What is phimosis

Phimosis is a condition where the foreskin is too tight to be pulled back over the head of the penis (glans) and is common in newborns and young boys. Phimosis is normal in babies and toddlers, but in older children it may be the result of a skin condition that has caused scarring. Phimosis isn’t usually a problem unless it causes symptoms. Phimosis usually eases without treatment. If it interferes with urination, circumcision (removal of the foreskin) might be recommended.

The penis has two main parts, the shaft and the head (called the glans). One continuous layer of skin, called the foreskin, covers the shaft and glans. When a child is not circumcised the foreskin is firmly attached to the glans. Gradually, the foreskin will begin to separate. As this occurs you may notice a white, cheesy material, called smegma, released between the layers of skin. You also may see ‘white pearls’ develop under the fused layers of the foreskin and the glans. These are not signs of an infection or a cyst. Smegma is just skin cells that are shed throughout life; it is normal.

When the foreskin separates from the glans of the penis it can be pulled back (retracted) away from the penis to expose the glans. Never forcibly retract your child’s foreskin. This can cause pain and bleeding and can lead to scarring and adhesions (where skin is stuck to skin).

In adults, phimosis can occasionally be associated with sexually transmitted infections (STIs).

It can also be caused by a number of different skin conditions, including:

• eczema – a long-term condition that causes the skin to become itchy, red, dry and cracked
• psoriasis – a skin condition that causes red, flaky, crusty patches of skin covered with silvery scales
• lichen planus – a non-infectious itchy rash that can affect many areas of the body
• lichen sclerosus – a scarring condition of the foreskin (and sometimes glans) that’s probably caused by urinary irritation in susceptible men and boys

Treatment for repeated phimosis may involve application of a steroid cream to the foreskin up to three times a day for about a month to loosen the adhesive ring. If the child has ballooning of the foreskin during urination after the age of 10, a circumcision (surgical removal of all or part of the foreskin) may be recommended.

Normal foreskin development

Most uncircumcised baby boys have a foreskin that won’t pull back (retract) because it’s still attached to the glans. This is perfectly normal for about the first 2 to 6 years. By around the age of 2, the foreskin should start to separate naturally from the glans (the head of the penis).

The foreskin of some boys can take longer to separate, but this doesn’t mean there’s a problem – it’ll just detach at a later stage.

Never try to force your child’s foreskin back before it’s ready because it may be painful and damage the foreskin.

Penis hygiene

It’s important to clean your penis regularly to avoid problems developing.

You should:

• Gently wash your penis with warm water each day while having a bath or shower. Their foreskin might still be attached to the head of the penis and will therefore not retract fully. At this stage of their development, there’s no need to clean inside the foreskin.
• Gently pull back your foreskin (if you have one) and wash underneath; don’t pull back the foreskin of a baby or young boy because it could be painful and cause harm
• Use a mild or non-perfumed soap (if you choose to use soap) to reduce the risk of skin irritation
• Avoid using talc and deodorants on your penis as they may cause irritation

Circumcised men should also regularly clean their penis with warm water and a mild soap (if you choose to use soap).

While regular personal hygiene is important, too much washing with soap and shower gels can cause soreness. Gently washing your penis once a day with warm water is sufficient to maintain good hygiene. If you want to use soap, choose a mild or non-perfumed soap to reduce the risk of skin irritation.

If you don’t wash underneath the foreskin correctly, a cheesy-looking substance called smegma may begin to gather.

Smegma is a natural lubricant that keeps the penis moist. It’s found on the head of the penis and under the foreskin.

If smegma builds up in the foreskin, it can start to smell, stop you easily pulling your foreskin back, and become a breeding ground for bacteria. This can cause redness and swelling of the head of your penis, called balanitis.

What causes phimosis in a child?

Phimosis is caused by a tightening of the opening of the foreskin. This is normal in a newborn baby. Over time the foreskin loosens and can be pulled down more easily. By age 17, most boys will be able to fully retract their foreskin. Phimosis can also occur if the foreskin is forced back before it is ready. This can cause a fibrous scar to form. This can stop the foreskin from retracting in the future.

Phimosis symptoms

Phimosis isn’t usually a problem unless it causes symptoms such as redness, soreness or swelling.

You should seek treatment if your child has the following symptoms of phimosis:

• Ballooning or bulging of the foreskin during urination
• Inability to completely retract the foreskin by age 10
• Frequent infections of the foreskin (balanitis)

If your child’s glans is sore and inflamed, they may have balanitis (inflammation of the head of the penis).

There may also be a thick discharge underneath the foreskin. If both the glans and foreskin are inflamed, it’s known as balanoposthitis.

Take your child to see your doctor if they have these type of symptoms. Your doctor will be able to recommend appropriate treatment.

Most cases of balanitis can be easily managed using a combination of good hygiene, creams or ointments, and avoiding substances that irritate the penis.

Balanoposthitis (inflammation of both the glans and foreskin) can also sometimes be treated by following simple hygiene measures, such as keeping the penis clean by regularly washing it with water and a mild soap or moisturizer.

Urine can irritate the glans if it’s retained for long periods under the foreskin, so if possible you should withdraw the foreskin to wash the glans.

If balanoposthitis is caused by a fungal or bacterial infection, an antifungal cream or a course of antibiotics may be needed.

Phimosis treatments

Treatment of phimosis varies depending on the severity of the condition. Doctors have found that phimosis can be safely and effectively treated with a topical steroid cream. Topical steroids (a cream, gel or ointment that contains corticosteroids) are sometimes prescribed to treat a tight foreskin. They can help soften the skin of the foreskin, making it easier to retract. Your child’s doctor will give you instructions on the proper use of the cream. If the steroid cream fails and the foreskin remains narrowed, a circumcision may be necessary.

Phimosis can cause pain, skin splitting, or a lack of sensation during sex. Using a condom and lubricants while having sex may make your penis more comfortable.

When surgery may be needed

Surgery may be needed if a child or adult has severe or persistent balanitis or balanoposthitis that causes their foreskin to be painfully tight.

Circumcision (surgically removing part or all of the foreskin) may be considered if other treatments have failed, but it carries risks such as bleeding and infection.

This means it’s usually only recommended as a last resort, although it can sometimes be the best and only treatment option.

Alternatively, surgery to release the adhesions (areas where the foreskin is stuck to the glans) may be possible. This will preserve the foreskin but may not always prevent the problem recurring.