Phimosis is defined as the inability to retract the skin (foreskin or prepuce) covering the head (glans) of the penis. Phimosis may appear as a tight ring or “rubber band” of foreskin around the tip of the penis, preventing full retraction. Phimosis is divided into two forms: physiologic and pathologic. Current incidence of phimosis is about 1% in 7th grade boys.
Physiologic phimosis: Children are born with tight foreskin at birth and separation occurs naturally over time. Phimosis is normal for the uncircumcised infant/child and usually resolves around 5-7 years of age, however the child may be older.
Pathologic phimosis: Phimosis that occurs due to scarring, infection or inflammation. Forceful foreskin retraction can lead to bleeding, scarring, and psychological trauma for the child and parent. If there is ballooning of the foreskin during urination, difficulty with urination, or infection, then treatment may be warranted.
Physiologic phimosis is present at birth and resolves without intervention. Most children will not have a fully retractable foreskin at birth, but do so as they get older with the majority having a fully retractable foreskin by early adolescence.
Pathologic phimosis is caused by scarring, balanitis, and underlying medical risk factors.
Physiologic phimosis results from adhesions between the epithelial layers of the inner prepuce and glans. These adhesions spontaneously dissolve with intermittent foreskin retraction and erections, so that as males grow, physiologic phimosis resolves with age.
Poor hygiene and recurrent episodes of balanitis or balanoposthitis lead to scarring of preputial orifices, leading to pathologic phimosis. Forceful retraction of the foreskin leads to microtears at the preputial orifice that also leads to scarring and phimosis. Elderly persons are at risk of phimosis secondary to loss of skin elasticity and infrequent erections.
Patients with phimosis, both physiologic and pathologic, are at risk for developing paraphimosis when the foreskin is forcibly retracted past the glans and/or the patient or caretaker forgets to replace the foreskin after retraction. Penile piercings increase the risk of developing paraphimosis if pain and swelling prevent reduction of a retracted foreskin.
With time, impairment of venous and lymphatic flow to the glans leads to venous engorgement and worsening swelling. As the swelling progresses, arterial supply is compromised, leading to penile infarction/necrosis, gangrene, and eventually, autoamputation.
The inability of the foreskin to retract can lead to difficulty cleaning of the area which can cause balanitis. Other symptoms include:
- difficulty urinating,
- painful urination,
- painful erection, or
Your doctor can diagnose phimosis based on a thorough history and physical examination. Additional tests are usually not necessary.
Treatments for phimosis vary depending on the child and severity of phimosis. Treatments may include: gentle daily manual retraction, topical corticosteroid ointment application or circumcision.
Topical corticosteroid therapy:
Medical providers may recommend topical steriod ointment application for children with phimosis. This is an effective treatment in most males. These topical ointments are used to help soften the tight foreskin around the penis, so the foreskin may be easily retracted. Your provider will demonstrate how to apply the ointment to the tight ring of foreskin and/or head of the penis. The ointment is massaged into the affected areas twice daily for 6-8 weeks along with manual stretching/retraction twice daily. Once the foreskin can be fully retracted, the ointment is discontinued and manual daily retraction (during warm baths and urination for the potty trained child) will prevent phimosis from reoccurring. The most common corticosteroids used are hydrocortisone 2.5%, betamethasone 0.05%, triamcinolone 0.01%, and fluticasone propionate 0.05%.
Male circumcision refers to the surgical removal of the foreskin. Circumcision is often not required for treatment of phimosis. In some rare cases your pediatric urologist may recommend circumcision due to failure of steroid ointment, pathologic phimosis, paraphimosis (foreskin stuck in the retracted position behind the head of the penis), recurrent urinary tract infections, or severe/recurrent balanoposthitis.