Almost all mammal penises have foreskins, although in nonhuman cases the foreskin is usually a sheath into which the whole penis is retracted. Only monotremes (the platypus and the echidna) lack foreskins in human. The prepuce firstly appears at 8 weeks’ gestation as a ridge of thickened epithelium; the prepuce grows forward over the developing glans so that preputial construction is complete by 16 weeks’ gestation. At this stage, however, the epithelia lining the prepuce and surfacing the glans are contiguous, with no plane of separation between them, so that “preputial adhesions” represent a feature of normal development, not a pathological process; spontaneous separation, commencing late in gestation and usually proceeding proximally, occurs by desquamation, with areas of cell nests degenerating to form a series of spaces that ultimately enlarge and coalesce to form a continuous preputial sac.

Preputial separation after birth proceeds at a rate varying from one individual to another and is uninfluenced by environmental or genetic factors: even at 5 years of age, some degree of preputial adherence persists upward of 70 % of boys; the process may be accompanied by mild inflammatory reaction. These episodes are possibly due to infection of retained smegma. At birth the prepuce is almost always nonretractable and usually remains so for a variable period thereafter, during which time attempted retraction results in the appearance of a blanched and apparently constricting ring of skin proximal to the preputial meatus.

Natural circumcision

Aposthia is a rare congenital condition in humans, in which the foreskin of the penis is missing in a normally developed penis and urethra.

Religious literature from various sources reflects the history of aposthia; this condition was first referenced in Jewish law of 1567 CE, in relation to a child born circumcised. Toward the end of the nineteenth century, E. S. Talbot claimed in Medicine that aposthia among Jews was evidence for the now-discredited Lamarckian theory of evolution. It is likely that the cases he described were actually hypospadias. The Midrash of Ki Tetzei notes that Moses was born aposthic. Other sources tell us that Jacob and David were also born aposthic. Jewish law requires males born without a foreskin or who lost their foreskin through means other than a formal circumcision ceremony to have a drop of blood let from the penis at the point where the foreskin would have been attached. Later on, the Prophet Muhammad was said to have been born with “natural circumcision” (in Ibn Sad Tabaqatul-Kubara). However, certain studies have reported that the trait aposthia with normal development of the urethra and glans is very rare because it is generally accepted that normal preputial development is required for the successful canalization of the glans urethra.

It is a very rare congenital anomaly; however, in the last few years, various cases of aposthia had been reported [2]. Amin et al. [3] reported aposthia inheritance as normal quantitative recessive human genetic trait in three strictly endogamous families. Aposthia being a quantitative recessive trait may be prevalent in certain ancient healthy and comparatively developed inbred population isolates; this condition has not been shown to have a higher frequency in Jews or Muslims. If the hypospadias surgeons are fully aware about this condition, a cumulative number of cases will be reported either in association with hypospadias or as an entire pathology (Fig. 3.2).

It is suggested that the extensive study on aposthia may be helpful for proper understanding of the importance of circumcision and reducing the controversy in medical sciences. As a result the circumcision may have been conventionalized into a forceful social motive due to constructive and healthy attributes of aposthia-bearing tribes/leader (Figs. 3.3 and 3.4).

Hypoposthia, peeper, which is a term that refers to the penis whose foreskin is short enough to expose some of the glans when flaccid

It is a condition of having a very small foreskin; microposthia is diagnosed if the glans penis could be seen partially in a flaccid penis.

Microposthia is not a rare condition, and it is difficult to put a sharp landmark between aposthia and microposthia; it could be considered commonly as a normal variant where the prepuce looks shorter to give the chance for the glans or the urinary meatus to be visible in a neonate without foreskin retraction, and sometimes the foreskin is mainly defective at the ventral rather than the dorsal aspect (Figs. 3.5 and 3.6). Microposthia itself is not harmful and could not be considered as a disease, but its importance came from the possibility to be associated with other congenital anomalies, where the deficient foreskin is an indicator for an underlying major genitourinary diseases, like penile rotation (Fig. 3.7), but the most common associated with microposthia is hypospadias. Very rare as in Fig. 3.6 the defective dorsal foreskin hides a urethral duplication, and also few cases of epispadias may have a defective short prepuce (Figs. 3.7 and 3.8).