Phimosis is a condition of the male foreskin where the skin is tight and unable to retract back behind the head of the penis. This condition is completely normal and physiologic in most baby boys whose penis is otherwise without abnormalities.
The foreskin should not be forcefully retracted or stretched during infancy and early childhood. Under normal circumstances, the foreskin will stretch on its own and retract normally for hygiene over the first three to five years of life.
Cleaning the outside of the foreskin with soap and water and with diaper wipes during this time period is all that is needed for hygiene.
There is a higher risk of urinary infection during the first year of life in uncircumcised boys as compared to those who are circumcised, but the overall risk is relatively low. If a child develops symptoms from phimosis or the foreskin cannot be retracted comfortably for routine hygiene by elementary school age, then medical or surgical treatment may become necessary.
Other issues such as skin infection or sexually-transmitted diseases in adulthood may be more common in uncircumcised individuals. This is usually due to lack of attention to genital hygiene and not necessarily due to the presence of an intact foreskin.
In approximately 70 to 80 percent of individuals, a course of prescription topical steroid cream applied to the tight foreskin along with gradual manual retraction of the foreskin over the course of weeks to a few months can be very effective for medical treatment of phimosis.
Surgical circumcision is another option for the treatment of phimosis. The circumcision removes the foreskin permanently. The surgery requires local anesthesia in infants and general anesthesia in toddlers and older children. Surgical risks of a circumcision are discussed below.
A newborn circumcision (or clamp-type circumcision) to remove the foreskin is a surgical procedure that can be performed using local anesthesia in the birth hospital or in a physician’s office. After the baby is over a certain age and weight, circumcision can only be done as an outpatient surgery in the operating room using general anesthesia.
In most cases, the choice to perform a circumcision earlier in life is based on social, cultural, religious or cultural reasons and is not specifically a medically necessary procedure in young children. Parental choice or preference is the main driving factor in circumcision in these children who are not having any symptoms and in some areas of the country may not be covered by medical insurance unless truly a medical problem.
The potential risks at any age include: bleeding, infection, inadvertent injury to the surrounding structures, insufficient removal of skin, adherence of the remaining skin to the head of the penis, entrapment of the head of the penis if the skin scars over the top or cosmetic concerns about the appearance after healing.
Parents should carefully weigh these risks against potential benefits for their child, especially for those who have chronic medical issues or known bleeding disorders and whose risks of complications may be higher than the general population. Discussion with the child’s primary care provider about this issue is always warranted and encouraged.
Once an uncircumcised boy becomes old enough to toilet-train, he should be taught how to clean the foreskin and penis himself and should be able to pull the foreskin back without discomfort for hygiene and urination.
Boys who have been toilet-trained and cannot retract the foreskin themselves without discomfort may have some element of phimosis. Phimosis is not an urgent condition unless there is associated pain, infection, ballooning of the foreskin when urinating or painful urination. Treatment may be required if discomfort persists.
Whenever the foreskin is retracted for cleaning or urination, it should be reduced back into its normal position afterwards so that the skin does not become swollen or stuck behind the head of the penis. Foreskin that becomes swollen or stuck behind the head of the penis is a condition called paraphimosis. Paraphimosis is an emergency if the foreskin cannot be reduced into the normal position. Children with paraphimosis should be brought in for immediate medical attention and treatment, as the condition can be quite painful.