Phimosis

Phimosis is a narrowing of the preputial ring that prevents the foreskin from being fully pulled back over the glans of the penis. It is important to distinguish between:

• physiological phimosis, which is a normal developmental stage, mainly in children. The foreskin may initially be adherent to the glans and gradually becomes more retractable; it should never be retracted by force, as injury can cause scarring and, as a result, secondary pathological phimosis.
• pathological phimosis, in which the preputial ring is scarred, whitish, thickened and less elastic. It develops as a result of recurrent balanoposthitis, trauma or forced retraction, chronic inflammation of the foreskin, or skin conditions (lichen sclerosus, balanitis xerotica obliterans (BXO)); in adults, metabolic factors, particularly diabetes, can also contribute.

Phimosis may cause no symptoms at all, or it may cause pain on retraction, recurrent balanitis/balanoposthitis, painful intercourse in adults, problems during intercourse due to tightness of the foreskin, difficult hygiene and, less often, problems urinating.

The diagnosis is clinical and is made by a urologist during the examination. Treatment depends on the patient's age, the cause, the degree of phimosis and the presence of symptoms.

In children, physiological phimosis without symptoms is normal and usually does not require treatment. If children have symptomatic or pathological phimosis, the first choice is usually conservative treatment with a topical corticosteroid applied to the narrowed preputial ring, together with gentle, painless stretching of the foreskin. Treatment usually lasts about 4–8 weeks and is very effective in children. After successful treatment, regular gentle retraction and hygiene are important, as phimosis can recur. If topical treatment fails, circumcision is recommended.

In milder forms of phimosis in adults, such as relative phimosis – when the foreskin can be retracted but retraction is difficult and tight – conservative treatment can be tried first. In cases of marked scarring, recurrent inflammation, pain during intercourse or failure of conservative treatment, we turn to surgical treatment – circumcision.

Circumcision is a surgical procedure in which the prepuce, the skin covering the head of the penis, is removed. It can be:

• Complete (total) circumcision – the entire foreskin is removed, so the head of the penis remains permanently uncovered.
• Partial (subtotal) circumcision – only part of the foreskin is removed; some skin remains and may partly cover the head of the penis.

In pathological or scarring phimosis, especially with lichen sclerosus (BXO), the entire affected part of the foreskin must be removed, which is why complete circumcision is often more appropriate.