This is a normal foreskin in a neonate
A normal foreskin will extrude a little when gentle retraction is attempted. Most newborn foreskins are adherent and not fully retractile.
Normal Pouting foreskin on gentle retraction
As the foreskin is retracted, a tight pale opening is revealed and the normal pouting of the foreskin is not happening. This is phimosis and may require circumcision
This foreskin is not retractile and has a pale firm lip around the preputial opening. It may stretch and retract eventually. If it is tight, a trial of steroid applied to the rim of the prepuce with some gentle traction may allow it to retract without the need for circumcision.
This is an example of accumulation of smegma under the foreskin. It is normal and does not need any treatment
Here there is accumulation of smegma under the adhered foreskin. This is normal and the natural method of foreskin glans separation. It presents as a white lump and may worry parents. They can be reassured that as the foreskin separates, the smegma will discharge without any treatment necessary.
These adhesions may separate naturally by puberty and may separate during sexual activity. EMLA and traction can also separate the attachment.
It is normal for the foreskin to be adherent to the glans at birth and separation is a gradual process over the first 3-5 years, with 90% of boys able to partly retract their foreskin by 5. About 50% of 10 yr olds will stil have some adhesions present, and this is normal.
There is a natural accumulation of smegma under the foreskin over this time which can present as a white mass. As separation occurs this may discharge and parents are often confused at this time thinking that the discharge is pus. They can be reassured that if it is not inflamed or tender, then the process is natural and needs no intervention. As the newly separated foreskin and glans become visible, the glans will be red and may appear inflamed. However the previously adhered glans is very thin skinned and red colour is normal until it matures and thickens to a pink grey colour.
A normal foreskin after glans separation will pout when retracted as seen above.
Phimosis occurs when the foreskin has separated and the phimotic ring - the tightest part of the foreskin is unable to stretch to allow the foreskin to retract and expose the head. It may be anatomically tight, or it may be the result of previous scarring from trauma or lichen sclerosis.
Some phimosis is able to be treated by the application of a strong steroid (eg Betamethasone 0.5% or diprosone cream with 5% testosterone added, from a compounding chemist) to the tight phimotic ring and applying stretching traction to the area twice a day for 4-6 weeks. The steroid allows the ring to stretch and enables retraction. If this fails, then consider circumcision for a non retractile foreskin by the age of 10 years.
Smegma accumulations and adhesions are a normal situation but may become a problem once sexually active, and separation may be advisable if still present into adolescence. They can simply be separated by traction after the application of ELMA cream for 60 minutes.