Phimosis (tight foreskin)

What it is

Phimosis is when the foreskin cannot be comfortably pulled back over the head of the penis. It can be there from childhood, or develop later in life.

In adults, phimosis is often caused by:

• Scarring of the foreskin.
• Repeated inflammation of the foreskin or glans (called balanitis).
• A skin condition called lichen sclerosus, which causes slow, progressive scarring.

Common symptoms

• The foreskin will not pull back easily, either at rest or with an erection.
• Pain or discomfort with erection or sex.
• The foreskin splits, tears, or bleeds.
• Repeated infections of the foreskin or head of the penis.
• Difficulty passing urine, or a "ballooning" foreskin during urination.
• Difficulty cleaning under the foreskin, which can cause irritation.

An emergency to know about

Paraphimosis is when a foreskin that has been pulled back gets stuck behind the head of the penis and cannot be brought forwards. This can cause swelling and reduce blood flow. It is a medical emergency that needs urgent attention through an emergency department.

How it is assessed

Assessment usually involves a history of the symptoms and an examination of the foreskin and head of the penis. If lichen sclerosus is suspected, a small piece of skin (a biopsy) may be taken to check, because it can change how the condition is managed.

The main treatment options

Conservative treatment (try first for milder cases)

• Steroid cream - several weeks of a strong steroid cream, with gentle stretching, can improve the flexibility of the foreskin in many men. This is a reasonable first step when there is no significant scarring.
• Hygiene and skin care - gentle cleaning and avoiding irritants can reduce repeated inflammation.
• Treating any infection - with the right antibacterial or antifungal treatment.

Surgery

• Circumcision - removal of the foreskin. Often the definitive treatment when steroid cream has not worked, when there is significant scarring, or when lichen sclerosus is present.
• Preputioplasty - a foreskin-preserving operation that widens the tight ring. Suitable for selected patients, but not always appropriate when scarring is extensive.

Both operations are usually done as day surgery.