Non-retractile Foreskin (Phimosis)

The medical term for not being able to pull the foreskin back is a PHIMOSIS. A phimosis can be normal as it is a normal stage in the development of the foreskin – see description above. It can also be caused by some conditions – such as trauma or Balanitis Xerotica Obliterans (BXO).

How does the foreskin develop?

In the vast majority of boys, when they are born the foreskin and the glans (the tip of the penis) are stuck together. This means that the foreskin cannot normally be retracted (pulled back) at birth. If the glans can be seen at birth

During childhood the glans and the foreskin need to separate. There are a number of things that happen to cause this:

Erections.
Boys ‘playing’ with themselves.
The opening of the foreskin is smaller than the opening of the pee tube (urethra) at the glans. This means that when the boy pees some of the urine cannot get out from the foreskin and is pushed down the sides which gradually separates the foreskin from the glans. This can sometimes be seen as “ballooning”.

Normally during childhood the foreskin can progressively be pulled back more and more.

At the age of 3 only 30% of boys can partially pull the foreskin back
At the age of 6 about 30% of boys cannot pull the foreskin back at all
By the age of 15 more than 95% of boys have a normally retractile foreskin.

How can you tell the difference between a foreskin that is normal and one that is diseased?

The difference between a normal foreskin and one that is non-retractile because of disease can be seen on careful examination.

Before puberty, if the non-retractile foreskin is due to the normal development of the foreskin, then it does not necessarily require treatment.

In the past some doctors gave the advice to try and pull the foreskin back when the boy was having a bath. We now know this is not a good idea because by pulling the foreskin back you can cause a little tear in the tight phimotic ring foreskin (like having a chapped lip), which heals with scarring. When the boy gets older the tight phimotic ring normally stretches. However if there is scarring of the foreskin it is not able to stretch and the foreskin can become non-retractile.

When should a non-retractile foreskin be treated?

A non retractile foreskin that is caused by a disease such as BXO should be treated with a circumcision.

When a child has a normal foreskin there there are some circumstances where surgery may also be recommended for medical reasons. These include:

• Having recurrent episodes of balanitis (infection that occurs behind the foreskin)

• Having recurrent episodes of paraphimosis

• Preventing UTIs (especially if there are other problems with the urinary tract)

If a boy has gone through puberty and the foreskin cannot easily be retracted then it is unlikely that this will get better. Treatment may be appropriate.

What is the treatment of a non-retractile foreskin?

The main treatment of a non-retractile foreskin is an operation called a CIRCUMCISION. This is an operation to remove the foreskin. For more information please see my information leaflet on circumcision.

If a boy has a normal foreskin that in non-retractile then is some circumstances some doctors may give a treatment of a steroid ointment to try to encourage the foreskin to become retractile. In a number of cases where the foreskin becomes retractile, after the steroid ointment is stopped the foreskin can go back to being non-retractile.

For older boys who have gone through puberty and have a non retractile foreskin then an alternative operation (called a PREPUTIOPLASTY) may be an option.

Ballooning

Ballooning of the foreskin is natural, and occurs during the natural development of the foreskin (see information above). It does not require any treatment.

Balanitis Xerotica Obliterans (BXO)

BXO is the commonest condition which causes a non retractile foreskin. It is a condition that causes excessive scarring of the foreskin. The scarring can also affect the glans (tip of the penis) and the urethra (pee tube).

The exact cause of BXO is unknown, but it may be related to the foreskin being constantly exposed to a urine.

The main treatment of BXO is a CIRCUMCISION. After surgery for BXO you will be started on a course of steroid ointment that starts 2 weeks after surgery. The ointment is applied 3 times per day.

If the scarring affects the pee tube then it can narrow the pee tube, making it difficult for the boy to pee. Narrowing of the pee tube may be found at the time of diagnosis, during a CIRCUMCISION or it may not become apparent until after a CIRCUMCISION has been done. Sometimes we use a test called UROFLOWMETRY (sometimes called Flow Rates or Flows and Residuals) to see how well a patient is able to pee. If there is evidence of narrowing of the pee tube then this may require surgery. In some mild cases further treatment with steroid ointment may be all that is required.

Photo demonstrating the typical appearance of BXO