Phimosis - tight foreskin: circumcision or alternative treatment

Dr Khan

Phimosis : Tight foreskin

We described the different grades of phimosis, the various appearances of the foreskin, and the treatment options available.

Phimosis is when the foreskin is tight and unable to pull back to see the head of the penis (glans). Sometimes it is retractable when the penis is flaccid.  But never able to retract when the penis is erect. Usually, phimosis does not remain the same as with each erection. There is minor trauma to the foreskin. This leads to loss of elasticity fibres due to scarring. This can lead to Balanitis Xerotica Obliterans (BXO). Phimosis can lead to paraphimosis.

Skin conditions can also cause a Phimosis 

1.   Balanitis Xerotica Obliterans (BXO), also called Lichen sclerosus (Read more about BXO)

2.   Lichen planus - a non-infectious skin condition which may affect the foreskin

3.   Eczema- long-term skin problems

Cleaning inside of the foreskin is essential to prevent infection. It is a good idea to wash the foreskin with mild soap or warm salty water when you take a shower or bath. This will help to keep the foreskin clean.

Grading of Phimosis: Assessing the Severity

Phimosis is categorised into six distinct grades, each indicating the degree of tightness and retraction capability of the foreskin:

  • Grade 0: The foreskin can be pulled back fully without any resistance.
  • Grade 1:The foreskin can retract, but it remains tight behind the head of the penis.
  • Grade 2: The head of the penis is partially exposed, but the inner foreskin is too tight to allow complete retraction.
  • Grade 3: Partial retraction is possible, and the urethral opening becomes slightly visible.
  • Grade 4: Some retraction occurs, but the head of the penis remains covered by the foreskin.
  • Grade 5: No retraction of the foreskin is possible.

Notably, grades 4 and 5 often necessitate surgical intervention for effective resolution.

Appearance of the Foreskin: Understanding Visual Indicators

The appearance of the phimosis provides further insights into the condition:

  • Score 0:The foreskin appears normal.
  • Score 1: Fissures or skin splitting at the tip of the foreskin may be present.
  • Score 2: A white scar partially surrounds the foreskin.
  • Score 3: Severe scarring due to conditions like Lichen Sclerosis or Balanitis xerotica obliterans, which may lead to occasional bleeding.

Scores 2 and 3 could indicate the presence of BXO phimosis, a more severe form of the phimosis .

Treatment Options for Phimosis: Tailoring Solutions

Treatment for phimosis depends on factors such as age and the severity of the condition. Here are some available options:

1. Steroid Cream or Ointment: Application of steroid-based creams or ointments can help alleviate tightness and promote gradual retraction of the foreskin.

2. Stretching Exercises: In the early stages, gentle stretching exercises may aid in loosening the foreskin.

It's important to note that attempting to stretch a scarred foreskin could result in further tearing and scarring. Additionally, various phimosis creams might be utilised with limited success in certain cases.

When Surgical Intervention May Be Necessary

For grades 4 and 5 phimosis, as well as cases involving complications like BXO, surgical solution become crucial. Some options include:

- Circumcision:This standard procedure involves removing the foreskin entirely. It's particularly recommended for adults with recurrent fungal infections, diabetes-related issues, or severe BXO phimosis.

- Alternative Surgical Procedures: Options like preputioplasty, frenuloplasty, and partial circumcision offer alternatives to full circumcision. These procedures can be discussed with urologists at specialized clinics.

Seeking Professional Advice

It's important to remember that this information serves as a guide and not a substitute for professional medical advice. If you're experiencing symptoms of phimosis or related issues, consider consulting a medical specialist. Video consultations are available for personalized guidance.

Phimosis - conclusion 

Understanding the grading, appearance, and treatment options for phimosis is essential for managing this condition effectively. Whether through non-surgical approaches or surgical interventions, seeking timely medical advice and tailored solutions can lead to improved comfort and overall well-being.