Brief overview
- Treatment: Phimosis can be treated with an ointment containing cortisone or by surgery.
- Symptoms: In the case of foreskin constriction, the foreskin cannot be pushed back over the glans or can hardly be pushed back at all. Other possible symptoms are pain and itching.
- Causes and risk factors: Phimosis is either congenital or acquired in the course of life. In most cases, acquired foreskin constriction is due to a condition known as lichen sclerosus.
- Diagnosis: The diagnosis is made by the urologist on the basis of the patient’s medical history and a physical examination.
- Course of the disease and prognosis: In children, phimosis usually disappears by itself as they get older. If this is not the case, untreated phimosis can lead to symptoms such as inflammation or injury to the foreskin.
- Prevention: Acquired phimosis can be prevented by avoiding inflammation and injury to the foreskin.
What is phimosis?
Phimosis is the narrowing or trunk-like extension of the foreskin (prepuce). This means that it can only be pulled back behind the glans penis with pain and the risk of injury or not at all.
There are two main forms of phimosis, depending on their extent:
- Absolute (complete) phimosis: The foreskin cannot be pushed back either when the penis is flaccid or stiff (erect).
- Relative (incomplete) phimosis: The foreskin cannot be pushed back only when the penis is erect.
A shortening of the foreskin frenulum (frenulum breve) is to be distinguished from foreskin constriction, which in the simplest case can be treated by cutting the band of connective tissue running along the base of the penis.
How is phimosis treated?
The narrowing of the foreskin is usually treated from pre-school age; in the case of repeated inflammation, it can also be treated from the age of three. The aim of the treatment is to normalize urination and enable sexual function later on. Good genital hygiene is also important in the case of phimosis.
Local ointments against phimosis
Conservative (non-surgical) and surgical treatment methods are available for the medical treatment of foreskin constriction in men of all ages. One conservative treatment for foreskin constriction and adhesions in adults is the local application of certain ointments. These are preparations containing cortisone, which patients can use to treat themselves at home according to their doctor’s instructions.
An appropriate ointment helps around three quarters of all patients against foreskin constriction, resulting in a significant improvement in phimosis. The problem, however, is that the narrowing of the foreskin very often recurs afterwards.
The often feared side effects of cortisone therapy are not to be expected with a local application of ointment.
Treatment of children
In the case of natural – i.e. physiological – phimosis in babies and small children, no treatment is usually required. Treatment is only necessary if symptoms such as repeated, painful inflammation of the foreskin occur.
In the case of foreskin constriction, even in small children, treatment is initially carried out twice a day with a cream containing corticosteroids. If this does not lead to the desired treatment success, the doctor may advise surgery.
Advice for parents
Parents are advised to only pull back their child’s foreskin if this is possible without any problems. It is important that the foreskin is never mobilized by force! If it is not possible to push it back, this is no cause for concern: The foreskin does not need to be retracted before puberty!
After cleaning, make sure that the foreskin slides back into its original position so that no paraphimosis remains. Paraphimosis is the constriction of the glans due to a tight ring of foreskin (phimosis ring). Even if the foreskin cannot be moved, it is important to wash the penis regularly.
If parents notice a sore or reddened foreskin, it is recommended that they explain to the child how important it is to shake out and dry the foreskin after washing and going to the toilet.
Phimosis: surgery
In many cases, circumcision is offered by doctors. Read everything you need to know about phimosis surgery here.
Alternative medicine
If you search the internet for treatment methods for foreskin constriction, you will come across alternative treatment approaches such as homeopathy and home remedies. For example, bathing in warm water is said to make it easier for children with phimosis to urinate.
However, the effectiveness of alternative remedies is often unproven or insufficiently researched and it is therefore unclear whether they actually help. It is therefore advisable to clarify with a doctor whether the foreskin constriction can be treated homeopathically.
How does phimosis manifest itself?
The main symptom of phimosis is that the foreskin cannot or can hardly be pushed back over the glans. In mild cases, this does not cause any symptoms. Under certain circumstances, phimosis can lead to other symptoms such as pain and itching. Phimosis also promotes inflammation and infections in the area of the foreskin.
