There are certain conditions involving the foreskin that only affect uncircumcised men. Some of these are infections or inflammation of the foreskin or disorders with tightness of certain portions of the foreskin. Here we will discuss foreskin retraction disorders, inflammation disorders, structural disorders that can cause tearing of the foreskin during sexual activity, and surgical removal of the foreskin (circumcision). Many of these conditions are caused by poor hygiene of the foreskin, issues with retracting, or structural abnormalities of the foreskin.
Phimosis refers to the inability to retract the foreskin off the glans, while paraphimosis refers to the inability to replace the foreskin onto the glans (it becomes stuck on the shaft of the penis).
Again, phimosis is the inability to retract the foreskin off the glans that has previously been retractable. This is important to note since infants and young boys who are not yet able to retract their foreskin are NOT considered to have phimosis.
Phimosis is more common during childhood(you just said above that phimosis doesn’t occur in young boys), but can also occur in adult men. The inability to retract the foreskin can leave little or even no portions of the head of the penis from showing. This can cause a near closure of the foreskin over the glans which can allow urine to balloon into the preputial sac (the space between the foreskin and the glans) during urination. This increases the chances of urinary tract infections and balanitis (see later on). This ballooning often requires men to squeeze the foreskin to force the trapped urine out of the tightly closed space. Phimosis can also make erections extremely painful because the foreskin is not able to retract, preventing the glans from expanding outward, thus trapping and constricting the glans during an erection. Click HERE to see an typical image of phimosis.
In mild cases, foreskin stretching with or without an anti-inflammatory cream can help loosen the foreskin so it can be retracted. However, in more serious cases the only way to remove the foreskin from the glans is through surgical removal of the foreskin with circumcision.
Phimosis is a condition that should be assessed by a healthcare provider since non-treatment can lead to other issues. Penile cancer is very rare; however, it occurs at the highest rate in men with phimosis. Phimosis can also lead to urinary tract infections, balanitis, and paraphimosis.
Foreskin that hardens due to scar tissue can also cause phimosis (click HERE to see an example). A rare type of phimosis/balanitis is called balanitis xerotica obliterans (or BXO). BXO is a type of inflammation that can progress and cause tissue damage. BXO usually appears as small white plaques or flakes. These can cause scarring that in turn causes hardening of the skin on the glans and foreskin. Getting treatment early can prevent spreading of the skin hardening. Progressive skin hardening can interfere with urination as the urethra becomes involved and less flexible. General penile pain develops as the skin becomes hardened. Erections can also become painful as the hardened skin doesn’t expand during an erection which can cause this hardened skin to crack and split. The exact cause in unknown, but it is thought to be either an infectious disease or an autoimmune reaction that may be caused by exposure to trapped urine under the foreskin. The skin itself becomes inflamed without a bacteria or fungus being present. Circumcision as a child is nearly 100% protective against BXO. Some boys and men circumcised later in life can still develop BXO after circumcision (although less commonly than men who are not circumcised). Treatment with corticosteroid creams may help prevent the spread of the plaques, so early treatment is highly recommended. Other treatments involve surgery to remove diseased tissue and to correct deformities/structural problems that may have developed. Click HERE to see an example of BXO.
Paraphimosis is the exact opposite of phimosis. It involves the inability to return a retracted foreskin back over the glans of the penis. As the foreskin becomes trapped in the retracted position, it can swell, thus cutting off blood circulation to the glans. Paraphimosis often appears as a ballooning ring of tissue at the neck of the penis. Click HERE to see an example of paraphimosis.
Paraphimosis is a MEDICAL EMERGENCY! If not treated, blood loss to the tip of the penis can lead to death of the tissue, which may result in amputation of the glans.
Paraphimosis is often caused by neglecting to replace the foreskin over the glans after cleaning, urinating, masturbating, or sexual activity. Treatment depends on the severity. In mild cases, the foreskin can be forced back over the glans. When this cannot be done, medical attention should be sought immediately. Treatment often involves firmly gripping the penis with a hand or wrapping it in a tight bandage to press some of the fluid out of the area. Icing the penis may also reduce inflammation. Once swelling has decreased, the foreskin can be placed over the glans. If this is not effective, a medical professional may slit the foreskin so it can be restored over the glans, then stitched to preserve the foreskin. However, in severe or repeated cases, circumcision is often performed which permanently solves this problem.
