Phimosis and Paraphimosis

What is the foreskin?

The foreskin is the retractable fold of skin that covers the tip of the penis. It acts as a protective covering for the glans, commonly known as the head of the penis.

The foreskin begins to form during the first weeks of fetal development. At birth, it is normal for the inner surface of the foreskin to still be attached to the glans and for the opening to be narrow, preventing complete retraction. This normal inability to retract the foreskin is called physiologic phimosis.

As the penis grows, these adhesions gradually separate and the foreskin opening becomes wider. Retractability progressively increases throughout childhood, but there is no single age at which all boys should be able to fully expose the glans.

Approximately half of boys can retract the foreskin beyond the glans by the end of the first year of life, and about 89% can do so by age 3. However, this means that being unable to retract the foreskin at age 3 can still be perfectly normal. Even before puberty, a foreskin that is not fully retractable may still be a physiologic variation if there are no symptoms.

It is neither necessary nor recommended to forcibly separate the foreskin in children. Forced retraction can cause small tears, bleeding, and scarring, turning a physiologic condition into pathologic phimosis.

Once the foreskin can be easily retracted, it can be gently pulled back during bathing to clean the glans. It should always be returned to its normal position after cleaning.

What is phimosis?

Phimosis occurs when the foreskin opening is too narrow, making it difficult or impossible for the foreskin to pass over the glans.

In children, however, it is important to distinguish true phimosis from physiologic adhesions between the foreskin and the glans. Both can prevent complete exposure of the head of the penis, but they behave differently. Adhesions are extremely common during childhood and tend to resolve spontaneously as the child grows.

Phimosis can be divided into two main types: physiologic and pathologic.

Physiologic phimosis

Physiologic phimosis is related to the normal development of the foreskin.

During the first years of life, the foreskin opening may still be narrow, and the foreskin may remain partially attached to the glans. As the child grows, these adhesions usually disappear and the foreskin opening tends to become progressively wider.

There is no scarring in physiologic phimosis. When the foreskin is gently retracted, the skin remains soft and elastic.

A non-retractable foreskin, foreskin adhesions, and even some ballooning of the foreskin during urination can be part of normal development before puberty and do not require treatment in the absence of symptoms. Only about 1% of adolescents between 16 and 18 years of age still have phimosis.

Therefore, persistence of a non-retractable foreskin during childhood, by itself, does not mean that there is a disease or that surgery is necessary.

Pathologic phimosis

Pathologic phimosis occurs when the foreskin opening becomes scarred and loses its elasticity. Unlike physiologic phimosis, it may not improve spontaneously.

Some signs suggest pathologic phimosis:

• A hardened, whitish, or scarred ring at the tip of the foreskin.
• Recurrent cracks or small tears.
• Pain when attempting to retract the foreskin.
• Painful erections.
• Recurrent balanitis (inflammation of the glans) or balanoposthitis (inflammation of the glans and foreskin).
• Progressive difficulty retracting the foreskin.
• A foreskin that previously retracted normally but no longer does.

Pathologic phimosis can develop after repeated episodes of inflammation or infection of the glans and foreskin, which can cause scarring. Another cause is forcibly attempting to retract a child’s foreskin, producing small tears that subsequently heal with scar tissue and further narrow the opening.

An important cause of pathologic phimosis is genital lichen sclerosus, also known as balanitis xerotica obliterans (BXO). This is a chronic inflammatory disease that can cause whitish patches, scarring, and narrowing of the foreskin. In some patients, lichen sclerosus can also affect the glans, urethral opening, and urethra.

Phimosis in adults

Phimosis can also develop in adulthood, including in men who were previously able to retract their foreskin without difficulty.

In these cases, there is usually an underlying process that has caused inflammation and scarring of the foreskin opening. Causes include recurrent balanitis or balanoposthitis, trauma, and skin disorders, particularly lichen sclerosus.

Men who develop progressive difficulty retracting the foreskin, cracks, whitish areas, pain during erections, or recurrent inflammation should be evaluated by a urologist or dermatologist.

Symptoms of phimosis

The characteristic feature of phimosis is difficulty retracting the foreskin over the glans.

There are different degrees of retractability. In simplified terms, they can be classified as follows:

1. Complete retraction of the foreskin, but with a tight ring below the glans, which increases the risk of paraphimosis.
2. Only partial exposure of the glans.
3. Minimal retraction, allowing only the urethral opening to be seen.
4. Very little retraction, without exposure of the glans or urethral opening.
5. Complete inability to retract the foreskin.

This classification only describes how far the foreskin can be retracted. By itself, it cannot determine whether the condition is physiologic or pathologic or whether treatment or surgery is indicated. The appearance of the foreskin, the presence of scarring, and the symptoms are more important when making this decision.

When phimosis is symptomatic, the following may occur:

• Painful erections.
• Pain or cracks when attempting to retract the foreskin.
• Recurrent episodes of balanoposthitis.
• Urinary tract infections.
• Pain or burning during urination (dysuria).
• Hematuria (blood in the urine).
• A very thin urinary stream or difficulty urinating.
• Difficulty maintaining adequate hygiene of the glans.
• Pain or discomfort during sexual intercourse.

Is ballooning of the foreskin during urination a sign of severe phimosis?

Some children experience balloon-like expansion of the foreskin during urination. Although this can be quite concerning to parents, by itself it does not mean that urine flow is obstructed or that the child needs surgery.

