Phimosis is a word that means ‘non-retractile foreskin due to a narrow end’. The term does not differentiate between normal and abnormal.
Physiologic phimosis implies that the foreskin will become retractable over time. The ‘normal’ appearance is differentiated by the appearance of pouting of the end of the foreskin when the skin is gentle rolled down the penis. In a small proportion of boys with a longer narrow part of the foreskin, but without scar, the narrow portion does not stretch over time.
Pathologic phimosis is scar tissue at the distal foreskin that prevents retraction. The end of the foreskin looks like a dome from the side view; it does not open like a rose bud blooming! Severe inflammation can be present, known as BXO; infection is called balanitis and noted by redness and soreness of the skin. Pathological phimosis may result from lack of adequate hygiene or ‘forceful’ attempts at retraction.
It should be noted that:
The foreskin may be unable to retract because of attachment of the foreskin to the head of the penis – known as adhesions. Most boys have some adhesion until puberty. These are usually normal and do not require treatment.
Ballooning while voiding may be an additional sign of a narrow foreskin, but alone, if minimal then deflates at the end of voiding, is not significant.
Waiting until puberty to discover a foreskin problem is not appropriate; gentle unrolling of the skin should be performed from birth.
Treatment options for Phimosis
- Betamethasone OINTMENT twice daily for 2 to 4 weeks – applied to the narrow point after gentle retraction. Longer courses may be needed. Hydrocortisone is less effective.
- The medical treatment MUST be supplemented with the retractable prepuce being unrolled at the time of bathing, and nappy changes or voiding, depending on age.
- Circumcision is needed when BXO exists, or if medical treatment fails. Some boys are able have the foreskin preserved and the narrow part refashioned (only in selected cases).
Dr Paddy Dewan
PhD MD MS MMedSc FRCS FRACS