Phimosis explained: How to treat tight foreskin in adults

What is Phimosis?

The foreskin is the thin layer of skin that covers the end of the penis in uncircumcised men. Phimosis is the medical term for tight foreskin (prepuce). In someone with phimosis, it's not possible to pull (retract) their foreskin back over the head of their penis (glans), or doing so hurts.(1)

It’s not usually a problem unless symptoms include pain, swelling and discomfort. The condition is common in infants and young children, as the foreskin tends to separate naturally over these years.

What are the different types of phimosis?

There are two primary types of phimosis: physiological and pathological.(2)

• Physiological phimosis is considered normal (and natural) in young boys and often resolves by puberty as the foreskin naturally loosens and becomes retractable. This is also sometimes referred to as congenital or primary phimosis.
• Pathological phimosis develops later in life due to scarring, infection, or other medical conditions. It is typically more problematic and may require treatment.

How common is phimosis?

Nearly all newborn boys have foreskins that are tight or stuck to the head of the glans. By the age of 16, only about 1 out of 100 boys have phimosis.(1). By the age of 17, most boys should be able to pull back their foreskin without pain or discomfort.(2)

Physiological phimosis is relatively rare in adult men and therefore phimosis in adults is most likely attributed to the pathological kind.

What causes pathological phimosis?

Pathological phimosis, also known as secondary or acquired phimosis, can develop in adults for a variety of medical reasons. Common causes include:

• Infections: Recurrent infections, such as balanitis (inflammation of the glans) or balanoposthitis (inflammation of both the glans and foreskin), can lead to scarring and tightening of the foreskin, as can some sexually transmitted diseases.
• Skin conditions: Such as eczema, psoriasis, lichen planus and balanitis xerotica obliterans (sometimes called lichen sclerosus).(3)
• Diabetes: High blood sugar levels can increase the risk of infections and poor skin healing, making diabetes a significant risk factor for phimosis.(4)
• Trauma or injury: Any injury to the foreskin, such as forced retraction, can cause scarring and result in phimosis.

How do skin conditions contribute to phimosis?

Certain skin conditions can cause the foreskin to become less elastic and more prone to tightness. Balanitis xerotica obliterans (BXO) is one such condition where the skin becomes thin, white, and scarred (5). This can lead to progressive tightening of the foreskin over time. Other common skin conditions are eczema and psoriasis, which contribute to the development of phimosis through chronic irritation and inflammation.

Can phimosis develop as a result of poor hygiene?

While hygiene alone does not directly cause phimosis, poor hygiene can contribute to infections like balanitis, which may lead to scarring.

Regular cleaning of the foreskin and glans can reduce the risk of infection and inflammation, thereby reducing the likelihood of developing phimosis. However, you have to strike a balance; over-vigorous cleaning or harsh soaps can also irritate the area.

What are the symptoms of phimosis?

The most obvious sign of phimosis is difficulty retracting the foreskin over the glans. Other symptoms can include:

• Pain or discomfort during erections or sexual activity
• Redness, swelling, or inflammation of the foreskin or glans
• Recurrent infections & a buildup of smegma (a whitish substance that can collect under the foreskin) due to difficulty cleaning the head of the penis and underneath the foreskin.(1)

How does phimosis affect sexual function?

Phimosis can make sexual activity uncomfortable or even painful. The tightness of the foreskin can restrict movement, causing discomfort during intercourse or masturbation. In some cases, the inability to fully retract the foreskin can lead to a condition known as paraphimosis, where the foreskin becomes stuck behind the glans, which is a medical emergency.(6)

When should you seek medical advice for phimosis symptoms?

You should seek medical advice if:

• You experience painful erections or discomfort during sexual activity.
• You notice recurrent infections or irritation under the foreskin.
• The foreskin becomes increasingly difficult to retract.
• There is any sign of paraphimosis—this requires immediate medical attention.

How is phimosis diagnosed?

Phimosis is usually diagnosed through a physical examination, but in some cases, further tests may be required. If the doctor suspects the phimosis is due to an underlying condition like infection, diabetes or a skin disorder, they may order additional tests.

How important is a physical examination in diagnosing phimosis?

A physical examination is important in diagnosing phimosis. Your healthcare provider will assess the degree of tightness and look for signs of infection, inflammation, or scarring. They may also check for complications like paraphimosis or restricted blood flow to the glans, which would require urgent treatment.

If you don’t want to see your GP, phimosis can be treated at sexual health clinics.

Can self-diagnosis be reliable for phimosis?

While some men may recognise the symptoms of phimosis, self-diagnosis is not always reliable. It’s important to have a proper evaluation by a healthcare professional to rule out other potential causes of foreskin tightness, such as skin conditions or infections. Self-diagnosing and delaying treatment could worsen the condition.

What are the treatment options for phimosis?

What non-surgical treatments are available for phimosis?

