Phimosis in Children and Adults

Phimosis is a condition in which the foreskin of the penis (prepuce) cannot be pulled back over the head of the penis (glans). Phimosis can cause the ballooning of the foreskin when urinating, inflammation of the head and foreskin, and pain with erections.

In uncircumcised younger children, phimosis is a normal condition that often corrects itself by age 13 and usually does not need treatment. For older children and adults who require treatment due to pain, recurrent infections, or problems with urination. Circumcision surgery (removal of the foreskin) and nonsurgical options like steroid creams can help.

This article explains what phimosis is in children, teens, and adults, including the symptoms and causes. It also explains how phimosis is treated with medications, dilation devices, and surgery.

Foreskin Changes in Childhood 

Phimosis is categorized as being either physiologic (related to how the body normally works) or pathologic (related to abnormal conditions or diseases).

In children with foreskins, phimosis is typically physiologic and a part of the normal development of the penis. The formation of the foreskin and penis starts during the seventh week of gestation (the period of development inside the uterus) and is completed by around week 17.

The foreskin serves different purposes during the various stages of sexual development, including:

• Preventing stool from entering the urethra (the tube through which urine exits the body) in babies
• Protecting the head of the penis from abrasion and trauma
• Secreting mucus on the penis head that enables smoother penetration during sexual intercourse

Around 96% of people with a penis have nonretractile foreskin at birth. This is because the foreskin and frenulum (the skin bridging the foreskin and the head of the penis) are tight and thin at birth. The foreskin and glans also stick together like pieces of tape to form adhesions.

These adhesions will only start to loosen as the inner foreskin forms a harder, drier layer called the stratum corneum. Reflex (involuntary) erections will also help loosen the foreskin and enable retraction.

This process can vary from one child to the next. Studies suggest that around 50% of uncircumcised children with a penis will still have phimosis by age 7, decreasing to less than 10% by age 13. Only around 1% will continue to have phimosis by 17.

Complications in Children

In children and teens, phimosis is considered a common pediatric condition that usually resolves on its own without treatment. While ballooning of the foreskin is common during urination, it rarely leads to complications if good hygiene practices are maintained.

With that said, around 12% of uncircumcised children with a penis will experience a condition known as balanitis. This is the inflammation of the head of the penis caused by the accumulation of yeast and bacteria under the foreskin. When the penis and foreskin are both affected, it is known as balanoposthitis.

As common as balanitis is in uncircumcised children, it is twice as common in uncircumcised children with phimosis, increasing to nearly 24%.

Phimosis in Adults

Roughly 1 in 5 people with a penis in the United States is uncircumcised, according to the Centers for Disease Control and Prevention (CDC).

Among uncircumcised people with a penis over age 18, the rate of phimosis hovers around 3.4%. This not only includes those born with phimosis but also those who acquire it later in life due to infection or disease.

As with children and teens, having phimosis as an adult doesn't necessarily mean that it is pathologic or in need of treatment. For many, phimosis is not a serious problem as long as it doesn't interfere with sex, cause pain, or make it difficult to clean under the foreskin.

Even so, the risk of pathologic phimosis is high. According to a 2022 study in the journal Urologiia, roughly 4 out of 5 adults with phimosis will develop complications requiring medical treatment, either surgical or nonsurgical.

Appearance

Phimosis is generally described as looking like a tight ring or "rubber band" of skin around the tip of the penis. In some cases, the ring of skin may be of a different color than the surrounding skin due to the formation of scar tissues.

The inability to retract the penis can lead to the excessive accumulation of sweat, body oils, and skin cells, known as smegma. Under normal circumstances, smegma is harmless and looks like tiny white pearls under the foreskin that you can easily wipe away.

However, if you are unable to clean beneath the foreskin, smegma can build up, harden, and look like crumbling pieces of cheese. The buildup of moisture under the foreskin, in turn, can promote the growth of bacteria and yeast, triggering symptoms of balanitis, including:

• Swelling and redness of the foreskin and glans
• Tiny rashes on the glans and lining of the foreskin
• Raw, red or discolored skin lesions on the glans and inner foreskin
• A foul, sour milklike odor
• Pain and tenderness of the glans and foreskin, especially with sex
  

Sensation, Intimacy, and Erection Ability

For some people with phimosis, the nonretractile foreskin may not interfere with their ability to have sex.

However, for those whose foreskin is especially tight, phimosis can cause significant pain with erections. It also can make having sex painful, even in the absence of any complications. In some people, the pain, combined with the psychological distress of having phimosis, can be extreme enough to cause erectile dysfunction (ED).

