Phimosis
Conditions · Phimosis
Phimosis: what it is, the four grades, why it happens in boys and in adults, the risks, and how it is treated with creams or surgery
Phimosis is a foreskin that cannot be pulled back over the head of the penis. In small boys it is normal and nearly always resolves by itself; in adults it is acquired, usually from repeated inflammation, and it causes pain, infections, difficulty with urination and sex, and the risk of the foreskin getting stuck behind the glans (paraphimosis), which is an emergency. This page explains how phimosis is graded, what causes it at each age, when to leave it alone and when to treat it, what steroid creams can and cannot do, and what the operation involves and what recovery looks like.
Phimosis at a glance
What is phimosis?
The foreskin (prepuce) is the fold of skin that covers the glans. Phimosis means it cannot be retracted to expose the glans, because its opening has become a tight, inelastic ring. Forcing it back over the glans can tear it, and if a tight foreskin is pulled back and left behind the glans it acts as a tourniquet: the glans swells, the ring tightens further and cannot be brought forward again. This is paraphimosis, a painful emergency which, untreated, can lead to loss of tissue. The opposite of phimosis is a foreskin that retracts freely and returns easily; everything in between is graded.
Two situations are often confused. Physiological phimosis is the natural state of almost every newborn boy: the foreskin is fused to the glans and separates gradually over childhood, so that most boys can retract it by the age of three to five and nearly all by puberty. It is not a disease and needs no treatment. Pathological phimosis is a foreskin that was once retractable and has become tight through scarring, or a foreskin in an older boy or adult that has never become retractable and is now causing symptoms. This is what needs treating.
The four grades of phimosis
We grade phimosis by how much of the glans can be exposed, because the grade decides the treatment.
Grade I: full retraction with effort
The foreskin can be pulled fully back, but a tight ring is felt behind the glans and the skin is tense; it may catch on the way back. Often causes discomfort only during erection or intercourse. Responds well to cream and stretching.
Grade II: partial exposure of the glans
The foreskin retracts enough to show the opening of the urethra and part of the glans, but not past the widest part. The commonest grade in adults who come to us; cream helps some, surgery is needed for the rest.
Grade III: only the urethral opening is visible
The foreskin moves a little and shows the tip of the glans or only the meatus. Hygiene is difficult, infections are frequent, and the stream may spray. Usually needs surgery.
Grade IV: no retraction at all
The opening is a pinhole; the glans cannot be seen, the foreskin balloons during urination and the stream is thin. In adults this is nearly always scarred (often lichen sclerosus) and needs circumcision.
What causes phimosis
In boys: usually nothing
Physiological phimosis is normal and resolves on its own. Pathological phimosis in a child comes from forced retraction, which tears the delicate skin and leaves a scar ring, from repeated balanitis (infection under the foreskin), and from lichen sclerosus (balanitis xerotica obliterans), a whitish, scarring skin disease of the foreskin that affects a small proportion of boys and will not resolve without treatment.
In adults: inflammation and scarring
Repeated infection under the foreskin (balanitis, balanoposthitis), most often with candida; sexually transmitted infections; lichen sclerosus, the commonest cause of a hard, white, scarred phimosis in adult men; and the small tears of intercourse that heal with scar in an already tight foreskin. Each episode of inflammation leaves the ring a little tighter.
Diabetes and general disease
Diabetes is the condition most often behind adult phimosis: sugar in the urine feeds candida under the foreskin, infections recur and the skin scars. New phimosis in a middle-aged man is a reason to test for diabetes. Immune suppression, obesity and poor hygiene, with retained smegma under a foreskin that is never cleaned, add to the risk.
Symptoms of phimosis
- A foreskin that will not pull back, or pulls back only partly, with a visible tight ring, sometimes pale and scarred.
- Ballooning of the foreskin during urination, a thin, spraying or dribbling stream, and having to strain, because urine collects behind the narrow opening.
- Pain on erection or during sex, small tears and bleeding at the ring, and difficulty with penetration.
