Male circumcision is hardly ever discussed, leading to a lack of information available regarding conditions regarding the foreskin. This leads to many conditions going undiagnosed, which can further complicate one’s health. Among one of these conditions, is phimosis, a term used for tight foreskin. Phimosis is a condition where you are not able to pull the foreskin back to see the tip of the penis. In some cases, the skin may fold back when the penis is relaxed, but is unable to withdraw when the penis is erect. When the foreskin is tight, there is minor trauma to the foreskin during each erection and sexual activity. This generates to loss of elastic fibres due to scarring. In adults, sexually transmitted infections or other infections such as balanitis can be associated with phimosis.

 

Facts 

Physiological phimosis in children usually improves as the child gets older. The foreskin attachment between glans and foreskin break down and form a white-coloured material called smegma pearls, which then come out. The majority of boys have a fully retractile foreskin by the age of 10 -12 years. Pathological phimosis, however, is a medical condition where the foreskin is diseased or scarred. It is important to distinguish between natural tight foreskin called physiological phimosis or pathological phimosis as treatment choices differ.  

The foreskin can be stuck behind the head of the penis due to the presence of a ring. Named paraphimosis,  this is caused by a tight ring at the inner foreskin and requires emergency treatment. This can be treated by pulling the foreskin forward or by a preputioplasty, to be able to preserve the foreskin.   

 

Causes

  1. Skin conditions like BXO (Balanitis xerotica obliterans), Lichen planus, or Eczema
  2. Infections: Studies showed that sexually transmitted infections like syphilis, chancroid, and genital herpes (HSV-2) are lower in circumcised men.
  3. Scarring: BXO can be severe scarring which leads to phimosis
  4. Potential cancer: A link between increased incidence of un-circumcised men and penile cancer has been known for a very long time. Additionally, penile cancer is strongly linked with a history of phimosis

 

Nonsurgical treatment 

Treatment for phimosis depends on the age as well as the degree of phimosis. It can be treated with:

  1.     Steroids cream or ointment  
  2.     Stretching exercises in early stages
  3.     Anti-fungal or antibiotics 

However, the stretching of a scarred foreskin may produce further tearing and scarring, so there is no hard scientific evidence that it produces adequate treatment for diseased tight foreskin. Different kinds of phimosis creams are used in some cases with limited success in recent medical reports. If phimosis symptoms become worse with time, it is crucial to check for traces of BXO. Adults can use a condom and lubricants during sexual activities in the presence of mild phimosis.

If there is a fungal infection which is causing mild tight foreskin, it can be treated with a combination antifungal medications and steroid cream. In adults with high blood glucose levels (diabetes mellitus) with phimosis, circumcision is the suggested treatment due to recurrent fungal infection or possible BXO. 

 

Surgical treatments

  • Frenuloplasty: This is simply a frenulum releasing operation. An incision is made on frenulum or excised the ridge underneath the surface, thus allowing the frenulum to be detached from the head of the penis. This will let you keep your foreskin free from the connection to the head of the penis and also be able to keep the area beneath clean.
  • Preputioplasty: This is the procedure which increases the diameter of the foreskin. An incision is made in front of the foreskin to expand it, thus allowing full retraction.
  • Partial circumcision: Partial circumcision leaves part of the foreskin which partially or fully covers the head of the penis (glans).  it has a few complications in the long term.
  • Full circumcision: Circumcision remains the standard surgical option for tight foreskin, especially BXO phimosis, traumatic injury or penile cancer. 

If sexual activity with phimosis is painful or uncomfortable, then you may require urgent treatment. Home treatment for tight foreskin is possible if the foreskin is otherwise healthy, by daily cleansing, washing, controlled stretching exercises and clearing the normal dry pearls (smegma). Infection with tight foreskin (balanitis) requires treatment like antibiotics or antifungal modification. It is important to be examined for sexually transmitted infections by a GUM clinic or by your GP.

In summary, there are many alternatives to full circumcision, such as antibiotics, antifungal medications, steroids cream or ointments, excision of the frenulum, V-Y preputioplasty, frenuloplasty, or combination of treatments. These are personal preferences and can be discussed further with a specialist or Urologist. Full circumcision should be considered in selected cases but it must be considered seriously as it is irreversible operation.  

 


 

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