Physiological Phimosis (tight foreskin)

A tight foreskin that can’t be pulled back or ‘retracted’ is known as phimosis. During embryonic development, the foreskin and prepuce are fused so at birth all boys’ foreskins are non-retractile. Over time, as boys pass urine and have erections, the foreskin opening widens and the adhesions between the head of the penis and the foreskin separate to allow the foreskin to retract. In some boys this happens quickly and in others it takes longer. By the age of 6, approximately 8/100 boys can’t retract their foreskin at all and 63/100 boys have adhesions which prevent the foreskin from being fully retracted. By the age of 14 only 1/100 boys can’t retract their foreskin at all and 13/100 still have preputial adhesions, and this continues to reduce through teenage years.

A normally narrow foreskin can still cause a problem for boys. The narrowing can mean that urine gets caught between the penis and the foreskin and can cause ballooning of the foreskin after urination. “Ballooning” can be of great concern to parents; it is important to reassure them that it is a natural phenomenon which does not require treatment in the absence of other symptoms.

Occasionally, trapped urine can act as an irritant, causing the foreskin and the penis to become red, swollen and painful, “balanoposthitis”. This will often improve with good hygiene and a short course of regular anti-inflammatory medications. Asking boys to drink plenty of fluids ensures that their urine is dilute and urination is less painful. It can also help to advise boys to pass urine in the bath if they are in a lot of pain. Sometimes an infection can also be present and, in this situation, clinicians will often give a course of oral antibiotics. 

The normal foreskin also produces fluid and sheds dead skin cells, as in every part of the body, which forms a creamy material that sits between the foreskin and the penis and is known as smegma. When the foreskin cannot be retracted the smegma can accumulate together and form a lump on shaft of the penis. It is usually soft, non-painful and mobile. These are known as smegma retention cysts and discharge as the foreskin retracts more with age. Parents should be warned to expect this discharge on nappies or underpants.

Taken together, most foreskin conditions can be managed with simple advice and reassurance. Treatment options depend on the age of the boy, the severity of the symptoms and the preferences of the boy and their family and the treatment choice support tool, above, can help to determine the options which you may offer to individual boys.

Treatment options

Watch and wait, steroid course. When indicated: preputioplasty, circumcision.

Key references

(BXO – also known as lichen sclerosus)

BXO is a skin condition that can affect small numbers of people from the age of 4 onwards. It causes phimosis and can occur in boys and men who were previously able to retract their foreskin or in boys who have never been able to retract their foreskin. A foreskin affected by BXO generally cannot be retracted and typically a characteristic white patch can be seen to be the cause of the phimosis. BXO can cause white, itchy patches on the skin of the foreskin and the glans penis, causing pain and irritation, and can bleed if scratched. It is very common for this condition to cause pain and discomfort during urination and sex. BXO can also cause narrowing of the distal urethral meatus which sometimes also requires treatment. 

It has been suggested that adult penile cancer is more likely to occur in people with BXO but the evidence to support this suggestion is inconclusive, particularly for children (rather than adults) who are diagnosed with BXO.

Cause

It’s not fully understood why people develop BXO. It is thought to be caused by the immune system inappropriately attacking the foreskin. In some people, certain types of soap, shower gels or condoms can irritate the skin. Some genetic conditions may make it more likely for some people to develop BXO than others.

Treatment options

Treatment in some form is always indicated for BXO. The decision about which treatment options are appropriate depend on the symptoms that a boy is experiencing and the preferences of the boy and their family.

• Topical steroid cream can be effective for mild cases of BXO. 
• For boys with moderate or severe BXO the options for management of the preputial BXO include foreskin-preserving surgery in the form of preputioplasty +/- intradermal injection of potent steroid (triamcinolone), or foreskin removal in the form of circumcision.

The decision around which option is best for the individual is best made with a full and open discussion about each operation. 

Concerns have been raised by some that failure to circumcise increases the rate of penile cancer. This type of cancer is very rare including in people with BXO and the presence of glanular and urethral BXO means that circumcision does not remove the risk of penile cancer. However, being open and complete with the information that is given to families is important.

Stenosis of the external urethral meatus resulting from BXO usually responds to urethral dilatation alone. Monitoring of the urinary stream using uroflow measurement in children with meatal stenosis after circumcision is recommended and if there is obstructed flow, further surgical management may be required in the form of meatotomy or meatoplasty. Occasionally children with persistent symptoms may need to perform daily urethral dilatations. This is generally reserved for older children with severe symptoms who are able to tolerate dilatations.

Key references

Paraphimosis

Paraphimosis is a medical emergency and is common in teenage boys. The condition can occur if the foreskin is retracted for too long and gets stuck in the retracted position. The foreskin can become tight behind the head of the penis, restricting blood flow and trapping fluid so the head becomes swollen.

Treatment options

Most cases are treated in A&E using manual reduction. Pain relief is administered and the penis is wrapped in swabs soaked in sugar or cold water to reduce the swelling. Constant manual compression is applied in an attempt to push the foreskin towards the tip of the penis.

If the foreskin cannot be released using this method, manual reduction may be attempted under general anaesthetic. If it is still not possible to replace the foreskin in this way, then an operation is performed to widen the foreskin so that it can be pulled back over the head of the penis. Circumcision is generally not performed in the acute situation as the swelling makes it difficult to achieve a good result and often these children do not have phimosis. It is recommended that children are reviewed in the outpatient clinic after an admission with paraphimosis to enable an examination for phimosis to be performed once the swelling has settled.

Frenulum tearing

In people who have a short frenulum between the ventral aspect of the glans penis and foreskin, tearing and pain during erections or sex can be common.

Treatment options

Tears normally heal without intervention. If the foreskin splits regularly or if significant pain is experienced during erections, surgical options such as frenuloplasty can be considered.

