This page provides information on conservative treatments of foreskin problems such as phimosis and preputial stenosis. In accordance with standard medical ethics, these treatments avoid unnecessarily radical surgery, and preserve normal physiologic function of the patient's body.
Note: Reports suggest that external irritants and other environmental factors may cause the foreskin to tighten. One such irritant that is suspected are the chemicals contained in bubble bath. Intact boys are urged to avoid the use of bubble bath. When tightness of a previously loose foreskin occurs (acquired phimosis), environmental factors and general state of health should be investigated before circumcision or conservative treatment is considered. For example, circulatory problems may cause edema of the prepuce and result in non-retractable foreskin.
"Phimosis" is a vague term. In common usage, it usually means any condition in which the foreskin of the penis cannot be retracted.
Most infants are born with a foreskin that does not retract. This is normal!
"True" phimosis—better termed "preputial stenosis," because "phimosis" has so many different definitions it now is devoid of any useful meaning—occurs in less than 2% of intact males. The incidence of preputial stenosis in circumcised men is actually similar.
Of these 2%, 85–95% will respond to topical steroids. Of those who fail this, at least 75% will respond to stretching under local anesthesia, either manually or with a balloon. The arithmetic is simple: At the very most 7 boys in 10,000 may need surgery for preputial stenosis. No wonder the Canadian Paediatric Society calls circumcision an "obsolete" procedure!
There are several alternatives to radical circumcision which preserve the function of the prepuce and result in less morbidity (pain, bleeding, complications). The best article to check out is the 1994 piece by Cuckow et al. After all, why would you want to lose all of those Meissner corpuscles, the same nerve complexes which provide fine touch to the fingertips?
The prepuce of boys may be tight until after puberty.1,7,8 This is an entirely normal condition and it is not phimosis. According to the experience in cultures where circumcision is uncommon, this tightness rarely requires treatment. Spontaneous loosening usually occurs with increasing maturity.1,7,8 One may expect 50 percent of ten-year-old boys; 90 percent of 16-year-old boys; and 98-99 percent of 18 year-old males to have full retractable foreskin. Treatment is seldom necessary. If treatment should be necessary, it should not be done until after puberty and the male can weigh the therapeutic options and give informed consent.8
It is important to note that the immature foreskin of a child must not be forced back for "cleaning" or for any other reason, because this will cause damage to the developing tissues. The child should be instructed that his foreskin will eventually retract. The first person to retract the foreskin should be the child himself.
Rickwood and colleagues provide a specific medical definition of phimosis: True phimosis is tight non-retractable foreskin caused by Balanitis Xerotica Obliterans (BXO) and is distingished by a whitish ring of hardened sclerotic skin at the tip of the prepuce.2,10 Histologic examination by a pathologist is necessary to confirm the diagnosis.2 If BXO is not present, then true phimosis is not present.2,10
A number of reports in the medical literature of the United Kingdom indicate that medical doctors are not trained to distinguish between normal developmental tight prepuce in boys and pathological phimosis.3,4,5,6,11 This results in cases of misdiagnosis of normal developmental preputial tightness as pathological phimosis in the UK.3,4,5,6,11
CIRP has received numerous reports to indicate that normal preputial narrowness in boys in the United States is frequently being misdiagnosed as pathological phimosis. CIRP believes that the situation in the United States is certainly not better, and probably much worse, than the situation in the United Kingdom. Parents of intact boys are also frequently improperly instructed to force the immature foreskin back for cleaning, contrary to the recommendations of the American Academy of Pediatrics.
As a consequence of misdiagnosis and confusion of normal developmental narrowessness and non-retractablity with pathological phimosis, many unnecessary circumcisions are performed. Shankar and Rickwood found that the number of circumcisions being performed in the United Kingdom is 8 times greater than the number required.10 The number of unnecessary circumcisions performed in the United States is unknown.
Circumcision is now recommended only in confirmed cases of phimosis caused by balanitis xerotica obliterans (BXO), however newer treatments may eliminate the need for circumcision. BXO is recognized by a hardened area of whitish skin near the tip of the foreskin which prevents retraction.2,9,10,11 Shankar and Rickwood found a low incidence of only 0.4 of 1000 boys per year, and only 6 in 1000 by age 15.10 See Balanitis Xerotica Obliterans for more information. Other cases of non-retractile foreskin respond to conservative, non-destructive, non-traumatic, less costly treatment.
Medical science has developed three classes of treatments other than radical circumcision for a narrow foreskin. The first treatment is medical by topical application of an ointment to the prepuce; the second is gradual stretching of the opening of the prepuce to make it wider; and the third is surgical reshaping of the prepuce opening to make it wider. The three treatments are discussed below.
The 1990s have seen the advent of the use of topical steroidal and nonsteroidal medication for the treatment of narrow foreskins (phimosis) in boys. Topical steroid ointment is now the treatment of choice for phimosis, due to low morbidity, lack of pain or trauma, and low cost.