- Redness, swelling, itching, discharge or a bad smell under the foreskin: balanitis, which comes back because the foreskin cannot be cleaned.
- Frequent urinary infections, especially in boys and in men with diabetes.
- White, hard patches on the foreskin or glans, which suggest lichen sclerosus and need examination.
Complications of untreated phimosis
Infections
Recurrent balanitis and balanoposthitis, urinary tract infections from urine trapped behind the foreskin, and in older men a higher risk of acquiring sexually transmitted infections, including HIV and HPV, because the moist, inflamed inner foreskin is easily breached.
Paraphimosis
A tight foreskin pulled back and trapped behind the glans: rapid, painful swelling of the glans, a constricting ring, and, if not reduced within hours, damage to the tissue. It is an emergency: go to a urologist or an emergency department at once; it is reduced under local anaesthetic and the phimosis is then treated so it cannot happen again.
Urination and the urethra
Chronic straining against a pinhole foreskin raises the pressure in the bladder; lichen sclerosus can spread to the opening of the urethra and narrow it (meatal stenosis) and, rarely, further along the urethra, causing a stricture that is far harder to treat than the phimosis was.
Sexual function
Painful erections and intercourse, tearing of the ring and the frenulum, avoidance of sex, and, in some men, premature ejaculation from the over-sensitive, chronically irritated glans.
Cancer of the penis
Rare, but phimosis is its strongest risk factor: chronic inflammation, retained smegma, HPV and lichen sclerosus under a foreskin that cannot be examined. Any lump, ulcer or persistent red patch on the glans or foreskin must be seen, and a phimosis that prevents the glans from being examined is a reason in itself to correct it.
In boys
Recurrent balanitis and urinary infections, ballooning and straining, and, after forced retraction, a scarred ring that will never loosen on its own. The risk of paraphimosis in a boy whose foreskin has been forced back is real.
Phimosis in boys: what is normal, and what never to do
At birth the foreskin is attached to the glans in nearly every boy, and it should not retract. It separates by itself over the years: about half of boys can retract it by the age of three, most by five to seven, and almost all by the end of puberty. During this time the only care needed is to wash the outside; the foreskin should never be pulled back by force, by a parent or by a doctor, because the tears that result are the commonest cause of a scarred, truly pathological phimosis later on. Ballooning of the foreskin during urination is common in this phase and is not, on its own, a reason to treat.
A boy needs to be seen when the foreskin opening is a pinhole with a thin stream and straining, when there are repeated infections under the foreskin or urinary infections, when the foreskin is white, hard and scarred (lichen sclerosus), when he has had an episode of paraphimosis, or when phimosis persists after puberty. The first treatment at any age is a steroid cream, which loosens the ring in the large majority of boys within a few weeks; circumcision is reserved for scarring, lichen sclerosus and failure of the cream.
Hygiene at every age
Once the foreskin retracts, it is pulled back gently during washing, the glans and the inside of the foreskin rinsed with water, dried, and the foreskin returned to its place, every time: a foreskin left retracted in a child or a drowsy adult is how paraphimosis happens. No soap under the foreskin, which irritates; no forcing; and in men with diabetes, good blood sugar control, which does more to prevent balanitis than any cream.
Diagnosis
Phimosis is diagnosed by examination: the degree of retraction, the state of the ring, the frenulum, the glans and the urethral opening, signs of infection or lichen sclerosus, and in adults the testing of urine and blood sugar when infections keep recurring. Imaging is not usually needed. When a severe phimosis has caused straining for years, or in a boy with urinary infections, we assess the effect on the urinary tract with ultrasound of the bladder and kidneys and, when there are signs that the urethra or bladder are involved, with a voiding cystourethrogram, an X-ray taken while urinating that shows the urethra and bladder neck and detects reflux of urine towards the kidneys. A suspicious patch of skin is biopsied.
