Tight foreskin (phimosis) – NHS

It’s normal for babies and young boys to have a tight foreskin (phimosis), but adults can also be affected. See a GP if your or your child’s foreskin is sore or swollen.

Check if you or your child has a tight foreskin

The foreskin is the thin layer of skin that covers the end of the penis. If you or your child has a tight foreskin, it will be difficult to pull it back from the end of the penis.

A tight foreskin is normal in babies and young boys. Most boys’ foreskins do not pull back (retract) before the age of 5, but sometimes it’s not possible until they’re 10 or older.

The end of a boy’s penis may bulge or balloon when they pee, particularly if their foreskin is tight.

A tight foreskin is not usually a problem, unless there are symptoms such as:

• swelling and tenderness
• pain when peeing or a weak flow of pee
• blood in urine
• frequent urinary tract infections (UTIs)
• bleeding or a thick discharge from under the foreskin or an unpleasant smell – these are signs of an infection (balanitis)
• painful erections, which can make having sex difficult

Things you can do if you have a tight foreskin

If your or your child’s foreskin is tight, but is not causing problems like pain or bleeding, there are some things you can do to help ease it and keep the penis clean.

Don’t

• do not pull back the foreskin of a baby or young boy because it could be painful and damage it, leading to problems in later life

• do not use perfumed soap, talcum powder or deodorants on your penis because they may cause irritation

Non-urgent advice: See a GP if:

• your or your child’s foreskin is tight and swollen or painful
• there’s bleeding around your or your child’s foreskin when peeing, a thick discharge from under the foreskin, or an unpleasant smell

Treatments for a tight foreskin

The foreskins of babies and young boys will usually loosen as they get older, so treatment is often not needed.

If your or your child’s foreskin is causing problems, treatments include:

• steroid creams or gels (topical steroids) to help soften the foreskin
• antibiotics if the foreskin or head of the penis is infected
• surgery – removal of the foreskin (circumcision) or a procedure where small cuts are made in the tip of the foreskin so it can be pulled back more easily (usually only suitable for children)

Information:

Find out more

• Circumcision in boys
• Circumcision in men
• British Association of Urological Surgeons: phimosis and phimosis treatments

Complications of a tight foreskin

Sometimes if the foreskin is very tight it can get stuck and cannot go back to its original position covering the end of the penis. The end of the penis can then become very swollen and painful.

This is known as paraphimosis and it’s a medical emergency.

Immediate treatment is needed to avoid serious complications like restricted blood flow to the penis.

A doctor may be able to return the foreskin to its original position. Sometimes surgery to remove the foreskin (circumcision) may be recommended.

Immediate action required: Call 999 or go to A&E if:

• you or your child’s foreskin is pulled back and cannot go back to its original position over the end of the penis

Community content from HealthUnlocked

Page last reviewed: 11 April 2022
Next review due: 11 April 2025

Phimosis | UCSF Department of Urology

What is Phimosis?

Phimosis is defined as the inability to retract the skin (foreskin or prepuce) covering the head (glans) of the penis. Phimosis may appear as a tight ring or “rubber band” of foreskin around the tip of the penis, preventing full retraction. Phimosis is divided into two forms: physiologic and pathologic. Current incidence of phimosis is about 1% in 7^th grade boys.

Physiologic phimosis: Children are born with tight foreskin at birth and separation occurs naturally over time. Phimosis is normal for the uncircumcised infant/child and usually resolves around 5-7 years of age, however the child may be older.

Pathologic phimosis: Phimosis that occurs due to scarring, infection or inflammation. Forceful foreskin retraction can lead to bleeding, scarring, and psychological trauma for the child and parent. If there is ballooning of the foreskin during urination, difficulty with urination, or infection, then treatment may be warranted.

Care of Uncircumcised Penis:

No special care is required for foreskin in infancy. The foreskin should not be forcibly retracted, however gentle retraction is okay. In the first few years of life, gentle retraction with cleansing underneath the foreskin is sufficient during diaper changes or bathing and will result in progressive retraction over time. Once the child is older and the foreskin retracts fully, he will learn to retract, cleanse and dry underneath the foreskin as part of his hygiene routine. After retraction, the foreskin should be pulled back over the head of the penis and returned to the normal position.

Smegma:

Smegma is a collection of skin cells from the glans penis and inner foreskin that is often noted with retraction of the foreskin. This natural skin shedding helps to separate the foreskin from the head of the penis. Smegma may appear as white pearls underneath the skin, which can easily be washed off once the foreskin is retracted.

How is phimosis diagnosed and evaluated?

