What exactly is Phimosis? Well, in common terms phimosis refers to a condition where the foreskin does not retract properly from the glans (or head) of the penis. In medical terms, however phimosis is a more specific condition where there is scarring and obstruction of the opening of the foreskin caused by Balanitis Xerotica Obliterans or BXO. This is a localised condition of the skin and is distinguished by white patches on the head of the penis and a white ring of hardened skin at the tip of the foreskin. The cause of BXO is not known, however it is generally the one cause of tight foreskin for which circumcision is required.

There are various causes of tight foreskin or what is generally termed ‘phimosis’, but very often it is simply because males are born that way. This is ‘Congenital Phimosis’ and all males are born with it. This usually resolves itself with development into adulthood, however for some the condition persists into later years.

There is a tendency for medical practitioners to immediately prescribe circumcision for phimosis, however there are much less drastic options which should be explored in the first instance, and surgery should only be used as a last resort.

So what can you do about it? Very often, simple stretching exercises will be able to sort it out. The majority of phimosis cases can be suitably loosened by careful stretching of the foreskin. This may be manual or can be assisted with a proprietary stretching instrument. Stretching exercises should be tried initially before any other treatment, however you should seek advice from your medical practitioner before undertaking exercises, to rule out any underlying medical reasons for your tight foreskin. It is also important that stretching is carried out correctly to avoid paraphimosis. This is where the foreskin becomes trapped behind the head of the penis and if this persists for a number of hours or if there are any signs of a lack of blood flow it should be treated as a medical emergency.

A less radical surgical procedure than circumcision is Preputial Plasty. This involves a small cut being made in the foreskin in order to widen the preputial ring so that the foreskin can pass over the head of the penis. This can be an effective cure for phimosis, it is usually done under local anaesthetic, and is much less severe than circumcision.

Non-surgical, conservative treatments for phimosis and foreskin problems are much easier and cheaper than circumcision, however many physicians are unaware of these and it has been estimated that 7 out of 10 circumcisions for medical reasons are unnecessary, and could have been treated with less radical means.

Stretching exercises, when carried out correctly are the simplest of all cures for phimosis and while they won’t cure all cases, they should be considered the first step before any other treatment is considered.

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

If phimosis in older children or adults is not causing acute and severe problems, nonsurgical measures may be effective. Choice of treatment is often determined by whether the patient (or doctor) views circumcision as an option of last resort to be avoided or as the preferred course. Some men with nonretractile foreskins have no difficulties and see no need for correction.

Non surgical methods include:

* Beaugé treated several hundred adolescents by advising them to change their masturbation habits to closing their hand over their penis and moving it back and forth. Retraction of the foreskin was generally achieved after four weeks and he stated that he never had to refer one for surgery.
* Application of topical steroid cream for 4-6 weeks to the narrow part of the foreskin is relatively simple and less expensive than surgical treatments. It has replaced circumcision as the preferred treatment method for some physicians in the U.K. National Health Service.
* Stretching of the foreskin can be accomplished manually. Skin that is under tension expands by growing additional cells. A permanent increase in size occurs by gentle stretching over a period of time. The treatment is non-traumatic and non-destructive. Manual stretching may be carried out without the aid of a medical doctor. The stretching can also be accomplished with balloons placed under the foreskin skin under anaesthesia, or with a tool. The tissue expansion promotes the growth of new skin cells to permanently expand the narrow preputial ring that prevents retraction.

Some may opt for surgery treatment straight away. This consists of the removal of the foreskin or cutting a slit in the foreskin:

* Circumcision is the traditional surgical solution for pathological phimosis, and is effective. Serious complications from circumcision are very rare, but minor complication rates (e.g., having to perform a second procedure or meatotomy to revise the first or to re-open the urethra) have been reported in about 0.2-0.6% in most reported series, though others quote higher rates.
* Preputioplasty, in which a limited dorsal slit with transverse closure is made along the constricting band of skin can be an effective alternative to full circumcision. It has the advantage of only limited pain and a short time of healing relative to circumcision, and avoids cosmetic effects.

What is Phimosis?