Phimosis (Tight Foreskin)

Physiological phimosis in boys

At birth, the inner foreskin is naturally stuck to the glans. It separates gradually, helped by erections and natural shedding of skin cells, which can form small white lumps (smegma pearls) under the foreskin. These are normal.

Approximate rates of full retractability:

• at birth: very few
• by age 6: about half or more
• by ages 16 to 17: about 99%

Ballooning of the foreskin during urination is common and usually harmless while separation happens. Do not force the foreskin back, as this causes tears, scarring and can lead to true phimosis. The American Academy of Pediatrics advises simply washing the outside; once the foreskin retracts naturally, teach the child to pull it back gently, rinse and always return it.

Pathological phimosis

A tight foreskin is considered pathological when it is scarred or causes problems, usually in older boys and men. Causes include:

• Lichen sclerosus (balanitis xerotica obliterans): a chronic inflammatory skin condition causing a white, firm, scarred ring at the tip of the foreskin; the most common cause in adults
• repeated balanitis or balanoposthitis (inflammation of the glans and foreskin)
• forced retraction in childhood causing scarring
• diabetes: high sugar in urine promotes yeast infections and scarring; new phimosis in an adult can be a sign of undiagnosed diabetes
• poor hygiene and sexually transmitted infections
• rarely, penile cancer

Symptoms

• inability to retract the foreskin
• ballooning of the foreskin while urinating, spraying or a weak stream
• pain, redness or swelling of the foreskin
• recurrent infections with discharge
• pain during erections or sex, or tearing
• white, scarred tissue at the foreskin opening

Paraphimosis: an emergency

Paraphimosis occurs when a tight foreskin is pulled back behind the head of the penis and cannot be returned. It forms a tight band that cuts off blood flow, causing painful swelling of the glans. It often happens after cleaning, catheter placement or sex. It needs emergency care to reduce the swelling and return the foreskin, sometimes with a small cut. Always return the foreskin forward after retracting it.

Diagnosis

A doctor diagnoses phimosis by examining the penis and asking about symptoms, infections, urinary problems and diabetes. Tests may include urine tests for sugar and infection, and a biopsy if lichen sclerosus or cancer is suspected.

Treatment

Topical steroid cream

A prescription steroid cream (such as betamethasone) applied to the tight part of the foreskin once or twice a day for 4 to 8 weeks, combined with gentle stretching, loosens the foreskin in most children and many adults. It is often the first treatment for pathological phimosis without heavy scarring.

Surgery

• Circumcision: removal of the foreskin; the definitive treatment for severe scarring, lichen sclerosus, recurrent infections or failure of creams.
• Preputioplasty: small incisions to widen the foreskin while preserving it.
• Frenuloplasty for a short, tight frenulum.

Treat underlying conditions

• antifungal or antibiotic treatment for balanitis
• blood sugar control in diabetes
• strong steroid ointment for lichen sclerosus, with long-term follow-up

Hygiene and prevention

• Do not forcibly retract a child's foreskin.
• Once the foreskin retracts, wash under it daily with warm water and dry gently.
• Avoid harsh soaps and scented products.
• Always pull the foreskin back over the glans after washing, urinating, sex or catheterization.

Frequently asked questions

Is phimosis normal?

In babies and young boys, yes. The foreskin is naturally attached to the glans and separates gradually through childhood. Most boys can retract their foreskin by their teenage years. Phimosis in adults, or with pain, infection or scarring, is not normal and should be checked.

At what age should the foreskin retract?

There is a wide normal range. About half of boys can retract the foreskin by age 6, and nearly all by ages 16 to 17. Forcing it earlier can cause scarring. See a doctor if there is pain, infection, urinary difficulty or scarring.

How is phimosis treated in adults?

Most adults start with a steroid cream applied for 4 to 8 weeks with gentle stretching. If that fails, or if there is significant scarring or lichen sclerosus, circumcision or a foreskin-widening procedure is recommended. Underlying diabetes or infections are also treated.

Can phimosis go away without surgery?

Yes. In children it usually resolves naturally with time. In adults and older boys, topical steroid creams are successful in a majority of cases. Surgery is needed when creams fail or there is heavy scarring.

What is the difference between phimosis and paraphimosis?

Phimosis is a foreskin that cannot be pulled back over the glans. Paraphimosis is when a retracted foreskin gets stuck behind the glans and cannot return, causing painful swelling. Paraphimosis is an emergency.