The natural history of the prepuce is characterized by a physiologic and almost complete “closure” starting at birth and in the first few months of life. It is therefore impossible and indeed contro-indicated to retract the foreskin and to free the glans since the normal adhesions require to desolve gradually and spontaneously. This process takes time and usually the complete and total retraction never occur before the age of 3-4 years.
There is no reason to intervene early and traumatically in the process of foreskin separation (adhesions lysis). There is no scientific evidence to demonstrate an increased risk of local infection (balanitis) or UTI, in the absence of concomitant urological problems (ie. VUR, megaureter).
In the presence of a persistent tight and non-retractable prepuce (phimosis) it is advisable an initial topical treatment with hydro-cortison ointment in order to evaluate the local response before considering a final surgical solution.
Two surgical options are technically available, depending on the anatomical prepucial conformation : the foreskin is removed partially or totally (circumcision) or is preserved and made wider and retractable (dorsal slit).
A particular pathological condition which is easily diagnosed is lichen sclerosus atrophicus (or Balanitis Xerotica Obliterans BXO) with an absolute and immediate indication to a radical circumcision.
Anatomical variations of the prepucial conformation (ie.prepucial variants, megaprepuce) are specific conditions which have well defined clinical characteristics and will require different timing and treatment options.