Treatment of phimosis
Conservative: creams, stretching, injections
A potent steroid cream (betamethasone or similar) applied to the tight ring twice a day for four to eight weeks, combined with gentle, painless stretching of the foreskin once the skin softens, loosens physiological and mild pathological phimosis in most boys and in a good proportion of adults with grade I or II phimosis, and it carries no risk if it fails. Infections under the foreskin are treated with antifungal or antibiotic creams first. In selected adults an injection into the fibrous ring softens it further. What does not work is force, and “natural” remedies that claim to dissolve scar tissue: a scarred ring, and above all lichen sclerosus, does not respond to creams for long and needs surgery.
Surgery: partial or complete circumcision
When the cream fails, the phimosis is scarred, there is lichen sclerosus, infections keep recurring or paraphimosis has occurred, the tight ring is removed surgically. Complete circumcision removes the foreskin and leaves the glans permanently exposed; a partial circumcision or preputioplasty removes or widens only the tight ring and preserves most of the foreskin, for men who want to keep it and whose skin is otherwise healthy. A short frenulum is lengthened at the same time (frenuloplasty). The choice is made with the patient, balancing function, hygiene and appearance, and the remaining skin is reconstructed carefully so that the result is cosmetically clean.
The operation and recovery
The procedure takes about half an hour, under local anaesthesia in adults (general in children or on request), as a day case. Fine, fast-absorbing sutures are used, so there is nothing to remove, and the patient goes home the same day with a light dressing. There is mild soreness for a few days, controlled with simple painkillers; the dressing comes off after one or two days; urination is normal from the start; work or school is possible within two or three days; and the wound is fully healed in about three weeks, after which erections and intercourse are allowed, usually at four to six weeks. The glans is more sensitive for a few weeks and then settles. Lichen sclerosus is followed up after surgery, because it can affect the glans and the urethral opening.
A tight foreskin, in you or your son?
We will tell you honestly whether it needs treating at all, whether a cream is worth trying first, and, if surgery is the answer, which operation and what the recovery involves.
Phimosis: frequently asked questions
At what age should a boy’s foreskin retract?
There is no deadline. About half of boys can retract it by three, most by five to seven, and almost all by the end of puberty. Until then it is physiological and should be left alone; it needs attention only if it causes infections, a pinhole opening with straining, scarring, or persists after puberty.
What causes phimosis in adults?
Scarring from repeated inflammation: infections under the foreskin (often candida, especially in diabetes), sexually transmitted infections, lichen sclerosus, small tears during intercourse and poor hygiene. New phimosis in a middle-aged man is a reason to test for diabetes.
Can you have sex with phimosis?
With grade I or II, usually, though erections and penetration may be uncomfortable and the ring can tear. With a tight phimosis sex is painful, the risk of paraphimosis is real, and the foreskin cannot be kept clean, so treatment is advisable before it causes more trouble.
Can phimosis be fixed naturally or without surgery?
Mild phimosis without scarring often responds to a steroid cream and gentle stretching over four to eight weeks. A scarred ring or lichen sclerosus does not, and no oil, herb or device dissolves scar tissue; forcing the foreskin makes it worse. Surgery is then a short day-case operation.
Is phimosis dangerous?
Not immediately, but it leads to recurrent infections, urinary problems, painful sex, paraphimosis, which is an emergency, narrowing of the urethral opening, and, rarely, cancer of the penis, for which it is the main risk factor. It is easily treated, and treating it removes these risks.
What is partial phimosis?
A foreskin that retracts partly but not fully over the glans, grade I or II. It is the commonest form in adults and the one most likely to respond to a cream; if it does not, a partial circumcision that removes only the tight ring usually suffices.
Can a circumcised man get phimosis?
If skin was left and has scarred, yes, as a tight ring of residual foreskin; and lichen sclerosus or scarring can narrow the urethral opening (meatal stenosis) in circumcised men, which feels similar. Both are treated surgically.
What is paraphimosis and what should I do?
A tight foreskin trapped behind the glans, with rapidly increasing swelling and pain. Do not wait: go to a urologist or emergency department at once, where it is reduced under local anaesthetic. The phimosis is then treated so that it cannot recur.
