Phimosis: Symptoms, What It Looks Like, Causes & Treatment

Phimosis is a penile condition that is characterized by excess skin covering the head of the penis that causing the difficulty or inability to retract the foreskin and expose the glans.

Phimosis is common in babies or children up to 2 to 4 years old and can resolve without the need for any specific treatment. However, it can also persist in adolescence or adulthood, or even develop as a result of another health condition, like balanitis.

Treatment of phimosis is carried out by a pediatrician or urologist and is not always necessary, however, in some cases the use of ointments or even surgery may be indicated.

Common symptoms

The main symptoms of phimosis are:

• Difficulty or inability to retract the foreskin and expose the glans
• Tight foreskin or the sensation of a tight "elastic" ring around the tip of the penis
• Redness or swelling due to local irritation
• Infection at the site
• Pain when urinating
• Weak stream of urine
• Frequent urinary infections
• Blood in the urine
• Bleeding from the head of the penis or foreskin

Additionally, phimosis in adults can cause painful erections or pain during intimate contact.

What it looks like

Phimosis looks like excess skin around the glans. You can identify and confirm the presence of phimosis by trying to manually retract the skin that covers the glans.

When it is not possible to completely see the glans, it is likely that phimosis is present.

Possible causes

The main causes of phimosis are:

• Congenital development, which is most commonly noted in newborn boys
• Inadequate hygiene;
• Balanitis or balanoposthitis
• Skin diseases such as eczema, psoriasis or lichen planus
• Penile lichen sclerosus or xerotic balanitis obliterans
• Infections, lesions, scars or adhesions in the foreskin

STIs can also increase the risk for phimosis.

Confirming a diagnosis

The diagnosis of phimosis is made by a pediatrician or urologist by assessing the patient's symptoms and examining the penis. No additional tests are usually required to confirm phimosis.

However, in some cases, if the doctor suspects there is an infection in the area or a UTI, he or she may order blood or urine tests.

Degrees of phimosis

Phimosis can be classified into different degrees, which vary by the capacity of the foreskin to retract. These include:

• Grade 1: the foreskin can be completely pulled back, but the base of the glans is still covered by some skin and it may be more difficult to move the skin forward;
• Grade 2: the foreskin can be pulled back, but the skin does not retract over the widest part of the glans;
• Grade 3: the glans can only be pulled up to urethra
• Grade 4: the accumulation of skin is so great that the retraction of the foreskin is very reduced, making it impossible to expose the glans;
• Grade 5: most severe form of phimosis in which the skin of the foreskin cannot be pulled back, making it impossible to expose the glans.

Although the degree of phimosis is not very important in determining the best treatment, this classification can be useful for the initital identification of phimosis and monitoring the progress of treatment.

Types of phimosis

Phimosis can be further classified into types according to the underlying cause and the characteristics it presents with. The main types of phimosis are: 

1. Physiological or primary phimosis

Physiological or primary phimosis is the most common type of phimosis and can be first identified in newborns, soon after bith.

It occurs due to adhesion of the inner layers of the foreskin and the glans during fetal development, which make complete retraction of the foreskin more difficult.

2. Pathological or secondary phimosis

Pathological or secondary phimosis can develop due to inflammation, scars, infections, repeated infection or local trauma.

This type of phimosis can appear at any stage of life.

3. Phimosis in children

Infantile phimosis is a type of primary phimosis that affects babies or children, usually up to 2 to 4 years of age and normally disappears without the need for specific treatment.

However, in some cases, the pediatrician may recommend the use of ointments for treatment.

4. Male phimosis

Male phimosis generally affects adults and is a type of secondary phimosis, caused by another health conditions. It can lead to difficulty pulling the skin of the foreskin and exposing the glans penis.

5. Female phimosis

Female phimosis is rare and characterized by the adhesion of the labia minora of the vagina which cover the vaginal opening.

This type of phimosis is more common in girls up to three years of age.

Treatment options

Phimosis detected in children is curable and doesn't always need specific treatment, and so it is important that the pediatrician evaluates the situation to determine the course of action because sometimes it resolves itself naturally around the age of 4 or 5. If phimosis persists after this age or secondary phimosis occurs, specific treatment is necessary, which can be done with:

1. Phimosis ointments

You should apply corticosteroid-based ointments that have anti-inflammatory, analgesic and antibiotic properties, making it easier for the skin to glide over the glans. The ointment prescribed by the doctor is normally applied twice a day for 1 month and may be enough to cure phimosis.

2. Phimosis retraction exercises

In boys over the age of 5 there are some exercises that can be done to try and reduce phimosis; however, they must be done without forcing or causing any pain.

To do the exercise you should hold the penis with one hand and with the other apply the ointment and pull the skin back slowly, for 1 minute, 3 to 4 times a day. This exercise should not cause pain or discomfort but should "loosen the skin little by little".  If the exercise is not done correctly, besides the pain, it may form scars, new adhesions, and a fibrosis ring, which is a characteristic of paraphimosis.

3. Phimosis surgery 

When the treatment mentioned above is insufficient, a patient can undergo surgery to treat phimosis which is called a postectomy, after 2 years of age. The surgical procedure should be carried out by the doctor, taking into account the age and degree of phimosis and consists of completely removing excess skin or making small cuts in the skin of the region to facilitate exposure of the glans.

Phimosis surgery isn't possible until any existing problems are resolved, such as problems with blood clotting, local infection, or in cases of penile abnormalities, because in these cases there is a greater risk of complications and it may be necessary to take advantage of the skin removed to reconstruct some tissue in the genital region.

Possible complications

Phimosis can cause complications such as difficulty cleaning the area, an increased risk for UTIs, pain during sex, and a greater likelihood of contracting an STI, HPV or penile cancer.

Furthermore, it can greatly increase the risk of developing paraphimosis, which is when the foreskin becomes trapped and does not return to cover the glans.