Phimosis Fact Sheet

Looking to understand phimosis? Check out the details below, medically reviewed by expert urologists and healthcare professionals.

What is Phimosis in Males?

Phimosis is a stricture (narrowing) of the prepuce (foreskin) resulting in an inability to retract the foreskin behind the glans. It is typically divided into physiological and pathological phimosis, where physiological phimosis is the normal condition in which infants are born with a tight foreskin, and separation usually occurs during late childhood to early adolescence. Pathologic phimosis is thought to be a consequence of several factors, including infection, inflammation, or scarring. 

Normal Foreskin Development

The inner layer of the foreskin is sealed to the glans penis at birth. The foreskin is usually non-retractable in infancy and early childhood. Experts advise that non-retractability may be considered normal for males up to and including adolescence. Sexual health studies have consistently found that the foreskin, due to its very high concentration of sensory nerve receptors, plays a significant role in sexual arousal and stimulation. Circumcision can significantly reduce sensation during sexual activity. The majority of adult patients post-circumcision report a significant loss of sensation and enjoyment of sexual activity.

What Causes Phimosis?

The major mechanical conditions that prevent foreskin retraction are:

1. The tip of the foreskin is too narrow to pass over the glans of the penis. This condition is normal in children and adolescents.
2. The inner surface of the foreskin is fused with the glans penis. This condition is normal in children and adolescents but abnormal in adults.
3. The frenulum is too short to allow complete retraction of the foreskin (a condition called frenulum breve).
4. Pathological Phimosis:
   Pathological phimosis (rather than the natural non-retractability of the foreskin in childhood) is rare, and the causes are varied. Some cases may arise from balanitis (inflammation of the glans penis), arguably due to inappropriate efforts to retract an infant's foreskin.
   
   It is believed that rough masturbation practices may cause phimosis. Patients are advised to stop exacerbating masturbation techniques and are encouraged to masturbate by moving the foreskin up and down so as to mimic more closely the action of sexual intercourse.
   
   
   
   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. This is a skin condition of unknown origin that causes a whitish ring of indurated tissue (a cicatrix) to form near the tip of the prepuce. This inelastic tissue prevents retraction.
   Phimosis may occur after other types of chronic inflammation (such as balanoposthitis), repeated catheterisation, or forcible foreskin retraction. Phimosis may also arise in untreated diabetics due to glucose in their urine, which can lead to foreskin infection.
   
   Phimosis in older children and adults can vary in severity, with some able to retract their foreskin partially (relative phimosis) and others completely unable to retract it even when the penis is in a flaccid state (full phimosis).

Treatment Options for Phimosis

Physiologic phimosis, common in males 10 years of age and younger, is normal and does not require intervention. Non-retractile foreskin usually becomes retractable during the course of puberty. If phimosis in older children or adults is not causing acute and severe problems, nonsurgical measures have been shown to 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. Advice should always be given that circumcision is permanent and cannot be reversed, has potential side effects and may lead to significantly reduced sexual sensation and performance.

Non-surgical Treatment:

Topical steroid creams are effective in treating mild phimosis and may provide an alternative to circumcision. It is theorised that the steroids work by reducing the body's inflammatory and immune responses and also by thinning the skin.

Stretching the foreskin can be done manually using a specialised foreskin stretching balloon. The balloon is modified to encourage adherence to the skin in between the foreskin and glans. The balloon is inflated and left in situ for up to 15 minutes twice daily. Skin that is under tension expands by growing additional cells.

A permanent increase in foreskin 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 foreskin-stretcher balloon-based tissue expansion promotes the growth of new skin cells to permanently expand the narrow preputial ring that prevents retraction.

In a landmark study, 86% of individuals were cured and could retract their foreskin within 2 to 6 weeks by applying a cream and stretching skin twice daily. Significant observational and cohort case studies are highly consistent with the aforementioned study. Gentle foreskin stretching preserves the foreskin and sexual sensitivity.

Surgical Treatments:

Circumcision is sometimes performed for phimosis, and while it is effective, it is now considered the treatment of last resort unless it is the preferred treatment pathway for an informed patient. A dorsal slit (superincision) is a single incision along the upper length of the foreskin from the tip to the corona, exposing the glans without removing any tissue.

A ventral slit (subincision) is an incision along the lower length of the foreskin from the tip of the frenulum to the base of the glans, removing the frenulum in the process. This is often used when frenulum breve occurs alongside phimosis. Preputioplasty, in which a limited dorsal slit with transverse closure is made along the constricting band of skin, can be an effective alternative to circumcision. It offers the advantage of only limited pain and a short time of healing relative to circumcision and avoids cosmetic effects.