Understanding ‘phimosis’: truth, lies and appropriate responses

In the 21^st Century, thankfully, most male babies leave Australasian hospitals with their genitals intact (uncircumcised). They are, however, still not assured of reaching adulthood (the age of consent) without being subjected to genital cutting practices. The most common ‘reason’ cited for the circumcision of post-infant boys is a diagnosis of ‘phimosis’. The predominant (traditional) view has been that having a foreskin which cannot be retracted is a medical condition which requires treatment, however modern, rational perspectives suggest that a tight foreskin is simply a natural variation of the norm, which hardly ever requires surgical intervention and, in the cases where such intervention may be required, any decision can (and should) almost always be left for the individual to make once they have reached the age of consent.

In recent times, accurate information about normal penile anatomy has become more readily available. The majority of new parents now learn that the foreskin is ‘fused’ to the glans (head) of the penis and that it remains this way for a number of years, sometimes until well after the onset of puberty. This makes a diagnosis of phimosis extremely problematic, especially in younger children. Despite this, (whether as a consequence of ignorance, or simply due to ‘taking the easy way out’), there are still some doctors in Australia and New Zealand who employ ‘radical prepucectomy’ (circumcision) as a front-line ‘treatment’ for a tight foreskin. In fact, in 2003, an Australian study provided clear evidence that nearly all of the circumcisions being performed upon minors as a consequence of a diagnosis of phimosis were unnecessary. It would appear then, that better education of physicians, and perhaps parents, with regard to foreskin development and management is still required.

In recent years, misconceptions about penile anatomy and health have been rightly refuted. Most health care professionals (and parents) now understand that no attempt to retract the foreskin should be made during a child’s formative years, especially given the well-documented protective functions that it serves. It is now broadly recognised that forcibly retracting the foreskin causes damage to the structure, including tearing, which can lead to a narrowing of the preputial sphincter and therefore ‘phimosis’.

Difficulty in urination is the most commonly cited indicator of phimosis in infants and young children. Inflammation or infections of the penis/foreskin have also been cited as indicators of phimosis, however these symptoms are rare, usually minor and generally resolve themselves without the need for surgical intervention. In either of these instances, caution and a conservative approach should be paramount. New parents are understandably worried if they notice that their young son ‘sprays’ urine, or has ‘ballooning’ of the foreskin when he urinates. In the absence of any sign of severe or lingering infection, those concerns are generally unfounded. The situation will almost always resolve itself as the child grows and therefore, the most appropriate front-line treatment is no treatment at all.

In cases where persistent symptoms of inflammation or infection are noticed, they are most commonly caused by external exposure to chemicals, including soaps and detergents (such as those contained in ‘bubble bath’ formulas) and highly chlorinated water. Halting exposure to these compounds is therefore the most appropriate front-line treatment in such situations. Regular changing of nappies is also important in order to prevent infections caused by exposure to fecal matter, as is good hydration, since dehydration can lead to the release of overly concentrated (acidic) urine.

There is some controversy over the role of anti-biotics and ‘pro-biotics’ in the resolution of infections resulting from a tight foreskin. Some experts use topical anti-biotic ointments in these situations, whilst others avoid them and believe that the infection can be treated by the ingestion of natural yoghurt, in order to correct the balance of microbial flora in the area.

Once a child reaches the point of ‘genital awareness’ (usually in the years just before the onset of puberty), they are in a position to have input into decisions that are made about their own sexual health. It is important to note that many boys reach adulthood and beyond without perceiving or experiencing any problems associated with having a foreskin that does not retract, however some teenagers do discover that they encounter difficulty with masturbation or pain/discomfort during sexual intercourse as a consequence of having a tight foreskin. Obviously, many teens in such a situation will feel embarrassed about discussing it with their parents or a doctor and will look to the internet for information. Sadly, in the past, accurate and helpful information on this issue has been difficult to find. Part of the aim of the publication of this article is to provide such a resource.

The simplest and most non-invasive method of resolving a tight foreskin in older children (and adults) is ‘manual stretching’. There are several methods of manual stretching that have been shown to be highly effective. One of the most popular methods requires no ‘devices’ or ‘equipment’ and is therefore completely cost free. All that is required is for the individual to adopt a daily routine in which the foreskin is pulled back as far as it can be without causing pain. Great care must be taken in the early stages of this process, to ensure that the foreskin is not retracted behind the glans prematurely, because doing so can result in so-called ‘paraphimosis’, a condition in which the foreskin becomes trapped and cuts off blood supply to the end of the penis. Patience is paramount. This process is most effective when repeated several times a day and often achieves good results within just a few weeks.

Some individuals have become creative and developed their own home made ‘equipment’, such as soft plastic rings or tubes, with which they gently stretch the foreskin. In many ways these manual stretching methods resemble the stretching of earlobes undertaken by many young people these days, in which increasingly larger ring-like jewellery is used to increase the size of the hole created by the initial piercing.

In the rare cases where specific forms of Balanitis have been positively diagnosed, the topical application of a steroidal ointment such as Betamethasone can provide good results. These ointments replicate the release of hormones that occurs during puberty which usually cause a natural dilation of the foreskin.

Profit-driven corporations are very good at identifying public demand for ‘goods and services’ and it is therefore hardly surprising that websites promoting products such as ‘Glansie’ and ‘Novoglan’ have recently started to appear on the internet. These products may well be effective in resolving concerns created by having a tight foreskin, however they may not necessarily be any more effective than the options referred to above and certainly incur a greater cost.

If the methods explored above do not have the desired impact, there is at least one surgical alternative to circumcision that can be considered. ‘Preputioplasty’ is a procedure that involves one or more incisions being made in the preputial sphincter, which are then sutured (stitched) to close the wound. Although preputioplasty is surgically invasive, it is certainly preferable to circumcision, since no bodily tissue is removed. A recently published study confirmed that preputioplasty provides a good outcome for the majority of boys who undergo the procedure.

Given all of the available evidence, surgical intervention in the form of circumcision, is almost never required to ‘resolve’ the issue of a tight foreskin in males of any age and, as such, it should be regard as a solution of last resort. Furthermore, the available evidence suggests that, in the overwhelming majority of cases, males should be allowed to reach the age of consent without being subjected to surgical intervention. Whatever course of action they decide to take once they reach the age of consent is a matter for them and them alone.