Balanitis & Balanoposthitis
Before starting, we should define a few terms. “-itis” refers to inflammation. There are two types of inflammation we will discuss—balanitis and posthitis. Balanitis is inflammation of the glans or tip of the penis. Even though all men have a glans, typically only men with a foreskin get balanitis. This is due to the fact that irritants or infectious diseases that can cause inflammation are held against the glans by the foreskin in uncircumcised men. Posthitis is inflammation of the foreskin – hence, inflammation of both the glans and the foreskin is called balanoposthitis. However, the term balanitis is often used to describe balanoposthitis as well. We will use the term balanitis to include both balanitis and balanoposthitis.
Balanitis often appears with pain, swelling, and redness of the glans and even foreskin. The foreskin may swell over the urethra causing phimosis. The foreskin can then balloon with urine during urination. In some cases there will be drainage from the preputial sac (between the foreskin and glans) that can have a bad odor. In many cases this creates inflammation of the urethra which can cause urination to be painful. If the inflammation of the foreskin or glans doesn’t go away, a man should see a healthcare provider. Inflammation of the foreskin can also lead to paraphimosis.
There are different causes for balanitis:
Poor hygiene is the leading cause of balanitis. The foreskin contains preputial glands (Tyson’s glands) that produce a waxy substance called smegma. Smegma is a fertile breeding ground for all sorts of bacteria which can cause inflammation of the glans and foreskin. In addition, fungus loves to grow in dark, moist areas, and the preputial sac is a dark, moist area. Keeping the foreskin, glans, and especially the preputial sac clean will prevent a build-up of smegma, thus preventing bacterial infections. Drying the area after cleansing will help reduce moisture, thus preventing fungal infections as well. However, if a man does contract an infection, usually an over-the-counter product is all that is needed to treat an infection. For bacterial infections, an anti-bacterial cream like neomycin-polymixin-B (triple antibiotic) can be used. For fungal infections, an anti-fungal cream like clotrimazole can be used. However, if symptoms don’t start to improve within a few days, seeing a healthcare professional is a good idea.
Allergic reactions to condoms, spermicides, personal lubricants, lotions, or anything else put on the penis can cause balanitis. This type of inflammation typically goes away with cleaning and drying the area well, and can be prevented by avoiding those products that cause allergic reactions.
Infections typically contracted from a sexual partner. This is most commonly seen in men who are sexually active with a woman that has a vaginal yeast infection (a type of fungal infection in the vagina). Nearly one-fourth of uncircumcised men who have sex with a woman who has a yeast infection will end up with an infection of that same fungus on their foreskin and develop balanitis – this is called Candidal Balanitis. Symptoms usually include itching and rash on the penis and often white flakes on the glans of the penis. It’s not uncommon for there to be a white discharge from under the foreskin. Typically, stronger antifungals are needed to treat these types of fungal infections, so seeing a healthcare provider is often warranted. Other causes may be due to a sexually transmitted infection. Men who have been sexually active with a new partner and are experiencing burning while urinating or have a discharge of pus or fluid coming from the urethra (a discharge that isn’t urine, semen, or pre-ejaculate), should see a healthcare provider right away as it may indicate chlamydia or gonorrhea (click HERE to learn more about sexually transmitted infections).
Friction is also a cause of inflammation, but this affects the frenulum more than the glans (see below). Some men may develop inflammation of the frenulum from sexual activity. When this does occur, it’s most often associated in men with a short or tight frenulum that masturbate for prolonged periods of time. Often this is one-time occurrence and abstaining from sexual activity for a few days or weeks until the inflammation resolves the issue. If this does not resolve the issue or if the frenulum tears or bleeds, seek medical attention for treatment options that will prevent future inflammation in this area.
In men who have repeated episodes of balanitis, some healthcare providers recommend circumcision to remove the foreskin, thus removing the chances for repeated infections and/or inflammation.
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