Phimosis from the Greek phimos is a condition where, in men, the male foreskin cannot be fully retracted from the head of the penis. The term may also refer to clitoral phimosis in women, whereby the clitoral hood cannot be retracted, limiting exposure of the glans clitoris. “Phimosis” is a vague term. In common usage, it usually means any condition in which the foreskin of the penis cannot be retracted.

Most infants are born with a foreskin that does not retract. This is normal!

In the neonatal period, it is rare for the foreskin to be retractable; Huntley et al. state that “non-retractability can be considered normal for males up to and including adolescence.” Rickwood, as well as other authors, has suggested that true phimosis is over-diagnosed due to failure to distinguish between non-retractability and a pathological condition (a condition deemed a problem). Some authors use the terms “physiologic” and “pathologic” to distinguish between these types of phimosis; others use the term “non-retractile foreskin” to distinguish this developmental condition from (pathologic) phimosis.

Pathological (acquired) phimosis has several causes. Lichen sclerosus et atrophicus (thought to be the same condition as balanitis xerotica obliterans), is regarded as a common (or even the main) cause of pathological phimosis. Other causes may include: scarring caused by forcible retraction of the foreskin, and balanitis. Beauge found that patients with phimosis had masturbation practices that differed from the usual pulling down of the foreskin that mimics sexual intercourse. Some studies found phimosis to be a risk factor for urinary retention and carcinoma of the penis. Common treatments include steroid creams and circumcision.

Phimosis Diagnosis

The prepuce of boys may be tight until after puberty. This is an entirely normal condition and it is not phimosis. According to the experience in cultures where circumcision is uncommon, this tightness rarely requires treatment. Spontaneous loosening usually occurs with increasing maturity. One may expect 50 percent of ten-year-old boys; 90 percent of 16-year-old boys; and 98-99 percent of 18 year-old males to have full retractable foreskin. Treatment is seldom necessary. If treatment should be necessary, it should not be done until after puberty and the male can weigh the therapeutic options and give informed consent.

It is important to note that the immature foreskin of a child must not be forced back for “cleaning” or for any other reason, because this will cause damage to the developing tissues. The child should be instructed that his foreskin will eventually retract. The first person to retract the foreskin should be the child himself.

Rickwood and colleagues provide a specific medical definition of phimosis: True phimosis is tight non-retractable foreskin caused by Balanitis Xerotica Obliterans (BXO) and is distingished by a whitish ring of hardened sclerotic skin at the tip of the prepuce. Histologic examination by a pathologist is necessary to confirm the diagnosis. If BXO is not present, then true phimosis is not present.

A number of reports in the medical literature of the United Kingdom indicate that medical doctors are not trained to distinguish between normal developmental tight prepuce in boys and pathological phimosis. This results in cases of misdiagnosis of normal developmental preputial tightness as pathological phimosis in the UK.

CIRP has received numerous reports to indicate that normal preputial narrowness in boys in the United States is frequently being misdiagnosed as pathological phimosis. CIRP believes that the situation in the United States is certainly not better, and probably much worse, than the situation in the United Kingdom. Parents of intact boys are also frequently improperly instructed to force the immature foreskin back for cleaning, contrary to the recommendations of the American Academy of Pediatrics.

As a consequence of misdiagnosis and confusion of normal developmental narrowessness and non-retractablity with pathological phimosis, many unnecessary circumcisions are performed. Shankar and Rickwood found that the number of circumcisions being performed in the United Kingdom is 8 times greater than the number required. The number of unnecessary circumcisions performed in the United States is unknown.

Circumcision is now recommended only in confirmed cases of phimosis caused by balanitis xerotica obliterans (BXO), however newer treatments may eliminate the need for circumcision. BXO is recognized by a hardened area of whitish skin near the tip of the foreskin which prevents retraction. Shankar and Rickwood found a low incidence of only 0.4 of 1000 boys per year, and only 6 in 1000 by age 15. See Balanitis Xerotica Obliterans for more information. Other cases of non-retractile foreskin respond to conservative, non-destructive, non-traumatic, less costly treatment.

Click to read about Phimosis Treatments

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