In many cases, non-surgical treatments can help resolve phimosis. These include:

• Topical steroid creams: These are often the first line of treatment and help to reduce inflammation and increase the elasticity of the foreskin.
• Stretching exercises: Gentle stretching of the foreskin over time can help to gradually improve retraction. It should not be forced. Enthusiastic attempts to correct congenital phimosis increase the risk of developing pathological phimosis.(6)
• Oral medications: In cases where infection is a factor, antibiotics or antifungal medications may be prescribed.

How effective are topical steroid creams in treating phimosis?

Topical steroid creams, such as betamethasone, have been shown to be effective in treating mild to moderate cases of phimosis. These creams work to reduce inflammation making it easier to retract the foreskin. The treatment typically lasts a few weeks, and most men experience significant improvement without needing surgery.

Hydrocortisone is another readily available steroid cream but due to its weaker potency it’s not first choice. A course of betamethasone is available from Oxford Online Pharmacy to treat phimosis in adults.

Topical steroid application to the preputial ring to treat 'phimosis' has reported success rates between 33-95%.(6)

When is surgery considered as a treatment option?

Surgery may be considered if non-surgical treatments fail or if the phimosis is causing significant discomfort or complications. The most common surgical procedure for phimosis is circumcision, which involves the removal of the foreskin.(6)

In less severe cases, a preputioplasty may be recommended —a less invasive procedure that loosens the foreskin.  The advantage of this approach is that the foreskin, or much of it, can be preserved. The disadvantage is that phimosis can recur.(7)

How to apply betamethasone cream or ointment for phimosis in adults

What is a fingertip unit?

One fingertip unit refers to the amount of cream that stretches from the tip of the index finger to the first crease.(8)

How much betamethasone cream or ointment to apply for phimosis

Men should use a quarter to half a fingertip unit (often described as a pea-sized amount) depending on how much of their foreskin requires treatment. The cream should be gently massaged into the foreskin and glans twice daily for several weeks or as the online doctor advises.

Half a male’s fingertip unit is around 0.25g, based on this a patient will need somewhere between 21-42g of cream or ointment for a potential full course of 12 weeks.(8) We offer betamethasone in either 30g or 100g pack sizes.

Betamethasone cream vs ointment

Steroid creams and ointments can both be used for treating phimosis, but they have slightly different properties.

Creams tend to be lighter and are absorbed more quickly by the skin.

Ointments are thicker and provide a more substantial barrier, which can be useful in very dry or irritated areas.

The choice of cream or ointment is partly a personal preference and should be discussed with your healthcare provider based on your skin type and the severity of your phimosis.

How Oxford Online Pharmacy can help

Oxford Online Pharmacy is here to support you. Our knowledgeable pharmacists and online doctor team understand the impact of phimosis on your health. We offer personalised advice and a variety of treatments to help manage your condition.

We stock steroid creams that can help relieve tightness and inflammation. If your doctor has already diagnosed you with phimosis, we can also provide guidance on stretching exercises and other treatment options.

It's easy to get help from us. You can call and talk to a pharmacist, email us your questions, or visit our website.

FAQs

What can you do at home to manage phimosis?

At-home management includes gentle foreskin stretching exercises and applying steroid creams, such as betamethasone. Keeping the area clean and dry is also important to prevent infection.

Avoid aggressive stretching or using non-prescribed creams, which can worsen the condition.

How can stretching exercises help with tight foreskin?

Gentle stretching of the foreskin can help gradually loosen it over time. Always do this carefully, as forcing retraction can cause injury or scarring, worsening the condition.

What hygiene practices can prevent worsening of phimosis?

Keeping the area clean and dry is also important to prevent infection. Focus should be on cleaning the head of the penis and under the foreskin. Avoid harsh soaps and over-cleaning, which may cause irritation and infections that can worsen phimosis.

What can happen if phimosis is left untreated?

Untreated phimosis can lead to recurrent infections, pain during sex, scarring and difficulty urinating. In severe cases, it can result in paraphimosis, a medical emergency.

Chronic phimosis can also lead to anxiety, embarrassment, or decreased self-esteem, particularly if it impacts sexual function or leads to discomfort during daily activities.

References

1. Overview: Phimosis. In: InformedHealth.org [Internet] [Internet]. Institute for Quality and Efficiency in Health Care (IQWiG); 2023 [cited 2024 Sep 29].
2. Top Doctors [Internet]. [cited 2024 Sep 29]. Phimosis: What is it, what causes it, when does it become serious, can it be prevented?
3. Tight foreskin: Causes, treatment, and prevention [Internet]. 2018 [cited 2024 Sep 29].
4. Bromage SJ, Crump A, Pearce I. Phimosis as a presenting feature of diabetes. BJU Int. 2008 Feb;101(3):338–40.
5. Tight foreskin (phimosis) [Internet]. [cited 2024 Sep 29].
6. Phimosis and paraphimosis [Internet]. [cited 2024 Sep 30].
7. Hayashi Y, Kojima Y, Mizuno K, Kohri K. Prepuce: phimosis, paraphimosis, and circumcision. ScientificWorldJournal. 2011 Feb 3;11:289–301.
8. Fingertip unit [Internet]. [cited 2024 Sep 30].