Key points

  • A tight foreskin is normal in babies and boys, and usually loosens by itself later in childhood or puberty.
  • Phimosis and paraphimosis are different conditions. Phimosis is a foreskin that won’t pull back. Paraphimosis is a foreskin that is pulled back and gets stuck.
  • A range of effective treatment options exist, and most don’t involve surgery.
  • Circumcision is only rarely needed for phimosis. It is not the treatment for a paraphimosis emergency, and many people never need it afterwards.
  • Paraphimosis is an emergency. Seek emergency care immediately.

 

What is phimosis?

Phimosis means the foreskin is too tight to pull back over the head (glans) of the penis. There are two kinds:

  • Physiological phimosis is normal. Almost all boys are born with a foreskin attached to the glans. The attachment separates gradually, and the age at which it does so varies widely. Most foreskins naturally retract late in childhood or puberty. Never forcibly retract the foreskin.
  • Pathological phimosis is tightness caused by scarring, repeated infection or a skin condition, most commonly inflammatory conditions such as lichen sclerosus (also called balanitis xerotica obliterans, or BXO). Lichen sclerosus does not get better on its own and usually needs treatment.

Diagnosis

Medical guidance says that children with physiological phimosis should not be referred for circumcision, and that circumcision should not be offered for it. 

Despite this, normal, non-retractable foreskin in children is often mistaken and misdiagnosed as pathological phimosis, even my medical practitioners, due to a lack of training in penile anatomy in medical curricula.

If you've been told your child needs circumcision for a foreskin that simply hasn’t separated yet, it is reasonable and recommended to ask whether it is physiological or pathological phimosis, and to ask for a second opinion.

Start with your GP. They may refer you to a paediatric surgeon, urologist or dermatologist, particularly if lichen sclerosus is suspected.

Causes and risk factors

  • Forced retraction, which can tear the skin and result in abnormal adhesions forming during wound healing.
  • Chronic and repeat inflammation, which results in restrictive scar tissue, can occur subsequent to repeat infections, and auto-immune conditions such as lichen sclerosus.
  • Diabetes, as some medications used to manage diabetes result in glucose in the urine, which promotes infection and associated inflammation. 

Signs and symptoms

A foreskin that won’t retract is not a problem by itself, especially in a child. See a GP if there is:

  • Swelling, soreness or tenderness.
  • Pain when passing urine, difficulty peeing or a weak stream.
  • Blood in the urine, or frequent urinary tract infections.
  • Bleeding, thick discharge or an unpleasant smell.
  • Painful erections or pain during sex.
  • White patches, thickened skin, cracking or scarring.

Ballooning of the foreskin when a boy passes urine is common and, on its own, is not a reason for surgery.

Treating phimosis without circumcision

For physiological phimosis, the best and only recommended course of action is to watch and wait. Don’t pull back the foreskin of a baby or young boy if it is still attached to the glans, because this can be painful and cause damage that leads to problems later. Wash with warm water, and do not use soaps, shower gels, talc or deodorants.

For pathological phimosis, a range of non-invasive treatment options exist:

  • Steroid creams. A prescribed steroid cream applied to the tight ring of the foreskin reduces inflammation and helps the skin stretch. It is a safe, non-invasive treatment option. Courses are usually a few weeks and normally no longer than three months, and some people need a repeat course. Steroid cream used combined with stretching works in most cases. For lichen sclerosus, creams help stop symptoms getting worse and can improve scarring in some people, and the first course is usually longer.
  • Gentle stretching. Regular gentle stretching of the foreskin can help it widen. It should never be painful and is usually combined with steroid cream use. 
  • Treating infection. Antibiotics or antifungal creams are used if the foreskin or glans is infected. 
  • Foreskin-preserving surgery. If creams and stretching haven’t worked, there are operations that keep the foreskin. Preputioplasty is when a surgeon makes small cuts to widen the tight ring, usually in hospital under anaesthetic. 

When is circumcision medically indicated?

Most cases of pathological phimosis respond to the treatments above, so circumcision is rarely needed, and is mainly considered when significant scarring is present, most often from lichen sclerosus that has not responded to treatment.

If stretching and steroid creams haven’t worked and pain continues, doctors usually offer a choice between preputioplasty and circumcision. Preputioplasty spares the foreskin and is recommended wherever possible. 

Circumcision is permanent and has risks, including bleeding, infection, reduced sensitivity, and sexual dysfunction. Many also report being dissatisfied with the cosmetic result. Rare serious complications include penile amputation and death. 

In adults, circumcision may also be used to biopsy or treat suspicious skin changes, which is one reason to have white patches or sores checked rather than waiting.

 

What is paraphimosis?

Paraphimosis happens when a retracted foreskin gets stuck behind the glans and can’t go forward again. The trapped band acts like a tight ring, the glans swells and blood flow can be restricted. If it is not treated, the tissue can die from lack of blood supply.

Causes and risk factors

  • Forced retraction in a child, and scarring from repeated forced retraction.
  • A urinary catheter, where the foreskin isn’t replaced afterwards. This is the most common cause in medical settings.
  • Genital piercings.
  • Chronic inflammation of the foreskin.

Signs and symptoms

  • A foreskin that won’t come forward.
  • A swollen, painful glans.
  • A glans that has turned blue or black in later stages.
  • Irritability in a baby.

Paraphimosis is a medical emergency

Go to the emergency department if the foreskin is pulled back and cannot return to its normal position. Don’t drive yourself: ask someone to drive you or call an ambulance, and bring any medicines you take. Don’t try to force it. Treatment should be done by a doctor or nurse.

How is paraphimosis treated?

Treatment is usually quick and effective, and starts with methods that keep the foreskin:

  • Pain relief or anaesthetic.
  • Reducing swelling with gentle compression, ice, or swabs soaked in sugar solution to draw fluid out.
  • Manual reduction, where the doctor guides the foreskin back over the glans.
  • Other minor methods if those fail, such as multiple small punctures in the swollen skin or an injection to help disperse swelling.
  • A dorsal incision in the occasional case where nothing else works: a small cut to release the tight band. Some surgeons later complete this as a circumcision.

Circumcision is neither the treatment for the emergency itself, nor recommended to prevent paraphimosis in someone who has never had it. Most will never require circumcision, but in some cases of recurrent paraphimosis, it may be an advisable treatment option. If it has happened more than once, ask about foreskin-preserving options as well. 

 

Preventing problems

  • Never forcibly retract a child’s foreskin. This can cause scarring and adhesions that lead to phimosis or paraphimosis.
  • Keep the area clean: wash with warm water, and do not use soap, shower gels, talc and deodorants as they can irritate the mucous membrane of the foreskin and glans.
  • Treat infections and inflammation promptly.
  • Have white patches, scarring or persistent tightness checked.
  • Manage diabetes well: sugar in the urine promotes infection and associated inflammation.

 

When to seek help

  • Seek emergency medical care if the foreskin is stuck behind the glans, with swelling or pain, or if the glans looks dark, blue or black.
  • See your GP if there is pain or difficulty passing urine, a weak stream, repeated infections, bleeding, discharge, scarring or white patches, or foreskin tightness that continues after puberty.

Disclaimer: This page is general information and doesn’t replace advice from a doctor who knows your situation.