Reports in the medical literature from Sweden, Norway, Denmark, Italy, France, Australia, Serbia, and the United States have demonstrated the efficacy of topical steroid ointment in the relief of preputial stenosis in boys. The application of steroid ointment to the foreskin has the effect of accelerating the normal growth and expansion of the foreskin that occurs over several years and which usually results in the spontaneous relief of the non-retractile condition. Narrow foreskins usually eventually widen without treatment.
The treatment is non-surgical. There is no trauma and no surgical risk. The treatment is inexpensive. The foreskin and all of its protective, erogenous, sensory, and sexual physiologic functions are preserved. A success rate in the range of 85-95 per cent is reported. Treatment of narrow non-retractile prepuce with topical steroid ointment is now recommended by the American Academy of Pediatrics in its 1999 Circumcision Policy Statement.
CIRP presents a bibliography of the medical articles on the use of topical steroid ointment in the treatment of phimosis. Scientists in have conducted research in the use of topical steroid ointment in the medical (not-surgical) treatment of non-retractile foreskin. All have found that the medical treatment is safe, and has about an 85% success rate. Yilmaz et al. recommend the use of topical steroid ointment to avoid the anxiety, stress, and trauma caused by circumcision. Articles are listed in the approximate order of publication.
Skin that is under tension expands by growing additional cells. A permanent increase in size occurs by gentle stretching over a period of time. The treatment is non-traumatic and non-destructive. Manual stretching may be carried out without the aid of a medical doctor. The treatment is inexpensive. Relief of phimosis by a stretching technique has the advantage of preserving all foreskin tissue and the sexual pleasure nerves. The Beaugé method has proved successful for many.
Addendum: Turumaki Corporation in Japan claims to have invented a device for stretching the foreskin. They claim that success can be achieved in a number of weeks. (Note: CIRP does not endorse or promote any product or commercial site.)
[CIRP Note: There now is an online bulletin board where men exchange notes regarding conservative treatment, especially stretching, of non-retractile foreskin. For more information, visit How to Fix Phimosis and Tight Foreskins, Solutions That Work.]
There is one report from Italy regarding the use of topical steroid ointment and stretching in combination to effect relief of non-retractile foreskin.
Preputioplasty is the medical term for plastic surgery of the prepuce or foreskin. It is a more conservative alternative to the traditional circumcision or dorsal slit for the treatment of preputial stenosis or phimosis. Many doctors have proposed surgical alternatives to circumcision because of the many problems, risk, complications, and disadvantages inherent in circumcision.
Advantages claimed for preputioplasty are more rapid, less painful recovery, significantly less morbidity, and preservation of the foreskin and its various protective, erogenous, and sexual physiologic functions.
There are a number of articles is the medical literature describing various preputioplasty techniques. CIRP presents below a bibliography of articles known to us (there may be others.) The articles are listed in the approximate order of their appearance.
Some of the procedures such as Y- and V- plasties are complex and require a skilled surgeon to perform properly. Consequently, they have not won favor.
Many doctors recommend the "dorsal slit with transverse closure" procedure described by Cuckow, Rix, and Mouriquand. The American Academy of Pediatrics now recommends the Cuckow procedure in its 1999 Circumcision Policy Statement. The procedure is relatively simple to perform and gives good results. The newer lateral procedure described by Lane et al., however, may offer a cosmetic improvement over the Cuckow procedure. It moves the "slit with tranverse closure" from the top to the sides.
Frederick M. Hodges, D. Phil., an Oxford medical historian, has researched the classical medical literature. He presents his report on the treatment of phimosis and paraphimosis in antiquity.
For many years, before modern methods had been developed, radical circumcision was the only treatment offered for tight foreskin. However, radical circumcision is now obsolete. It is more painful and has a more difficult recovery than the newer conservative treatments. Radical circumcision also destroys much functional tissue, results in severe loss of sexual sensation, and destroys normal male sexual-mechanical functioning. According to cost-benefit studies, radical circumcision is also the most expensive method of treating tight foreskin, but is still promoted by many medical doctors. Holman and Steussi provide us with an excellent description of this traditional but outmoded procedure. Choe and Kim provide a description and images of the traditional procedure.
If this condition persists the tissue may become oedematous and swell thus further aggravating the problem.3 First aid for this condition is simple. The head of the penis must be squeezed very tightly between thumb and forefinger. This forces blood out of the head and reduces the size. The foreskin can then be brought forward to its normal position.
Application of ice may also be helpful.3 Hospital treatment with injection of hyaluronidase has been shown to be successful.1,3 Hyaluronidase works by reducing the oedema, after which the foreskin may be returned to its normal position. When the foreskin has been returned to its normal position, no further treatment is necessary. Some doctors recommend circumcision but there is no evidence in the medical literature to support this recommendation.
Reynard and Barua recommend the puncture technique.2 Incisions are not necessary. Improved cosmetic outcome is claimed. Again no circumcision is necessary.
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