Phimosis is the technical term for a narrowing of the foreskin on the penis, which thus cannot be pushed back over the glans. In babies and young children, phimosis is a normal condition – usually the foreskin loosens on its own by kindergarten age. Such a narrowing of the foreskin can also occur in adults. The cause is then usually scarring as a result of inflammation or injury to the penis. In children, phimosis can often be treated with an ointment and careful stretching of the foreskin. Circumcision by surgery is usually necessary only when complications such as recurrent inflammation occur.
What is phimosis?
Phimosis refers to a narrowing of the foreskin that prevents it from being retracted (absolute phimosis) or makes it incomplete or difficult to retract (relative phimosis) over the glans. Ninety-five percent of all newborn males are born with phimosis, which in most cases develops by school age. By age three to five, phimosis is considered physiological (not pathological).
Phimosis common in children
Phimosis is common in children: By the age of six, eight percent of children have a narrowing of the foreskin, and by the age of 16, one percent of adolescents are still affected. It is not known why congenital foreskin stenosis does not resolve or is delayed in some children.
Lichen sclerosus as a cause
If phimosis occurs for the first time at school age, a so-called lichen sclerosus may be the cause under certain circumstances. Among other things, this chronic inflammatory skin disease can affect the genital area and lead to keratinization and hardening of the foreskin in boys and men. Other signs of lichen sclerosus are whitish, hard skin elevations that appear on the back, neck and genitals. The condition can usually be treated with an ointment containing cortisone.
Scars as a cause in adults
New-onset phimosis in adults is often due to scarring of the foreskin, which can result from recurrent inflammation of the penis. Scarring can also result from injuries to the foreskin – such as forcible retraction. Therefore, stretching the foreskin should always be done very carefully. Adults with phimosis should also be screened for diabetes mellitus, because diabetics have an increased risk of infection – especially in the genital area – which promotes phimosis.
Signs of phimosis
The main symptom of phimosis is a foreskin that cannot be pushed back or is difficult to push back. In absolute phimosis, the glans and possibly the urethral opening are then not visible. In adolescents and adult men, this may cause pain during erection, sexual intercourse, or masturbation.
Complications: Inflammation and urinary retention
Phimosis can cause problems with urination when urine cannot drain properly because of the narrowed foreskin: Signs include a thin or deflected urine stream and a “distended” foreskin under which urine collects. In extreme cases, urination is impossible or only possible in droplets – in the case of such acute urinary retention, surgery is then usually necessary. By restricting the flow of urine, phimosis can promote urinary tract infections such as cystitis. In addition, phimosis makes intimate hygiene more difficult: a mixture of glandular secretions and dead skin cells (so-called smegma) can accumulate under the foreskin, providing an ideal breeding ground for bacteria. This can easily lead to inflammation of the glans and foreskin (balanoposthitis).
Treat phimosis
If there are no symptoms or complications, phimosis in young children does not need to be treated: If it progresses without problems, treatment can even wait until elementary school age. However, it is advisable to start treatment at the age of seven to eight years at the latest, since non-surgical (conservative) treatment is more likely to be successful up to this age than in older children. In addition, it makes sense to treat phimosis before the onset of puberty, since a narrowed foreskin can lead to discomfort with the onset of sexuality.
Treatment by ointment and stretching
In a child with an uncomplicated course of phimosis, conservative treatment can usually be tried first.This involves applying an ointment or cream with active ingredients similar to cortisone, such as betamethasone, to the foreskin ring twice a day for four to eight weeks. After two weeks, parents can begin to gently stretch the foreskin and try to push it back. However, avoid forcible retraction at all costs during stretching therapy, as this can cause tearing of the foreskin or, in the worst case, strangulation of the glans due to the constricted foreskin (paraphimosis).
Phimosis: surgery unavoidable in some cases
If conservative treatment does not lead to success or complications occur, surgery is usually necessary. As a rule, phimosis should be operated in the following cases:
- Recurrent urinary tract infections or inflammation of the penis.
- Malformations of the urinary tract with increased risk of urinary tract infections
- Obstruction of urination with “bloating” of the foreskin.
- Lichen sclerosus
- Scarring of the glans and foreskin
- Paraphimosis
A certain age, from when one should operate a phimosis, does not exist. The decision for or against surgery is made individually depending on the symptoms and clinical picture. However, adults with phimosis are usually treated by surgery, because in them usually scars or lichen sclerosus are the cause.
Surgery: circumcision or foreskinoplasty.
There are several procedures to choose from when operating for phimosis: The most common is circumcision, in which the foreskin is removed either completely or partially. If parts of the foreskin are preserved, phimosis may recur under certain circumstances (recurrence). Another possibility with preservation of the foreskin is a so-called foreskin plastic: In this case, the foreskin is cut longitudinally several times and sutured extended. Here, however, there is an increased risk of recurrence due to scarring. The procedures are usually performed in children under a short general anesthesia – in an adult male, surgery under local anesthesia is also possible.
Emergency paraphimosis
Paraphimosis (“Spanish collar”) refers to the constriction or pinching of the glans in phimosis. The cause is usually the forcible retraction of the foreskin, which cannot be pushed forward again due to the constriction. A cord ring is formed, which obstructs the outflow of blood. This is then manifested by a swollen, bluish-red tip of the penis and severe pain. Paraphimosis is an emergency that must be treated immediately by a urologist or tissue damage may occur. The urologist will then attempt to correct the paraphimosis by hand – in cases of severe pain, anesthesia may be used for this purpose in affected individuals if necessary. If the paraphimosis cannot be resolved in this way, a small incision is usually made in the foreskin.
