Phimosis is defined as the inability to retract the skin (foreskin or prepuce) covering the head (glans) of the penis. Phimosis may appear as a tight ring or rubber band of foreskin around the tip of the penis, preventing full retraction. Phimosis is divided into two forms: physiologic and pathologic.
The current incidence of phimosis is about 1% in 7th-grade boys.
Physiologic phimosis: Children are born with tight foreskin at birth and separation occurs naturally over time. Phimosis is normal for the uncircumcised infant/child and usually resolves around 5-7 years of age, however, the child may be older.
Pathologic phimosis: Phimosis that occurs due to scarring, infection or inflammation. Forceful foreskin retraction can lead to bleeding, scarring, and psychological trauma for the child and parent.
If there is a ballooning of the foreskin during urination, difficulty with urination, or infection, then treatment may be warranted.
Care of Uncircumcised Penis:No special care is required for foreskin in infancy. The foreskin should not be forcibly retracted, however, gentle retraction is okay.
In the first few years of life, gentle retraction with cleansing underneath the foreskin is sufficient during diaper changes or bathing and will result in progressive retraction over time.
Once the child is older and the foreskin retracts fully, he will learn to retract, cleanse and dry underneath the foreskin as part of his hygiene routine. After retraction, the foreskin should be pulled back over the head of the penis and returned to the normal position.
Smegma:
Smegma is a collection of skin cells from the glans penis and inner foreskin that is often noted with retraction of the foreskin. This natural skin shedding helps to separate the foreskin from the head of the penis. Smegma may appear as white pearls underneath the skin, which can easily be washed off once the foreskin is retracted.
How is phimosis diagnosed and evaluated?
In physiologic phimosis, benign (non-life threatening) conditions may occur that are common in uncircumcised males, including; cysts related to smegma production/trapping and transient painless ballooning of the foreskin during urination.
These are considered normal variations that usually resolve with daily gentle manual retraction.
Pathologic phimosis that does not resolve naturally or causes other complications, including; penile irritation or bleeding, ballooning of the foreskin with urination resulting in forceful/difficult urination, urinary retention, painful urination (dysuria), painful erections, recurrent infections of the foreskin (balanoposthitis), paraphimosis (foreskin stuck in the retracted position behind the head of the penis), or urinary tract infections may require further treatment.
Your medical provider will refer your child to a pediatric urologist for further evaluation.
How is phimosis treated?
Treatments for phimosis vary depending on the child and the severity of phimosis.
Treatments may include gentle daily manual retraction, topical corticosteroid ointment application or circumcision.
Topical corticosteroid therapy:
Medical providers may recommend topical steroid ointment application for children with phimosis.
This is an effective treatment in most males. These topical ointments are used to help soften the tight foreskin around the penis, so the foreskin may be easily retracted. Your provider will demonstrate how to apply the ointment to the tight ring of the foreskin and/or head of the penis.
The ointment is massaged into the affected areas twice daily for 6-8 weeks along with manual stretching/retraction twice daily.
Once the foreskin can be fully retracted, the ointment is discontinued and manual daily retraction (during warm baths and urination for the potty trained child) will prevent phimosis from reoccurring.
The most common corticosteroids used are hydrocortisone 2.5%, betamethasone 0.05%, triamcinolone 0.01%, and fluticasone propionate 0.05%.
Circumcision:
Male circumcision refers to the surgical removal of the foreskin.
Circumcision is often not required for the treatment of phimosis. In some rare cases, your pediatric urologist may recommend circumcision due to a failure of steroid ointment, pathologic phimosis, paraphimosis (a foreskin stuck in the retracted position behind the head of the penis), recurrent urinary tract infections, or severe/recurrent balanoposthitis.