With a pronounced foreskin constriction, urination is also more difficult: the urine stream is very thin and weakened. The direction of the urine stream may deviate to one side. In addition, the tight foreskin may inflate like a balloon (ballooning) when urinating due to the retention of urine.
In adults, phimosis may also hinder erection and ejaculation. Sex with phimosis may therefore be painful.
Paraphimosis
Paraphimosis is an absolute emergency. You can read more about this in the article Paraphimosis.
Phimosis in children is normal
In children under the age of three, foreskin constriction is not considered pathological. In newborns and infants, it is completely normal that the foreskin cannot be moved.
This adhesion normally loosens over time: Through repeated (involuntary) erections and a strengthening (keratinization) of the foreskin, the process of detachment of the foreskin from the glans underneath is accelerated.
From the age of three, the foreskin is mobile in 80 percent of boys and should at least be movable from the age of five at the latest. In many five-year-olds, however, the foreskin cannot yet be pushed back completely.
Among six to seven-year-old boys, five to seven percent are affected by a narrowing of the foreskin, while around one percent of 16 to 18-year-olds have phimosis. Adults, on the other hand, are less frequently affected.
Prolonged phimosis increases the risk of inflammation and urinary tract infections, which justifies starting treatment in some cases.
Phimosis: causes and risk factors
A distinction is made between primary and secondary phimosis.
Foreskin constrictions in small children are almost always primary, i.e. congenital. The narrowing of the foreskin is then present from birth and does not regress as usual in the course of growth. The causes of this are not known.
Acquired (secondary) phimosis occurs in the course of life, mainly due to scarring as a result of local inflammation and injury. This often results in the formation of a scarred lacing ring.
In addition, infections and other inflammatory processes of the foreskin may lead to scarring and thus to phimosis. These are common causes of phimosis in adulthood.
Scars also frequently occur if attempts are made to retract the foreskin too early and too intensively. These so-called retraction attempts are responsible for around 20 percent of cases of secondary foreskin constriction.
In addition, diabetes mellitus sometimes also leads to a narrowing of the foreskin in the form of secondary phimosis.
Examinations and diagnosis
The specialist for the examination and treatment of phimosis is the urologist. He deals with the organs responsible for urine formation and urine drainage, as well as with the male genitals.
In an initial consultation with the patient or (in the case of children) with the parents, the urologist will take a medical history. He will ask the following questions, among others:
- Has the foreskin ever been pulled back?
- Are there any problems with urination (such as the foreskin blowing up)?
- Are there frequent infections of the urinary tract or penis?
- Has the penis ever been operated on?
- Is there a known injury to the penis?
- Does the penis become hard when aroused (erection)?
In the case of foreskin constriction, the foreskin is examined with regard to the narrowest point, shape, condition and retractability. This is very important for possible treatment. Scarring can sometimes be recognized by a white ring around the foreskin opening.
If the doctor notices a secretion or inflammation (balanitis = inflammation of the glans), he will take a smear. This allows any infections to be detected or ruled out. However, such inflammation is often caused by retained urine and is therefore a purely chemical irritation.
The doctor will then observe urination to assess the strength and deviation of the urine stream. Any bloating of the foreskin will also become apparent during urination.
Based on the results of the examination, the doctor then decides what to do in each case of foreskin constriction and which treatment method is the right one.
Phimosis: course of the disease and prognosis
In children, a narrowing of the foreskin or phimosis often progresses with age. For this reason, it is often possible to wait with treatment without any major risks.
This risk is lower in circumcised men. They also have a lower risk of HIV infection because there are many HIV-sensitive immune cells in the foreskin. The risk of cervical carcinoma (cervical cancer) is also lower in partners of circumcised men.
In most cases, surgery is a successful and safe treatment option for phimosis.
Prevention
As inflammation and injury to the foreskin may lead to acquired phimosis in the course of life, it is important to avoid this as far as possible. Adults are therefore advised to be very careful with their children and themselves when handling the foreskin.
Prophylactic circumcision (e.g. to prevent infection with sexually transmitted diseases) is not recommended in Western European industrialized nations, as any possible benefit does not sufficiently outweigh any possible harm.