A 2021 study in the journal Sexual Medicine reported that pain with sexual intercourse (dyspareunia) was the most common reason for adults with phimosis to seek circumcision. Among the group of 59 people with phimosis, no less than 40% had moderate to severe ED, while 17% had mild to moderate ED.

Though pain was the main factor associated with ED, embarrassment due to the appearance of their penis also contributed. In fact, the embarrassment of having phimosis was a concern among all study participants, even those without ED.

After circumcision, all 59 participants reported satisfaction with how their penises looked. Even those without ED reported improvement in erectile function after the surgery.

Physical Exam for Phimosis 

Phimosis is diagnosed with a physical exam of the penis. This can be done by your general practitioner or your child's pediatrician, but complicated cases may require the care of a specialist of the male reproductive tract, known as a urologist.

As part of the exam, the urologist will grade the severity of phimosis based on how much or how little the foreskin retracts. The grade helps determine the appropriate course of treatment.

The most commonly used system (called the Kikiros scale) categorizes phimosis into the following five grades:

• Grade 0: A fully retractable foreskin (no phimosis)
• Grade 1: A fully retractable foreskin but with narrowing below the head
• Grade 2: A partially retractable foreskin that partially exposes the head
• Grade 3: A partially retractable foreskin that only exposes the opening of the penis where urine exits the body (meatus)
• Grade 4: Not retractable

In addition to grading, the urologist will look for signs of inflammation, scarring, and narrowing of the opening of the meatus. On rare occasions, a skin biopsy (collecting a skin sample to be analyzed in the lab) will be performed if a skin disease is suspected.

The urologist may also ask questions about your medical and family histories, sexual activity, symptoms, and any genital injuries and infections you may have had in the past.

Age also factors into the diagnosis. For children, adolescents, or teens, the healthcare provider will need to decide if the condition is natural or an abnormal condition in need of treatment.

Phimosis Treatments

The treatment of phimosis varies based on a person's age and the severity of their symptoms. Conservative treatment is generally used for grades 0–2, while more intensive treatments are prescribed for grades 3–4.

Treatment options range from watchful waiting and medications to foreskin dilation and surgery.

Nondrug Treatments

Parents of children with phimosis are often reassured that the condition is normal and advised to take a watch-and-wait approach. Over time, most cases resolve themselves on their own.

For babies and toddlers, the main focus is to teach parents how to keep the foreskin clean. Cleaning typically involves washing the penis with a mild soap and water. Washing from the outside is usually enough; there is no need for cotton swabs or special cleansers.

Gentle retraction is OK after bathing, but forceful retraction should be avoided. If your child shows any signs of discomfort or the tissues under the foreskin look red and inflamed, you are being too rough and need to stop.

If the phimosis doesn't improve and your child has trouble urinating, call your pediatrician. They can advise you if gentle, at-home care can resolve the problem or if further treatment is needed.

Medications

When indicated, topical corticosteroids (steroids) are the first-line drug of choice for phimosis. This is especially true with children, whose success rates hover between 65% and 90%.

The steroids are applied to the foreskin twice daily for six to eight weeks, accompanied by gentle retraction. Once retraction is achieved, treatment is stopped.

Some of the more commonly prescribed steroids include:

• Betamethasone 0.05% to 0.1% 
• Hydrocortisone 1%
• Clobetasol propionate 0.05%
• Triamcinolone 0,1%

While topical steroids can be extremely effective, phimosis is more than likely to return. Even so, the treatment can be repeated several times, if needed. Side effects, if any, tend to be mild and include foreskin redness and pain.

Topical steroids are also good for managing phimosis in adults whose condition is caused by autoimmune or inflammatory skin conditions.

Medical Devices

For teens and adults with phimosis, foreskin dilation and stretching may be a reasonable option. Unlike topical steroids, foreskin dilation affords permanent results.

Medical devices called preputial dilation retractors can be used at home. They gently stretch the foreskin over a period of weeks to encourage the release of adhesions.

The kits typically consist of a set of 20 silicone rings of increasing size that you pull over the head of your penis. Once the device is comfortably positioned behind the head, you wear it for 72 hours. After 72 hours, the retractor is removed, and the next-sized retractor is put in its place. This continues, 72 hours at a time, until the treatment is completed at day 60.