In physiologic phimosis, benign (non-life threatening) conditions may occur that are common in uncircumcised males, including; cysts related to smegma production/trapping and transient painless ballooning of the foreskin during urination. These are considered normal variations that usually resolve with daily gentle manual retraction. 

Pathologic phimosis that does not resolve naturally or causes other complications, including; penile irritation or bleeding, ballooning of the foreskin with urination resulting in forceful/difficult urination, urinary retention, painful urination (dysuria), painful erections, recurrent infections of the foreskin (balanoposthitis), paraphimosis (foreskin stuck in the retracted position behind the head of the penis), or urinary tract infections may require further treatment. Your medical provider will refer your child to a pediatric urologist for further evaluation.

How is phimosis treated?

Treatments for phimosis vary depending on the child and severity of phimosis. Treatments may include: gentle daily manual retraction, topical corticosteroid ointment application or circumcision.

Topical corticosteroid therapy:

Medical providers may recommend topical steriod ointment application for children with phimosis.   This is an effective treatment in most males. These topical ointments are used to help soften the tight foreskin around the penis, so the foreskin may be easily retracted. Your provider will demonstrate how to apply the ointment to the tight ring of foreskin and/or head of the penis. The ointment is massaged into the affected areas twice daily for 6-8 weeks along with manual stretching/retraction twice daily. Once the foreskin can be fully retracted, the ointment is discontinued and manual daily retraction (during warm baths and urination for the potty trained child) will prevent phimosis from reoccurring.  The most common corticosteroids used are hydrocortisone 2.5%, betamethasone 0.05%, triamcinolone 0.01%, and fluticasone propionate 0.05%.

Circumcision:

Male circumcision refers to the surgical removal of the foreskin.  Circumcision is often not required for treatment of phimosis. In some rare cases your pediatric urologist may recommend circumcision due to failure of steroid ointment, pathologic phimosis, paraphimosis (foreskin stuck in the retracted position behind the head of the penis), recurrent urinary tract infections, or severe/recurrent balanoposthitis.

surgeon, vascular surgeon, Honored Doctor of the Republic of Tatarstan Glyakin Vladimir Yakovlevich.

The problem of phimosis is more often faced by young parents with boys of preschool age. And, if in an adult man the approaches to the treatment of this pathology are clearly defined by urologists, then in children there are controversial points in the approaches to the diagnosis and treatment of this condition. The problem of phimosis is also related to the question of the attitude of official medicine to the rite of circumcision for religious reasons.

Phimosis is a narrowing of the foreskin in which the glans penis does not open at all or opens with difficulty and pain. Only in 4% of newborn boys is the foreskin so mobile that the head of the penis can be fully opened. At the age of 6 months, the glans penis opens in 20% of boys, and at the age of 3 years, the foreskin is well displaced and allows the glans to be exposed in 90% boys.

Symptoms depend on the severity of the process:

• 1 degree. In a calm state, the glans penis is exposed without problems, with an erection, this requires little effort.
• 2nd degree. During an erection, the glans penis does not open at all, in a calm state – with difficulty or without effort.
• 3rd degree. The head of the penis does not open in any way or only in a calm state of the penis and with considerable effort, but phimosis does not cause problems with urination.
• 4th degree. Phimosis leads to difficulty urinating. When urinating, the preputial sac swells first, then the urine is excreted in a thin stream or drop by drop. The head of the penis cannot be opened even slightly. As a rule, the child is worried and cries when urinating.

Most often, phimosis occurs in most children under 2-3 years of age. This condition is called physiological phimosis. But there is still no consensus on up to what age to consider phimosis physiological, when to plan an operation for phimosis in children, and so on. It should also be borne in mind that physiological phimosis has all the same complications as ordinary phimosis. It is necessary to decide on the appropriateness of the operation and its timing for phimosis in children each time individually. It should be noted that most often phimosis in children goes away on its own, the head opens and there are no problems with the foreskin. However, before the head has opened, special attention should be paid to its hygiene, it is best to rinse the head once a day. In general, most experts believe that by the age of 6-7 years, the glans penis should open freely, and if this does not happen, then treatment is required.

In adult males, phimosis may persist from childhood or may develop during puberty. During this period, there is a rapid growth and development of the genital organs. In this case, there may be a discrepancy between the development of the penis and the foreskin. In this case, the foreskin is smaller than the head, its opening is narrower, and it is difficult or impossible to open the head.

