Phimosis (Tight Foreskin)

Phimosis is the inability to fully retract the foreskin (or prepuce) over the glans penis due to a narrow opening. The foreskin is the extra skin attached to the head of the penis and is generally folded onto itself as a sleeve. The glans is the sensitive bulbous structure at the distal end of the penis.

Facts on Phimosis or Tight Foreskin

• Nonretractile foreskin is present in about 96% of males at birth that slowly becomes retractable by the time they reach their adolescence.
• The foreskin cannot be retracted completely before the age of 5 and in some until adolescence
• Statistics say that 50% of uncircumcised boys have retractable foreskin by 1 year of age, 90% by age 3, 92% by age 6 to 7, and 99% by adolescence.
• Tight foreskin can be caused due to injury or infection of the foreskin
• Tight foreskins can cause a ballooning or blowing up of the skin when passing urine
• The tightness can interfere with the normal passage of urine and can, in severe cases, cause acute retention of urine
• Tight foreskins (not circumcised in childhood) can cause penile tumors

What are the Types of Phimosis?

Physiologic Phimosis:

A type of phimosis that is present since birth and is due to the adhesions between the epithelial layers of the inner prepuce and glans penis. The foreskin is not retractable. This is normal and does not require intervention.

Physiologic phimosis resolves with age. As males grow, these adhesions are dissolved with intermittent foreskin retraction and erections. Glanular secretions aid in the process.

As the foreskin retracts, there can be an accumulation of white discharge called “smegma”. Sometimes urine can accumulate under the foreskin causing a ballooning effect of the penis. These symptoms and the general non retractile nature of the foreskin should be accepted as part of a normal growing process. Forced retraction can be harmful to children and must be avoided. It can lead to soreness and bleeding or pathologic phimosis.

Pathologic Phimosis:

A type of phimosis that is acquired or developed due to underlying causes like poor hygiene, forceful retraction of the tight foreskin and recurring infections of the foreskin and glans penis.

What is the Difference between Phimosis and Paraphimosis?

	Phimosis	Paraphimosis
Condition	The foreskin is fused with the glans penis and so unable to retract fully over the glans.	The foreskin of an uncircumcised penis while trying to retract it, gets trapped behind the glans penis. It cannot be brought back to its flaccid state to cover the glans.
Causes	Forceful retraction, poor hygiene, inflammation and infection of the foreskin.	Improper handling of the foreskin by medical professionals during a penile examination or by parents while cleaning.
Treatments	Non-surgical treatments are application of a steroid cream to the foreskin with or without manual stretching.Surgical treatments are circumcision and preputioplasty.	Lubrication of foreskin and tip of penis and then gently squeezing the tip of the penis while pulling the foreskin forward.

What are the Causes of Phimosis?

• Poor hygiene
• Forceful retraction of the foreskin over the glans penis. This could lead to microtears at the preputial orifice and scarring
• Balanoposthitis - inflammation of the foreskin along with glans penis
• Balanitis xerotica obliterans (BXO) or Lichen sclerosus et atrophicus - a skin condition affecting the male genitalia. A whitish ring of indurated tissue is formed near the tip of the prepuce preventing retraction
• Repeated cathertization
• Loss of skin elasticity and infrequent erections in elderly males.
• Untreated diabetics leads to residual glucose in the urine causing foreskin infection leading to phimosis
• Balanitis- inflammation of the glans penis

What are the Symptoms of Phimosis?

• Preputial pain.
• Inability to fully retract the foreskin over the glans
• Skin irritation
• Local infections
• Scarring of the foreskin and bleeding
• Ballooning of the foreskin during urination - a bulge can be seen in the tip of penis as urine accumulates under the foreskin.
• Pain during urination and weak urinary stream: sometimes urinary retention
• Presence of blood in urine
• Frequent episodes of urinary tract infections
• Meatal opening is small
• Tissue in front of the foreskin is white and fibrotic
• If Phimosis occurs due to BXO then it is severe with meatal stenosis and / or glanular lesions
• Pus from penis in case of balanoposthitis
• Painful erections
• Pain during sexual intercourse

What are the Grades of Severity of Phimosis?

Severity of phimosis has 6 grades according to Kikiros et al in the Pediatric Surgery

International. They are:

• Grade 0 - Full retractability
• Grade 1 - Full retraction but tight behind glans
• Grade 2 - Partial exposure of glans
• Grade 3 - Partial retraction with meatus just visible
• Grade 4 - Slight retraction but neither meatus nor glans visible
• Grade 5 - Absolutely no retraction

What are the Complications and Risk Factors of Phimosis?

Complications are:

• Infected foreskin that can lead to infection of glans.
• Paraphimosis - When the foreskin gets hidden behind the glans due to forceful retraction and cannot be brought back to cover the glans
• Urine Retention
• Penile carcinoma
• Type 2 Diabetes - Phimosis with preputial fissures is predictive of type 2 diabetes in patients not previously diagnosed with diabetes (Study conducted in Taiwan and published in Acta Dermato - Venerologica in 2016)
• Meatal stenosis or narrowing of penile opening

Risk Factors are:

• Forceful retraction of the foreskin
• Frequent foreskin infections
• Frequent urinary tract infections

How can we Diagnose Phimosis?

A physical examination of the penis and foreskin should suffice to diagnose a tight foreskin. Sometimes non retractibility could be due to a short penile frenulum (an elastic band of tissue that is connected to the foreskin and helps it to contract over the glans).

Doctors might question whether the penis has had any injuries or infections in the past or if the tight foreskin has affected sexual activity.

Other tests might be suggested in specific conditions. Examples are urine test and general blood test to exclude infection and to test for the presence of glucose (sugar). A swab from the foreskin area to check bacterial culture might also be taken.