Phimosis - Tight Foreskin

Phimosis is described as a tightness of the foreskin, which prevents or limits it’s ability to retract over the glans. It is normal for males during childhood, as the glans remains attached to the foreskin, then begins to detach as a normal part of development. Approximately 96% of males are born with a nonretractile foreskin, which resolves without intervention between birth and 18 years of age (often teenage boys may have the remains of preputial adhesions, which will usually separate and resolve during the teenage years).


Attempts to forcefully retract the foreskin should be avoided as this can cause damage and can be extremely painful. As the child develops, the increase in erections and inquisitiveness of the individual can be enough to ensure that the foreskin retracts without the need for phimosis treatment, however for around 2% of adult males, the foreskin remains nonretractile. This is usually physiological phimosis and is commonly stretched to resolve the problem, provided that the individual perseveres with stretching at a duration and frequency which is comfortable and not aggressive. When phimosis develops on a previously retractable foreskin, this is known as pathological phimosis and will show an element of scar tissue. Occasionally, phimosis may be secondary to other illness such as circulatory issues e.g. diabetes, and often patients with Lichen Sclerosus (read more at mayoclinic.org/diseases-conditions/lichen-sclerosus/symptoms-causes/syc-20374448) will encounter the issue. Needless to say, the primary objective in the circumstances of poor circulation and Lichen Sclerosus, should be to control the factors causing the phimosis.


How Is Phimosis Treated?

In terms of treatment options to resolve phimosis, clinical reasoning has, in recent years become questioned, as the common consensus within the medical field was to circumcise. This unfortunately was likely to have been led by a lack of appreciation of the function of the foreskin. Once considered to have little function, the foreskin was often circumcised at the first instance of phimosis, even in the developing child. Thankfully, in more recent times, the treatment advice for physiologic phimosis is usually to stretch the foreskin. In cases of pathological phimosis however, there remains a limited acceptance within the medical profession to accept that this can also be treated and circumcision can be avoided. This train of thought being led by the fact that scar tissue has reduced elasticity, which is undoubtedly correct, but before we accept this, we should first explore the scar process.
When the skin is injured, the repair process follows four stages which are outlined in very basic detail below.
1.    Hemostasis: Blood vessels constrict to reduce the blood flow. Next, platelets stick together to seal the injured skin. Finally, coagulation occurs to form a blood clot.
2.    Inflammatory stage: Damaged cells, pathogens and bacteria are removed from the site of the injury. Heat, pain, and redness are seen at this stage.
3.    Proliferation stage: The wound contracts, and new tissue is rebuilt (Type III Collagen) 
4.    Remodeling stage: This is a very important stage to consider in terms of the scarring seen in pathologic phimosis. The type III collagen present is disorganised and thick, the scar has very little elastin, so has inelastic properties. This is gradually replaced by type I collagen which forms a thinner healthier scar, improving the tensile strength. As the scar matures, an improved network of elastin improves it’s ability to stretch. 


In a study performed by Roten et al (1996), it was noted that elastic fibres increase considerably during the remodeling stage, which indicates a significantly improved ability to stretch, when the initial injury has completed the healing process. Thus, we may conclude from this, that provided the scarring has completely healed, stretching should be considered as a modality for the conservative treatment of phimosis. Of course, we need to adjust any aggravating lifestyle factors which may have caused the original scarring, for example, if the tight foreskin is frequently being injured by sexual activity, the activity should be modified to reduce the likelihood of further injuries.


As we have noted, there is often a lack of appreciation of the functions of the foreskin, which has inevitably led to needless circumcisions. If we were to fracture a finger, it would be a ridiculous prospect to suggest amputation, as we respect the function as a part of our anatomy, yet a tight foreskin is often resolved with circumcision without question as its functions are often ignored. 
The foreskin consists of skin, smooth muscle, mucous membranes, blood vessels and neurons. It’s functions include protection of the glans from trauma and abrasion, keeping the glans moist and lubricated, and improving sexual pleasure. Some may argue that sexual pleasure is not reduced following circumcision, however, we only need to consider that the glans contains thousands of nerve endings, which following circumcision will eventually be covered by kerratinised skin (as the glans is exposed to air and abrasive materials such as clothing, the skin dries out and thickens), thus, we may form our own conclusions on the possibility of reduced sexual pleasure.


Inevitably, circumcision will be required for some individuals, due to incidences of illness and anatomical dysfunction, however we hope that the shift in recent years towards more conservative phimosis correction will continue, and stretching of the foreskin will be more commonly accepted as a treatment.

[Phimosis in children, Shahid. ISRN Urol. 2012; 2012: 707329. Published online 2012 Mar 5. doi:  10.5402/2012/707329] Access at: ncbi.nlm.nih.gov/pmc/articles/PMC3329654/


Elastic fibers in scar tissue. J Cutan Pathol. 1996 Feb;23(1):37-42. Roten SV1, Bhat S, Bhawan J.


Van Howe RS (1998). "Cost-effective treatment of phimosis". Pediatrics. 102 (4): e43–e43. doi:10.1542/peds.102.4.e43. PMID 9755280


Øster J. Further fate of the foreskin: incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child. 1968;43(228):200-3. doi:10.1136/adc.43.228.200. PMID 5689532


Spilsbury K, Semmens JB, Wisniewski ZS, Holman CD (2003). "Circumcision for phimosis and other medical indications in Western Australian boys". Med. J. Aust. 178 (4): 155–8. PMID 12580740


McGregor, TB; Pike, JG; Leonard, MP (March 2007). "Pathologic and physiologic phimosis: approach to the phimotic foreskin". Canadian family physician Medecin de famille canadien. 53 (3): 445–8


What are the treatment options for phimosis?". PubMed Health. Institute for Quality and Efficiency in Health Care. 7 October 2015
 

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