Most often it is phimosis of 1-2 degrees, while phimosis preserved from childhood is not less than 3 degrees. In adolescents, young men and adult men, phimosis does not stand still, the disease is steadily progressing. This is due to the appearance of erections, masturbation and sexual activity. During an erection, the glans penis enlarges and the foreskin stretches tightly. At the same time, cracks and microcracks appear on the foreskin. As a rule, they are small in size, do not bleed and do not cause any concern. But, when healing, a scar or micro scar is formed in their place. Scar tissue is much less elaphimostic than normal foreskin tissue. Therefore, with the appearance of each new scar, the foreskin narrows more and more, the disease progresses.

This process is especially pronounced during masturbation and during sexual intercourse. In this case, ruptures of the foreskin can be significant and accompanied by profuse bleeding. The most common complications of phimosis are: increment of the head to the foreskin, paraphimosis, ballanoposthitis 3 and 4 degree of phimosis, when the glans penis does not open at all, can ultimately lead to an increment of the foreskin to the mucous membrane of the head. First, a small area grows, after a while it expands, and as a result, the foreskin adheres to the glans penis along its entire length. This condition does not cause any particular discomfort, only attempts to open the glans are accompanied by severe pain and bleeding. Treatment of the increment of the foreskin is only surgical, and with a large area of ​​​​fusion, the operation can be very difficult.

Paraphimosis is an infringement of the glans penis, narrowed by the foreskin. Most often, attempts to open the foreskin with phimosis of 2-3 degrees lead to paraphimosis. Pinching can occur during intercourse or masturbation. With paraphimosis, swelling of the glans penis and part of the foreskin quickly develops, the presence of an infringing ring behind the glans penis is visible. It significantly increases in size, which makes the reduction of paraphimosis impossible after some time. All this is accompanied by a sharp pain, blue head. With paraphimosis, you need to try to set the glans penis. Sometimes this is easy, sometimes it is extremely difficult, sometimes it does not work at all. Unsuccessful attempts to reposition the foreskin require emergency surgery. With untimely assistance, even necrosis of the head is possible.

Ballanoposthitis is an inflammation of the glans penis and foreskin. With phimosis of 2 and higher degrees, the hygiene of the glans penis is difficult. Often this leads to stagnation of smegma (a whitish-grayish putty-like mass – the result of the work of the glands) in the preputial sac, its infection and the development of inflammation.

There is pain and redness, discharge of pus from the preputial sac. With the ineffectiveness of conservative measures, which include baths with a pink solution of potassium permanganate, washing the preputial sac with solutions of miramistin, chlorhexidine, furacillin, surgical treatment is indicated. The foreskin is dissected to improve the outflow of pus. The problem of inflammation and phimosis is solved, but a cosmetic defect remains, which, as a rule, requires a full excision of the foreskin in the future.

Treatment of phimosis.

Of the several ways to treat phimosis, there is really only one – this is surgery – circumcision. However, other methods or attempts to treat phimosis will be considered here in order to dispel myths in this regard and not leave ambiguities.

• Corticosteroid therapy. The essence of the method is the regular and prolonged use of corticosteroid ointments on the glans penis and foreskin. Corticosteroid ointments slightly increase the elasticity of the tissue of the foreskin, as a result of which it can stretch, and the degree of the disease decreases. In addition, the use of glucocorticoids reduces swelling, inflammation, and accelerates the healing of microcracks.

In general, this method of treating phimosis should be recognized as ineffective, and it should not be recommended for use. Perhaps it makes sense to recommend it to children after 7 years of age, in whom surgical treatment is contraindicated for some reason.

• Stretching of the foreskin. The essence of the method is quite clear from the name. A man should systematically stretch the narrowing ring of the foreskin with his fingers or tools so that after a while it becomes wider. This method has really helped get rid of phimosis for some people. It is sometimes used in combination with corticosteroid therapy. The effectiveness of this method is not equal to zero, but differs little from this. To get a real effect from stretching the foreskin, these exercises should be done for 1-2 hours a day, daily, for months or even years. Few people have the patience to do all these manipulations to get a real effect. In addition, in grade 3-4 phimosis, it is not possible to stretch the foreskin strongly enough for it to have any meaningful effect. Moreover, it is unrealistic to use it in children.
• Circumcision (circumcision). The fastest and most effective way to treat phimosis is a circumcision operation, or circumcision. With this operation, the foreskin is removed completely or partially, as a result of which there are no more problems with the exposure of the glans penis. Circumcision is indicated for any degree of phimosis. A contraindication for circumcision is severe inflammation of the glans penis and foreskin – ballanoposthitis.

Prevention of phimosis.

