In uncircumcised males, the foreskin protects the head of the penis or glans penis, medically. An adult male’s foreskin is typically stretchable and retracts over the glans during erections. However, during fetal development, the foreskin attaches to the glans and does not become retractable until well into the child’s life. Some males develop a condition called phimosis that renders the foreskin unable to retract over the glans at all. Phimosis can occur naturally, or it can result from trauma to the penis. It may be asymptomatic, or the condition may lead to complications.

Development of Phimosis

Infants and toddlers typically have tight foreskins that do not retract because the inner layer of the foreskin seals to the glans penis before birth. Phimosis in infants and toddlers is not a sign of a larger issue. Typically, by the age of three, the foreskin begins to loosen, becoming fully retractable by the age of seven in 90 percent of cases, and by 16 in 99 percent of cases. Medical experts advise parents not to attempt to retract the foreskin in young males, as it can result in scarring or other trauma.

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Phimosis Severity

There are two levels of phimosis: relative and full. Men with relative phimosis can retract their foreskin partially, while full phimosis prevents any retraction, even while the penis is in a flaccid state. Some physicians use a scale to determine how severe a patient’s phimosis is. A score of one on the scale shows that the foreskin can fully retract and is tight behind the glans. Two means the foreskin can retract and slightly expose the glans. A score of three refers to a slight ability to retract the foreskin. Four means the foreskin cannot retract enough to expose the glans but is still slightly mobile. Five is the highest score and refers to a foreskin that is completely stationary.

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Signs and Symptoms

Many people with phimosis exhibit no symptoms beyond the primary sign of being unable to retract the foreskin over the glans. There may also be some level of pain during erections, depending on the age of the affected individual. Some males experience foreskin swelling during urination. If phimosis results from an underlying medical condition or infection, other symptoms relating to that condition may also exist. Typically, these conditions cause redness, swelling, or soreness.

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Mechanical Causes

Physicians usually describe three mechanical conditions for phimosis. The first is the fusing of the interior area of the foreskin with the glans penis. This fusion is normal in young children and infants but is unusual in adults. The second condition is that the tip of the foreskin is too narrow to properly retract over the glans. This condition is normal in children and will typically resolve itself as the child develops. The third condition occurs when the frenulum is too short to allow the foreskin to retract. The frenulum is a thin, elastic band of tissue under the penis that connects the foreskin to the glans.

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Pathological Issues

Certain infections and diseases can cause men to develop phimosis. Balanitis is inflammation of the glans penis. If the inflammation also affects the foreskin, physicians refer to it as balanoposthitis instead. Both conditions feature redness, inflammation, and phimosis. Diseases such as lichen sclerosus may also lead to an inability to retract the foreskin. Many possible causes for infections and disease affect the glans and foreskin. Some people develop them as side effects of a sexually transmitted disease, while others fail to properly clean their foreskin, leading to infection. This includes inadequate cleaning as well as excessive cleaning.

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Trauma and Scarring

A variety of physical trauma that affects the penis, foreskin, or glans can cause phimosis. Some parents attempt to retract their child’s foreskin during infancy to clean after urination. However, this can cause serious scarring leading to phimosis as the child grows. Individuals who experience frequent catheterization may develop scarring and inflammation as well. Some skin conditions lead to dry skin that prevents the foreskin from fully retracting.

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Nonsurgical Treatments

Doctors can take non-surgical steps to prevent further issues or trauma for older children and adults with asymptomatic phimosis. Physicians find that topical steroid creams are effective at treating phimosis and are viable alternatives to circumcision. They believe the steroids reduce the body’s inflammatory response, allowing the foreskin to retract more easily. Other treatment options include manual stretching exercises using lubricants or specialized tools such as balloons.

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Surgical Treatments

Surgeons opt for the surgical treatment that will cause the least amount of trauma while providing relief. Some procedures aim to relieve foreskin tightness while others involve complete removal of the foreskin. Superincision or a dorsal slit involves a single incision from the tip of the foreskin to the rounded edge of the glans, the corona. Subincision or ventral slit is an incision from the tip of the foreskin to the underside of the glans, removing the frenulum in the process. A circumcision involves complete removal of the foreskin. Preputioplasty is a modern alternative to circumcision that provides the same relief while avoiding the cosmetic effects and healing more quickly.

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Phimosis vs. Paraphimosis

A condition similar to phimosis affects many men. Paraphimosis leads to a foreskin that retracts and cannot return to its original position. This can damage the penis and limit blood flow to the glans. Paraphimosis typically occurs as a result of premature and forceful retraction of the foreskin. Lubricants may help the foreskin return to its position, though surgery may be necessary in extreme cases. People with this condition should see a doctor before attempting at-home treatments.

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The outlook for a man with phimosis is variable, though it is likely very good. Some experience no symptoms, but there is a high risk of infection and other complications without treatment. For some men, daily retraction and stretching exercises are enough to treat phimosis and allow for normal function. The surgeries to treat phimosis are effective and usually permanent, especially in the case of circumcisions. As long as the child or man seeks medical observation when symptoms appear, they will likely lead a normal life.

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