What are the treatment options for phimosis?

Parents should never try to force the foreskin back in an attempt to loosen it or to wash the penis. This can be very painful for their son. It can also lead to injury. In the first few years of life, the foreskin doesn’t have to be pulled back completely to keep the penis clean. Washing it from the outside is enough.

The foreskin should also never be forced back after puberty or in adulthood. This can lead to injuries and scarring that make the foreskin even tighter.

There is also a risk that the foreskin might get stuck behind the glans when it is pulled back, forming a ring that restricts the blood supply to the glans. This is known as paraphimosis. It is a medical emergency that should be treated by a doctor immediately.

A naturally tightened foreskin in childhood doesn’t need to be treated, unless

• it is causing problems like pain or is making it difficult to pee (temporary inflation of the foreskin caused by urine that is not flowing out properly isn’t any reason to worry though),
• there is frequent inflammation affecting the foreskin and the glans.

Treatment of phimosis without any symptoms might be considered if the foreskin

• remains too tight into and beyond puberty (congenital phimosis), or
• was loose enough at first, but then became too tight because of scarring (acquired phimosis).

There are two treatment options:

• Use a steroid cream to help stretch the foreskin.
• Have surgery to partially or completely remove the foreskin (circumcision).

A steroid cream is usually tried first. Surgery is then recommended if the cream doesn’t work. But there are exceptions: surgery is typically used right away to treat acquired phimosis.

If the foreskin gets stuck behind the head of the penis (paraphimosis), it needs immediate medical treatment. The doctor will first try to return it to its original position using their hands. A local anesthetic is used to numb the area beforehand. If it isn’t possible to move the foreskin back into position in this way, surgery will be needed in order to restore normal circulation of blood to the "pinched off" head of the penis.

In this conservative (non-surgical) treatment approach, a steroid cream is applied to the tip of the foreskin twice a day over a period of four to eight weeks. The steroid cream makes it easier to stretch the skin.

After two weeks, the child or his parents can start trying to gradually stretch the foreskin. This involves only pushing the foreskin back as far as you can without it hurting. It is important to stretch the skin gently so as not to damage the foreskin. Once the foreskin can be pulled back a bit, the cream can also be applied to the front part of the glans that is exposed. Then the foreskin is returned to its normal position.

Researchers have found out that this treatment is often successful:

• Without treatment: The phimosis went away completely in about 18 out of 100 children who used a cream without medication (a placebo) for 4 to 8 weeks, or didn’t have any treatment at all, were then able to pull their foreskin back properly.
• With treatment: The phimosis went away completely in about 62 out of 100 children who used a steroid cream for the same amount of time were then able to pull their foreskin back properly.

The phimosis did not go away completely in some of the other children, but the treatment was at least able to loosen the foreskin somewhat.

Treatment with a cream is well tolerated. While phimosis is quite likely to come back after some time following treatment with steroid cream, the treatment can be repeated several times. If phimosis still persists, surgery may be a good idea.

Surgery for phimosis is usually described as circumcision. A full circumcision involves removing all of the foreskin. If the tight part of the foreskin is close to the tip, then sometimes only the tightened part of the foreskin is removed (partial circumcision). In both approaches surgeons close the edges of the cut with several stitches. The suture typically loosens within two weeks and then falls off.

It is also possible to keep the foreskin and simply widen it. To do this, surgeons make lengthwise cuts into the tight foreskin in two or three places and then close the cuts by stitching across them.

The operation is carried out using a general anesthetic in children with an additional local anesthetic applied to the penis. In adults, it is typically enough to use a local anesthetic to numb the area.

The area that was operated on will start to hurt once the anesthetic wears off, so painkillers are used for the first few days after the surgery. In older boys and men there may also be pain a few days later as soon as the penis becomes hard – while sleeping, for instance. The doctor will make sure that everything is healing at check-up appointments – usually the day after the surgery and again two weeks later. Until then you should typically stay home from work to rest and not do any sports. A final check-up is done after four to six weeks.

Phimosis is no longer possible after the foreskin is completely removed and the head of the penis is no longer covered. Following partial circumcision the foreskin may tighten as a result of scarring. If that happens a second procedure is done to remove the foreskin completely.

Circumcision is now a routine procedure. About 5 out of 100 boys or men have side effects like bruising on the penis, but this isn't harmful and usually goes away on its own after a while. Only about 2 out of 100 people who have the operation experience more serious complications that need to be treated. Those may include bleeding, inflammation of the surgical wound, curving of the penis or tightening of the urethra (urine tube) opening. Sometimes bothersome skin tags can form where the foreskin was removed.

Experts believe that the sensitive foreskin plays a role in sexual experience. So they recommend conservative treatment, especially in children whose foreskin is still loosening on its own. A number of studies have shown that circumcised men are generally as satisfied with their sex life as uncircumcised men. Before a circumcision is carried out, doctors explain that sex may feel different after the procedure.