Hypospadias

Hypospadias is a relatively common condition of the penis and foreskin that boys are born with. It is generally described as a triad of findings which can occur individually or together. In hypospadias the urethral meatus is located on the ventral aspect of the penis anywhere from the underside of the glans to the scrotum; the foreskin can be hooded, meaning that it does not completely wrap around the glans penis but instead only covers the dorsal and lateral glans penis; and there can be a chordee of the penis which causes a downwards bend in the penis, particularly when boys have an erection. Circumcision of a boy with hypospadias is absolutely contraindicated by non-specialists as sometimes the foreskin is needed to graft the urethra in the repair of hypospadias.

Treatment options

Mild cases don’t require treatment but surgical options are available if the parents wish this to be performed for cosmetic reasons. Some boys may need surgery to bring the urethra further towards the end of the penis and to straighten the penis, and this is usually performed at a young age. Children with hypospadias should never have a circumcision until they have seen a hypospadias specialist, as the foreskin is often needed to correct the hypospadias condition. A circumcision may be performed as part of the hypospadias correction, but in mild cases of hypospadias, the foreskin can be reconstructed. Options should be discussed with the patient and their parents.

Topical steroid creams/corticosteroids

A steroid course involves the topical application of a very potent steroid cream to the prepuce. The prepuce should be gently retracted to the point where it is narrow, without using force or causing pain, and applying the steroid cream to this area. It is generally recommended that a steroid course is continued for 4-6 weeks.

Manual reduction

Pain relief is administered and the penis is wrapped in swabs soaked in sugar or cold water to reduce the swelling. Pressure is applied in an attempt to push the foreskin towards the tip of the penis. If the foreskin cannot be released using this method, manual reduction may be attempted under general anaesthetic. If it is still not possible to replace the foreskin in this way then an operation is performed to widen the foreskin so that it can be pulled back over the head of the penis.

Preputioplasty

An operation performed for phimosis which preserves and widens the foreskin to allow the foreskin to be fully retracted. The operation involves performing 3 radial incisions into the narrowed prepuce which are closed longitudinally to increase the circumference of the foreskin and allow it to be fully retracted. Triamcinolone can be injected intradermally at the time of preputioplasty when BXO is present and may help to treat the scarring caused by skin disease. 2 weeks after the preputioplasty has been performed it is recommended that boys retract and replace their foreskin twice a day to help it to remain retractile.

When preputioplasty is performed in boys with BXO there is a 1/5 chance that the foreskin becomes narrow again and a further procedure may be required. For some boys and families this risk is acceptable: there is a good chance that the foreskin is preserved; the appearance of the foreskin is similar to before the operation; and the sensory nerves which are present within the foreskin are preserved. Other may wish to choose an alternative option, primarily circumcision, to avoid the risk of failure.

References

Fischer-Klein Ch, Rauchenwald M. (2003) Triple incision to treat phimosis in children: an alternative to circumcision? BJU Int. Sep;92(4):459-62 https://bjui-journals.onlinelibrary.wiley.com/doi/full/10.1046/j.1464-410X.2003.04354.x

Binet A, Fracios-Fiquet C, Bouche-Pillon MA. (2016) Review of cinical experience for a new preputioplasty echnique as circumcision alternative. Ann Chir Plast Esthet. Feb;61(1):23-8 https://www.sciencedirect.com/science/article/abs/pii/S0294126015000254?via%3Dihub

Impellizzeri P, Turiaco N, Antonuccio P et al. (2006) Preputioplasty in the treatment of phimosis in paediatric age. Indications and results. Minerva Pediatr. Feb;58(1):15-9 https://wwww.unboundmedicine.com/medline/citation/16541003/[Preputioplasty_in_the_treatment_of_phimosis_in_pediatric_age__Indications_and_results]_

Barber NJ, Chappell B, Carter PG et al. (2003 ) Is preputioplasty effective and acceptable? J R Soc Med. Sep;96(9):452-3 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC539601/

Cuckow PM, Rix G, Mouriquand PDE. (1994) Preputial plasty: a good alternative to circumcision. J Pediatr Surg;29: 561-3 http://www.cirp.org/library/treatment/phimosis/cuckow/

de Castella H. (1994) Prepuceplasty: an alternative to circumcision. Ann R Coll Surg Engl ;76: 257-8 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502252/pdf/annrcse01590-0049.pdf

Frenuloplasty

An operation on the underside of the glans penis that is used to lengthen a short frenulum which either prevents foreskin retraction or produces symptoms.

Circumcision

The surgical removal of the foreskin, usually performed in children under general anaesthetic.

Psychological and sexual impact

Circumcision has a high success rate and is relatively safe, with few side effects reported. However, there are relatively few published studies looking at the long-term patient reported outcomes of circumcision undertaken in children of different age groups, including the impact on their sexual and mental health. Some clinicians suspect side effects are under-reported and more common than the available evidence suggests. Improved awareness of men’s health issues, particularly mental health, have led to increased public scrutiny. Campaign groups opposing circumcision have emerged, and recent news articles of young adults who have been circumcised highlight the negative impact that circumcision can have on men.

Reducing unnecessary circumcisions

A greater awareness of the natural history of the foreskin – which, for some, may retract naturally in their teens – has led to debate about the over-diagnosis of pathological phimosis and higher rates of circumcision than is necessary. The COVID-19 pandemic and the necessary infection control measures that were introduced have put immense pressure on an already stretched health service, leading to staff burnout and increasing waiting lists for non-emergency appointments and elective procedures. Offering evidence-based treatment alternatives to circumcision, which reduce the need to receive treatment in a hospital (where these are clinically appropriate) will help reduce the backlogs and the burden on the NHS.

Meatotomy and meatoplasty

Surgical widening of the urethra.