Phimosis – A Misdiagnosis?

To the average American, phimosis is likely an unfamiliar term. To the medical community, it seems as if phimosis is an equally confusing topic. Phimosis is typically defined as a tightness or constriction of the foreskin, preventing retraction over the glans. This may be present at birth, or develop later in life. From this definition, it can be understood that the term phimosis stands for the inability to fully retract the foreskin at any point in a man’s life. Given this broad definition it is necessary to distinguish between instances when the inability to retract is normal, and when it is a problem. 


In adulthood, retraction is an important part of intact penis as it allows for proper sexual functioning and hygiene. During intercourse, movement of the foreskin facilitates the gliding motion of penile skin over the shaft and head of the penis. This movement, combined with the high density of sexual nerve endings in the foreskin, provides for a full sexual experience in the intact man. The gliding motion also acts as a natural lubrication mechanism. Furthermore, retraction allows for proper washing of the head and foreskin during daily hygiene routines and especially after intercourse.


A common misunderstanding is that phimosis, under the above definition, is a detrimental medical condition at any age. The reality is, for roughly 96% of newborn boys, the foreskin is not fully retractable. It is generally not supposed to retract in early childhood, as it is fused to the head of the penis, therefore protecting the sensitive head of the penis from contact with potentially harmful substances. Studies on retraction have found that full retraction of the foreskin may not occur naturally until a boy reaches his late teens, and that on average full retraction occurs somewhere between late childhood and early adolescence (around 10 to 18 years of age). In this respect, the inability to retract during childhood is a protective biological phenomenon and should be considered a normal step in maturing.


So, when does phimosis become a problem? Is it after puberty? At what age is a non-retractable foreskin an issue? Phimosis is frequently divided into two categories: physiologic and pathologic phimosis. Physiologic phimosis is the natural tightness and adhesion of the foreskin at birth, which, as discussed above, usually resolves itself by adulthood. Pathologic phimosis is the onset of phimosis at a later age after full retraction has occurred due to scarring, infection, or inflammation. A common form of pathologic phimosis is balanitis xerotica obliterans (BXO). BXO is a condition in which a hardened ring of whitish tissue appears at the opening of the foreskin, reducing the man’s ability to retract. (Some argue this is the only “true” form of phimosis.) What about physiologic phimosis that never resolves itself? The question arises: What are the best methods to treat each type of phimosis?


In regards to enduring physiologic phimosis, this is extremely rare. Less than 2% of intact males experience a non-retractable foreskin past the age of 18. If a boy is over 18 and his foreskin has never fully retracted, or a previously retractable foreskin becomes non-retractable, then corrective action may need to take place. This definition of problematic phimosis brings to light another issue in the medical community: misdiagnosis of problematic phimosis. In many cultures, a diagnosis of phimosis has traditionally meant the removal of the foreskin (circumcision) as a permanent cure. However, circumcision destroys much of the natural function of the penis as well as blunting sexual sensitivity. Numerous men in fact resent their circumcision and are seeking to restore their foreskin.


Many studies suggest that circumcision is often prematurely prescribed. In a study from the United Kingdom examining circumcision referrals for patients with perceived phimosis, all 120 patients were between the ages of four months and 13 years. That means that all patients were below the age of 18, when physiologic phimosis may become problematic. Either these patients were not given enough time for natural retraction to occur, or they were experiencing pathologic phimosis. Out of the 120 patients in this study, only 30 were experiencing true pathologic phimosis. In another study out of Western Australia, the incidence rate of circumcision for phimosis was seven times the expected rate of true phimosis. Again, the procedure was conducted entirely on boys less than 15 years of age, and mostly before the age of five. This is well before the age of 18 when physiologic phimosis is expected to resolve itself. This trend of misdiagnosis and over prescription of circumcision is assumed to be similar if not worse in the US, and also an outdated method of treatment worldwide.


With advances in the medical field, circumcision for phimosis is unnecessary except in extreme cases. Many studies examining the effectiveness of topical steroids used for problematic phimosis, which encourage foreskin growth and expansion, have shown effective results. One study using betamethasone cream saw good retraction in 19 out of 20 boys treated. Another study using fluticasone proprionate saw successful results in 1079 out of 1185 (91.1%) boys. If the foreskin is unresponsive to steroids, stretching techniques can be utilized to widen the opening of the foreskin, or surgical techniques other than circumcision can also loosen the foreskin without removing its many functions and sensitivity. Again, in this study many of these treatments were performed on boys less than 18 years of age, perhaps indicating that the medical community fails to give enough time for natural retraction to occur before diagnosing problematic phimosis.


The medical and scientific community is beginning to openly question itself. Another study out of the United Kingdom questioned the diagnosis of true phimosis in the Mersey Region of England. The researchers found that two-thirds of performed circumcisions for phimosis were unnecessary as patients were not given enough time for natural retraction to occur. When it comes to a diagnosis of phimosis, it is probably best to pursue other methods rather than the removal of tissue with important sexual and hygienic function.  


The question now arises; how should parents care for their intact boys? When it comes to the intact penis of a child or adolescent, the best advice is to leave it alone. When a boy is still too young to clean himself, simply wipe the penis as you would a finger, from base to tip, with no cleaning beneath the foreskin. Forced retraction of the foreskin can lead to irreparable damage, and may cause infection or other complications. Within circumcising cultures, doctors and parents frequently do not understand that forced retraction is unnatural and damaging. Many of these individuals forcibly retract their child’s foreskin believing that it is necessary in order to keep their penis clean. Once a boy’s foreskin begins to retract fully, usually around 10 years old, instruct him to retract it each time he bathes, rinse the inner foreskin and head of the penis with water, and then cover the glans with the foreskin. Foreskin hygiene should become a normal part in an intact boy’s hygiene routine, and following these simple steps should prevent almost any potential foreskin complication.


The evidence suggests that circumcision is an outdated practice, both as a preventative measure for penile disorders and as a treatment for phimosis. For intact boys and men with problematic phimosis, thorough research should be conducted looking into treatments alternative to circumcision. For parents of intact boys, a diagnosis of problematic phimosis should not be seriously considered unless the boy is over 18 or a previously retractable foreskin has become non-retractable. In regards to men who were already circumcised, Foregen plans on soon being able to fully regenerate the foreskin.


Finally, one of our supporters from Finland sent us his story explaining that he was circumcised due to phimosis:


“My name is Tom, and I am 40 years old. Here is my story of why I support Foregen.


I was circumcised at the age 27 because of phimosis. The doctor recommended circumcision and no alternative treatment was offered to me. Before the surgery, I had always had good and satisfying sex life. But during a few years after the surgery things changed for the worse. I started to have trouble reaching orgasm during sex and I my penis just felt numb. The doctor had cut off all of my sensitive inner skin, and my scar was right next to my glans.


I soon realized that I no longer feel any pleasure from oral sex, and even intercourse is difficult. This has had dramatic effect on my relationships. It was traumatic to realize what had been done to me and that it couldn't be fixed. I have a pretty good self-esteem, but my sexual problems hit my self-confidence pretty hard. To make matters worse, in my country circumcision is very rare, and no one really understood what I am going through. I visited several urologists, but they could offer me no support whatsoever.


If Foregen can someday give my foreskin back, it will be like a dream come true for me.”



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