The development of phimosis is largely due to a genetic predisposition to this disease, so there is actually no serious prevention of phimosis. Boys need to pay attention to the head of the penis every day, gently open it when washing. In adults, the prevention of phimosis is the timely treatment of inflammation of the head and foreskin, try to avoid injury to this area. If phimosis has already developed, you should not delay for a long time, contact a urologist and schedule an operation. This will avoid a lot of problems. In Tatarstan, circumcision is common, as it is done for religious reasons by most boys in families that adhere to Islamic traditions. The relation of traditional medicine to cult circumcision is not clearly defined. In the US, where about 1.2 million circumcisions are made a year, it is more tolerant. It is believed that circumcision eliminates the need for daily hygiene, reduces the risk of developing penile cancer, genitourinary infections, and the number of sexually transmitted diseases. In Europe, where the number of such operations is an order of magnitude smaller, there are more opinions about the need to preserve the foreskin, which apparently has a protective, erogenous, sensory, and sexual function.

Neither supporters nor opponents of circumcision for religious reasons have absolute arguments “for” and “against”. Probably, one should agree with the opinion of the professor of the Department of Urology of KSMU Sitdykov E.N.: “If there are no problems and it is possible to observe the hygiene of the genital organs, then circumcision is not indicated. If there are problems or there is no possibility of proper hygiene, then circumcision is potentially useful.

Boy problems – articles from the specialists of the clinic “Mother and Child”

The head of the penis in boys and men is closed by the so-called foreskin – this is a movable area of ​​\u200b\u200bthe skin, which consists of two sheets: the outer one (looks like skin) and the inner one (reminiscent of the mucous membrane). In an adult male, the foreskin is easily displaced and opens the head. Between the glans penis and the inner leaf of the foreskin there is a space – the cavity of the foreskin, into which the secret of the glands located under the foreskin is secreted. This secret is called smegma, thanks to which the skin is easily displaced from the head of the penis. The head of the penis in men is very sensitive, and the foreskin is needed in order to cover it, and even during intercourse it slides over the head, which increases the man’s sexual arousal and reduces friction.

as in boys

In all boys from birth, the foreskin completely covers the glans penis, preventing it from showing out – this is a completely normal condition and is called physiological phimosis. Moreover, from the inside, the foreskin is also glued to the glans penis with the so-called synechiae (thin, tender adhesions), which are also quite common in little boys.

Gradual withdrawal of the head with separation of synechiae begins somewhere around 3 years of age and most often ends at 7–9 years of ageyears. But there are boys whose head opens only at puberty – at about 12 years old. So there is simply no single age at which the head opens, each child has his own.

as it was before

Even 10-20 years ago (and sometimes even now) doctors believed that if the glans penis does not open in a little boy, especially if there is synechia, this is not a norm, but a pathology. It was believed that during each wash, the head should be tried to slightly open, and the accumulated smegma (the secret of the glands of the penis) should be removed, otherwise inflammation of the foreskin will begin. Therefore, when they saw a completely healthy baby at the reception, but with an unopened head, the doctors suggested opening it. Moreover, they recommended doing this if there were synechia or an inflammatory process. Very often, many surgeons opened the head of the penis without even warning the parents about it – simply by sharply displacing the foreskin during a routine examination of the baby. If the boy had synechiae, then they naturally burst, the child was in pain, he cried. The same thing happened if the doctor divided the synechia according to plan: the boys remembered this manipulation for a very long time and reacted extremely painfully to it.

what they are doing now

Now modern and qualified doctors know that physiological phimosis is the norm and nothing needs to be done about it. In addition, over time, doctors saw that after the division of the synechiae and the removal of the head before all this happens on its own, repeated synechiae often occur, but these will no longer be thin, tender adhesions, but coarse cicatricial adhesions. Many boys had to separate synechia more than once, and as a result, everything often ended with circumcision of the foreskin. There is nothing to say about psychological problems after such manipulations.

Therefore, if the child is not bothered by anything, then modern urologists strongly advise not to touch the foreskin.

how to care

Parents who try to wash their child as often and as cleanly as possible are advised by doctors not to overdo it. Until the moment when the foreskin can separate, the boy’s penis should only be washed with plain water and nothing more. It is not even necessary to slightly pull the foreskin, it will open when the time comes. If smegma accumulates behind the foreskin (it looks like a white curdled substance), do not worry and try to wash it completely with all your might. Smegma in boys is a normal manifestation of the work of the glands, it is easily washed off under running water and this is quite enough.

when and to which doctor to go to

If physiological phimosis is the norm, then what is pathology? If a boy suddenly begins to complain that it hurts or is unpleasant for him to write, if his parents see that urine does not come out in a jet, that during urination the skin of the foreskin swells with a ball, redness, swelling or purulent discharge appears on the penis – this is an occasion immediately visit a doctor.