What are the treatment options for phimosis?

Parents should never try to force the foreskin back. This can be very painful for their son. It can also lead to small injuries, causing scarring which can make it even harder to pull the foreskin back. This is known as acquired or pathological phimosis.

If the foreskin is tight, there is also a danger that it might get stuck behind the head of the penis (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.

In the first few years of life, the foreskin doesn’t have to be pulled back completely to be able to keep the penis clean. Washing it from the outside is enough. It's not a good idea to try to clean the space between the foreskin and the head of the penis with an object like a cotton swab because that could damage or hurt the sensitive skin there.

If the phimosis doesn't gradually improve and the child is having problems like difficulty peeing as a result, it's a good idea to see a doctor about it. They can check whether the phimosis is natural or acquired, and whether pulling back the foreskin could lead to paraphimosis.

The need for treatment will depend on the child’s age, the extent of the problem and what is causing it. The aim of treatment is to enable the boy to wash his penis properly and urinate without any difficulties or pain. Erections shouldn't be painful either.

There are three treatment options:

• Continue to “wait and see” if the phimosis will go away on its own.
• Use a steroid cream to help stretch the foreskin.
• Have surgery to partially or completely remove the foreskin (circumcision).

A lot of doctors first suggest waiting to see whether the problem gets better on its own. Alternatively, you could start treatment with a steroid cream. If that isn’t effective, surgery is recommended.

In secondary phimosis, the foreskin becomes tight or stuck to the head of the penis over the years as a result of injury, scar tissue or inflammations. This type of phimosis typically requires surgery.

If the foreskin gets stuck behind the head of the penis (paraphimosis), the doctor will first try to return it to its original position using their hands. To make sure this isn’t painful, 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 once a day. This involves only pushing the foreskin back as far as you can without it hurting. It's 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 from the Cochrane Collaboration (an international research network) found out that this treatment is often successful:

• Without treatment: 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: 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.

In other words: Treatment with steroid cream helped the phimosis to go away completely in about 44 out of 100 children. In some of the other children the treatment was at least able to loosen the foreskin somewhat.

No side effects of steroid creams were observed in the studies. 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, or pain or complications occur, surgery may be a good idea.

Surgery for phimosis is usually described as circumcision. A full circumcision involves removing all of the foreskin. It is also possible to remove only the tight part of the foreskin (partial circumcision) or 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.

In partial circumcisions or in procedures that don't remove the foreskin, the remaining foreskin may become tight or stuck to the head of the penis again after some time. This is not the case if all of the foreskin is removed because the head of the penis is then no longer covered by foreskin so phimosis is no longer possible.

The operation is carried out under general anesthetic in children. In adults, it can also be carried out using a local anesthetic to numb the area.

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.

If only part of the foreskin is removed, scar tissue can lead to the recurrence of phimosis. In such cases, a second operation is usually done to remove all of the foreskin. Some people might wish to have another operation for cosmetic reasons – for instance, if the foreskin wasn’t removed evenly.

A number of studies have shown that circumcised men generally don’t seem to be any less satisfied with their sex life than uncircumcised men. But the role that the sensitive foreskin actually plays in sexual experience hasn't been fully explained. Circumcised men might be more likely to have problems during sex if they had the operation as an adult. So before a circumcision is carried out, doctors explain that sex may feel different after the procedure.