Ballooning can be part of the normal development of the foreskin and usually disappears as the opening becomes wider.

The condition should be evaluated when ballooning is accompanied by pain, recurrent balanoposthitis, significant difficulty urinating, a persistently very thin urinary stream, or other urinary symptoms.

What is paraphimosis?

Paraphimosis occurs when the foreskin can be retracted behind the glans but cannot return to its normal position.

The tight ring of foreskin becomes trapped in the groove behind the glans and begins to impair venous and lymphatic drainage. This causes progressive swelling, making it increasingly difficult to return the foreskin to its normal position.

Unlike phimosis, paraphimosis is a medical emergency. If the compression persists, arterial blood flow may also become impaired and, in severe cases, tissue ischemia and necrosis can occur.

The main factors that can contribute to paraphimosis include:

• A very tight foreskin.
• Forced retraction of the foreskin.
• Failure to return the foreskin over the glans after cleaning or a medical procedure.
• Balanoposthitis.
• Penile trauma.
• Piercings that interfere with the movement of the foreskin.

Paraphimosis can also occur after sexual intercourse or masturbation when the foreskin is retracted and remains trapped behind the glans.

In children, a common cause is an attempt by parents or caregivers to forcibly retract the foreskin. For this reason, whenever the foreskin is retracted, it should always be returned to its normal position covering the glans.

Symptoms of paraphimosis

Swelling of the glans and penile pain are the most common symptoms of paraphimosis.

Marked swelling of the glans and retracted foreskin, with the formation of a tight ring just behind the glans, is another highly characteristic finding.

If treatment is delayed, the glans may become increasingly swollen and develop a purplish or dark discoloration due to impaired blood circulation. In severe cases, difficulty urinating may also occur.

The absence of severe pain does not rule out paraphimosis. If the foreskin is trapped behind the glans and cannot return to its normal position, medical care should be sought promptly.

Treatment of phimosis

Not all cases of phimosis require treatment.

In children without symptoms, scarring, recurrent inflammation, or significant urinary problems, a non-retractable foreskin may be part of normal development. In these cases, observation alone is usually appropriate.

The child’s age alone does not determine whether treatment is necessary. The most important factors are the presence of symptoms, scarring, recurrent inflammation, or signs of pathologic phimosis.

When phimosis is symptomatic and treatment is indicated, topical corticosteroids are usually the first option.

The medication should be applied directly to the tight ring of the foreskin, combined with gentle retraction only as far as possible without causing pain, cracks, or bleeding.

The most commonly used topical corticosteroids include betamethasone 0.05% and mometasone furoate 0.1%. Treatment usually lasts four to eight weeks, with the medication applied directly to the tight ring of the foreskin. The frequency of application depends on the corticosteroid used and the doctor’s instructions.

When applied correctly, topical corticosteroid treatment has a success rate of more than 80%. Recurrence may occur in up to approximately 17% of patients, which is why gentle and regular retraction of the foreskin during hygiene is usually recommended after improvement.

Exercises should not involve pulling the foreskin forcefully. The goal is simply to promote gentle, progressive retraction.

Physiologic adhesions between the foreskin and the glans do not respond to corticosteroids and should not be forcibly separated.

Surgery for phimosis

Surgery may be indicated when phimosis causes significant symptoms and does not respond adequately to conservative treatment or when there are recurrent episodes of balanoposthitis.

Persistent limited retractability of the foreskin, in the absence of symptoms or pathologic scarring, is not by itself an indication for surgery. Likewise, isolated ballooning of the foreskin during urination is not an indication for surgery.

The approach to childhood phimosis has changed over time. In the past, age and persistent difficulty retracting the foreskin were more commonly used as criteria for referral and treatment. It is now understood that a non-retractable foreskin may persist for several years as part of normal development. For this reason, current guidelines place greater emphasis on symptoms, scarring, and other signs of pathologic phimosis than on age alone.

The most commonly performed surgery for phimosis is circumcision, also known as posthectomy, in which the foreskin is removed.

Circumcision can be performed under local, regional, or general anesthesia, depending mainly on the patient’s age and the characteristics of the case.

During the first few days, some degree of pain, swelling, and increased sensitivity of the glans is common. Sexual intercourse and masturbation should only be resumed after adequate healing, generally after at least four weeks.

In some patients, particularly children, a preputioplasty may be performed. This procedure widens the tight foreskin opening while preserving the foreskin. Its main disadvantage is the possibility that phimosis may recur.

In boys with confirmed balanitis xerotica obliterans (BXO), circumcision is one of the main treatment options and is recommended by the European Association of Urology. In adults, however, lichen sclerosus can also initially be treated with potent topical corticosteroids under medical supervision, with surgery mainly reserved for cases with persistent narrowing or an inadequate response to treatment.

We explain the procedure in detail in the article: Circumcision: Risks, Benefits and Postoperative Care.

Treatment of paraphimosis

As mentioned above, paraphimosis is a medical emergency and requires prompt treatment.

Initial treatment usually involves carefully compressing the glans and swollen tissue to reduce the swelling and then attempting to return the foreskin over the glans. Anesthesia or pain medication is often needed to perform the maneuver.

If manual reduction is not possible, a small incision in the constricting ring or another emergency surgical procedure may be necessary.

After the acute episode has been resolved, a urologist should evaluate whether phimosis or another foreskin abnormality is present that could increase the risk of recurrence.

Frequently asked questions about phimosis and paraphimosis (FAQ)

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