"

May The Foreskin Be With You T-shirts
Made By Momma tee sported by Jess at Intact Michigan today.
"May the Fourth be with you. And enjoy the Revenge of the Fifth!"

Further Intact Star Wars memes from Kristina of Intact Houston:





2018 Remake via Intact Rhode Island -
Use the foreskin, Luke!
Use the Foreskin, Luke!
Wishing you a Happy 4th!




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