What is phimosis?

Phimosis is the inability to reduce the foreskin with full exposure of the glans. It can be divided into two types: primary or physiological phimosis and secondary or pathological phimosis. The phenomenon of phimosis should not be confused with the presence of “excess skin”. In other words, a foreskin that can be retracted exposing the entire glans of the penis, regardless of the amount of skin, does not represent a phenomenon of phimosis.

Sometimes, it is not possible to retract the skin that covers the glans of the penis (preputial retraction) due to limitations of the penile frenulum / prepuce frenulum, as it is too short. See top photos.

Degrees of phimosis

Male phimosis can be divided into different degrees depending on the amount of glans exposed, namely:

  • Grade 1: Complete retraction without narrowing behind the glans. Balanopreputial adhesions may exist;
  • Grade 2: complete retraction with narrowing behind the glans;
  • Grade 3: only partial exposure of the glans;
  • Grade 4: very reduced foreskin retraction, not being possible to expose the glans;
  • Grade 5: most severe form of phimosis; no preputial retraction is possible.

Phimosis – causes

Infantile phimosis or phimosis that appears early in the baby (primary or physiological phimosis) is a congenital pathology that tends to resolve spontaneously over the years, with the progressive development of the child. About 99% of male babies are born with physiological phimosis and only 1% of adolescents aged 17 years still have phimosis.

In the case of later developed phimosis, pathological phimosis, the main causes are related to episodes of trauma or infections. For example, in an attempt to manually retract a physiological phimosis, lacerations may appear on the foreskin if this is done violently. These scars can lead to pathological phimosis in the future.

Chronic infections of the glans and foreskin, or specific infections such as Balanitis xerotica obliterans or lichen sclerosus, can lead to pathological phimosis in the long term.

Phimosis – symptoms

Among the most frequent signs is the inability to fully expose the glans, with subsequent limitation of the quality of personal hygiene. Some children may experience urination difficulties or a so-called voiding balloon (urine balloon formed at the tip of the penis when the child starts to urinate).

The most typical symptoms are the presence of pain when retracting the penis or pain with erection. In the future, sexual intercourse may be affected by the presence of pain or problems related to the complete exposure of the glans. However, there is no direct relationship between phimosis, erectile dysfunction (inability to have an erection) and male fertility (bearing children).

The risk of developing urinary tract infections and infections of the glans also increases and these situations should be monitored. The child should be encouraged to tell the parents if it hurts when urinating or with an erection.

Phimosis – diagnosis

The diagnosis of phimosis is made by the sexologist through physical examination and clinical history. Rarely, other tests are necessary, unless there is a suspicion of an infection or associated injury to the penis.

In children, the first specialty to make the diagnosis is usually Pediatrics, which, depending on the clinical severity, will guide them to Urology / Pediatric Urology for surgical treatment.

Complications of phimosis

Incomplete foreskin retraction can predispose men to some diseases such as:

  • Paraphimosis – the presence of a tight preputial ring can give rise to the formation of a paraphimosis. This situation occurs when the tightening area is retracted behind the glans and, due to inflammatory phenomena, it starts to become very inflamed and edematous, not allowing the foreskin to be replaced in its anatomical position, above the glans.
  • Urinary tract infections (UTI): The presence of phimosis modifies and intensifies balanopreputial bacterial colonization. This fact contributes to the increased incidence of inflammation of the glans (balanoposthitis) and UTI, especially in the first five years of life.
  • Sexually transmitted diseases (STDs): the probability of contracting a sexually transmitted disease, including HIV, is higher in uncircumcised men, given some specificities of the skin of the foreskin.
  • HPV and cervical cancer: According to some authors, circumcision reduces the risk of HPV infection in women (sexual partners) and, consequently, reduces the probability of developing cervical cancer in the sexual partners of circumcised women.
  • Penile Carcinoma: Phimosis is a significant risk factor for penile cancer, probably in connection with poor penile hygiene in these cases.

Is phimosis curable?

Physiological phimosis can be cured without resorting to surgery. Most cases of physiological phimosis will resolve spontaneously with male sexual development. In some children, particularly when in the presence of a preputial voiding balloon, it may be suggested to the Mother/Father to apply a corticoid ointment on the child’s penis daily, while gently performing preputial gymnastics, that is, gentle and careful retraction of the child’s foreskin, easier during bathing or performed by the child, without causing significant pain. Surgical treatment is indicated when certain criteria are met.such as the presence of urinary infections or balanoposthitis, deficiency in urination and this does not resolve with preputial gymnastics. See more information on treatment.

Pathological phimosis rarely resolves with medical therapy and requires corrective surgery in most cases.

In some countries it is common to perform circumcision in the context of social, family or religious beliefs.

Phimosis – treatment

The main treatment in primary (congenital) phimosis is vigilance and waiting for the natural evolution of the clinical situation with spontaneous resolution. In some cases, if indicated by your doctor, preputial gymnastics (doing an exercise that allows you to carefully retract the foreskin (“pull the skin back”), while bathing with warm water and applying a topical corticosteroid ointment (eg betamethasone) for several weeks.

This retraction massage, although it can be performed by the child alone, comfortably at home, must always require help / supervision from the Parents, in order to allow a careful retraction of the foreskin without causing complications, such as lacerations on the penis.

There are currently no oral medications (or remedies) that can resolve phimosis. There is, however, specific medication for cases associated with balnoposthitis (glans infection) that can relieve pain and treat the infection. An abundant intake of liquids, such as water or any type of homemade tea, helps to prevent the emergence of urinary infections.

In cases where it is not possible to solve the problem with the measures described above, surgical treatment (surgery or operation) should be considered. Surgical treatment consists of performing a surgical intervention called circumcision. It is a technique that removes excess foreskin, including the pinch zone, and corrects cases of short frenulum. At the end of the surgery, most children will have, under normal conditions, a glans not covered by the foreskin (partially or completely).

Phimosis – when to operate?

Surgical treatment is indicated in physiological phimosis that do not resolve with preputial gymnastics associated with urinary infections, balanoposthitis or changes in urination such as voiding balloon formation and voiding effort or incomplete emptying.

Pathological phimosis rarely resolves with medical therapy and requires corrective surgery in most cases. In some countries it is common to perform circumcision in the context of social, family or religious beliefs.

Surgical treatment in phimosis

Surgery for phimosis (circumcision) should be performed as soon as possible, only when there are clinical criteria for doing so.

In cases of religious, cultural or personal preferences, the operation should be performed several years after birth, preferably in early adolescence and before sexual activity begins.