Dilation retractors are indicated for teens and adults with grade 2 and possibly grade 3 phimosis. Studies have shown that a dilator model called PhimoStop was extremely effective, averting the need for circumcision in 81% of cases.

While several models are available for sale online, it is best to speak with a urologist first to ensure that the model is appropriate and safe for your specific condition and circumstance.

Surgery 

Circumcision is considered the gold standard for treating phimosis. Among adults in the United States, phimosis is the most common reason for circumcision. It can be used to relieve phimosis symptoms, to avoid complications, or for cosmetic reasons.

While there are several ways to perform circumcision, the best option for adults and older children is a traditional sleeve circumcision. This procedure involves cutting the foreskin around the base of the frenulum and then stitching the cut ends together with dissolvable sutures.

Circumcision is typically performed on an outpatient basis using local or regional anesthesia. It is a relatively simple procedure with a low risk of complications (mainly bleeding or infection).

However, circumcision is not the only surgical option for children or adults with phimosis. For those wanting to retain their foreskin, there is also:

• Preputial adhesiolysis: This procedure used in children under 5 involves cutting and releasing adhesions beneath the foreskin. Performed under general anesthesia, preputial adhesiolysis can relieve ballooning and urine dribbling without submitting the child to unnecessary circumcision.
• Preputioplasty: Also known as a dorsal slit, this procedure is used to widen the foreskin by cutting a slit at the top edge of the foreskin. Preputioplasty is an option for older children and adults who want to avoid circumcision for religious, cultural, or personal reasons.

Why Do Some People Have Phimosis?

Physiologic phimosis is something you are born with. Pathologic phimosis is something you acquire that develops secondary to scarring of the opening of the foreskin.

Among some of the possible causes of pathologic phimosis are:

• Lichen sclerosus: This inflammatory skin condition causes itchy discolored patches on the penis and foreskin that can crack, peel, bleed, and scar over. Though the cause of lichen sclerosus is unknown, chronic dribbling and exposure to urine are thought to contribute.
• Diabetes: Phimosis has long been associated with poor blood sugar control in people with diabetes. Uncontrolled diabetes can cause progressive scarring of the foreskin due to reduced blood circulation, recurrent infections, and chronic balanitis.
• Lichen planus: This noninfectious skin condition thought to be autoimmune can affect different parts of the body, including the genitals in people of all sexes. In people with a penis, lichen planus can cause white, painful sores on the lining of the foreskin, leading to swelling and scarring.
• Eczema: Also known as atopic dermatitis, this chronic inflammatory skin disorder often targets the genitals, including the penis and scrotum. Eczema on the penis mostly occurs on an uncircumcised penis, causing the progressive thickening and hardening of the foreskin.
• Psoriasis: This autoimmune skin condition often targets the genitals, triggering the rapid turnover of skin cells and the formation of itchy, scaly plaques. Along with eczema, psoriasis is one of the most common pathologic causes of phimosis in adults.

Healing From Phimosis Surgery 

Although circumcision is a common and relatively safe procedure, care needs to be taken to ensure proper healing after surgery.

Most people return home on the same day of the procedure. Swelling and bruising can be expected for the next couple of days. The pain is typically mild to moderate and can usually be managed with over-the-counter pain relievers like Tylenol (acetaminophen) or Advil (ibuprofen).

You can also ease pain by applying a cold compress to the groin for 10 to 20 minutes every hour for the first day. Place a cloth between the ice pack and your skin to avoid frostbite.

To aid with healing, change the dressing on your penis as directed by your surgeon. Wear comfortable underwear that holds the penis upright to reduce swelling and pain. You can usually shower once you no longer need a bandage.

Most surgeons will recommend avoiding heavy lifting or other strenuous physical activity for two weeks until the wound has amply healed. You should also avoid masturbation and sex for six weeks or until your urologist tells you otherwise. An occasional erection will likely do you no harm, but avoid touching or manipulating the erection.

Summary

Phimosis is a condition in people with an uncircumcised penis in which the foreskin cannot be retracted over the head of the penis. Physiologic phimosis is a normal condition in children that usually resolves as the child gets older. Pathologic phimosis is when a disease or disorder causes scarring that reduces the retractability of the foreskin.

Phimosis is diagnosed with a physical exam and a review of your medical history. The treatment is based largely on your age and the severity of your condition (graded on a scale of 0 to 4).

For most children, the treatment of phimosis involves watchful waiting, good hygiene, and gentle retraction. Other children and adults may require topical steroids, dilation devices, or surgery. Circumcision is considered the gold standard treatment for phimosis.