Tight foreskin (phimosis)

Phimosis means the foreskin will not slide back over the head of the penis, or slides back only with difficulty. In small boys this is almost always a feature of age that settles on its own and needs no intervention. In teenagers and adults, tightening usually means the skin is inflamed or scarred — and that is worth looking into rather than waiting for it to sort itself out.

Why it is usually normal in boys

In a newborn the inner layer of the foreskin is fused to the glans; that is how natural protection works. These attachments separate gradually, with no help from adults. In some boys the foreskin moves freely by three or four, in others only around school age, in a few later still — all of these fall within the normal range.

Parents are often alarmed when the skin at the tip of the penis balloons slightly during a wee. On its own this is not a disease: the urine comes out, the flow is normal and the child feels no pain. Concern is warranted if the flow becomes thin or interrupted, or if the child strains, cries or puts off going to the toilet.

Smegma builds up under a foreskin that has not yet separated — whitish lumps showing through the skin. They are often mistaken for spots of pus. They are shed cells, they work their way out by themselves, and there is no need to open, squeeze or scrape them.

Signs that the tightness has stopped being harmless

A foreskin that does not retract needs no treatment in itself. What deserves attention are the symptoms that come with it:

• swelling, redness and tenderness of the foreskin or glans;
• pain on passing urine, a thin or spraying stream, having to strain;
• blood in the urine or blood spots on underwear;
• thick discharge from under the foreskin and a strong smell;
• repeated inflammation of the glans, several times a year;
• a firm whitish ring at the edge of the foreskin that will not stretch;
• pain with erections, tears and small splits in the skin during sex;
• in a child, frequent urinary infections with fever and no obvious cause.

Any of these is a reason to see a doctor within the next few days. There is one exception, and it has a section of its own below.

Age-related tightness and scarred tightness: the difference that decides treatment

These are two different situations and they should not be mixed up, because the approach to each is the opposite.

Physiological tightness, the kind that goes with age. The skin is soft and elastic, the rim gathers into folds and gives when you try to draw it back, and there is no inflammation. This foreskin will open on its own. Time and simple washing are what work here; forced stretching only does harm.

Scarred, pathological tightness. The rim is thickened and whitened, does not give at all, and the skin splits when you try to draw it back. This foreskin will not open by itself: scar tissue does not dissolve. Here a doctor and treatment are needed.

In adults, scarring most often follows: lichen sclerosus, a long-term skin condition that turns the tissue white and stiff; repeated inflammation of the glans and foreskin; poorly controlled diabetes, against which inflammation keeps coming back; and injury, including injury from forcing the foreskin back in childhood or during sex.

What it gets confused with

Not everything that stops the glans being uncovered is phimosis.

• A short frenulum. The foreskin moves freely, but with an erection a band on the underside tightens, the glans is pulled downwards, it hurts, and sometimes the frenulum tears and bleeds. This is a separate problem with its own small operation.
• Balanitis and balanoposthitis. Inflammation of the glans and foreskin: redness, swelling, discharge, itching. While the swelling lasts the foreskin will not move, but movement returns once the inflammation is treated. That kind of phimosis is temporary.
• Adhesions after inflammation. The foreskin has healed onto the glans in places through bands of scar tissue; a doctor separates them, and stretching achieves nothing.
• A tumour. Rare, but the most important cause to rule out. Be suspicious if an adult man has only recently lost the ability to retract a foreskin that used to move freely, especially if there is a lump underneath, a sore that will not heal, a plaque or a blood-stained discharge. The doctor should then inspect the whole glans and take a biopsy if needed.

Paraphimosis: when hours matter

If a tight foreskin is pulled back behind the glans and will not return, the ring of skin squeezes the glans like a tourniquet. The glans swells quickly, turns dusky and the pain builds. This is paraphimosis, an emergency: without blood flow the tissue starts to suffer within a few hours.

It happens most often in boys whose foreskin has been pulled back "for hygiene", in men after sex, and in hospital after a urinary catheter is fitted and the foreskin is not returned to its place.

Go to an emergency department at once, or call an ambulance (in Spain, Italy, Portugal, Poland and Ukraine the single number is 112), if:

• the retracted foreskin will not go back over the glans;
• the glans has swollen and looks purple, blue or feels cold;
• the pain is severe and getting worse;
• urine has stopped coming out.

The sooner a doctor reduces it, the more likely this can be done without surgery. On the way, a cold pack wrapped in cloth and keeping the penis raised will take some of the swelling down.

Care that helps and habits that harm

Helps: washing the penis daily with warm water and no fragrance; in adults, drawing the foreskin back as far as it goes without pain, rinsing and always returning it to its place; drying the skin thoroughly; checking blood glucose if inflammation keeps returning.

Harms: pulling back the foreskin of a baby or small boy, which causes splits and, over them, the scars that later make surgery necessary; forcing it through pain at any age; washing with perfumed soap or shower gel and dabbing on alcohol; using talcum powder and deodorants in the area; leaving the foreskin retracted for any length of time.

What a doctor can offer

The diagnosis is made by examination: the doctor looks at how the rim of the foreskin behaves and whether there is a scarred ring, inflammation or adhesions. A swab may be added if there is discharge, a blood glucose test if inflammation keeps recurring, and a biopsy if the skin looks suspicious.

Treatment is chosen according to the type of tightness:

• Steroid creams. A topical corticosteroid as a course, usually combined with gentle stretching; for most boys and some adults this is enough. The regimen and its length are set by the doctor: a medicine of this group is not applied indefinitely.
• Treating the inflammation. Antifungal or antibacterial preparations if an infection is behind it; once the inflammation settles, movement often returns on its own.
• Preputioplasty. A minor operation in which the tight ring is cut and stitched so that the foreskin slides freely. The foreskin itself is kept.
• Circumcision. Complete removal of the foreskin. It is chosen for a hard scar, lichen sclerosus, frequent inflammation and repeated paraphimosis.

In a child, a decision to operate is not taken at the first appointment unless there is difficulty passing urine or repeated infections: in most boys the question resolves itself with age.

Online consultation

In an online consultation the doctor works out whether this is a feature of age or a scarred narrowing, explains what discharge and redness mean, advises how to care for the area without causing damage, and says whether a urologist needs to examine it in person. It helps to note beforehand from what age the foreskin has not retracted, whether there has been inflammation and how often, whether it hurts to pass urine or with erections, and whether the picture has changed recently. Photographs are not needed for this consultation.

If the glans is swollen and the retracted foreskin will not go back, an online consultation is not the right route: face-to-face care is needed straight away.

This material is for information only and does not replace medical advice.