Foreskin problems and care
What is the foreskin?
The foreskin is the fold of skin that covers the glans penis (head of the penis). At birth, the foreskin and the glans penis are lightly joined. In most boys, by about five years of age the foreskin can be at least partly retracted (pulled back) and by puberty it is fully retractable in about 9 out of 10 boys.
Illustration by: Vanessa Dudley, Medical Illustrator.
Supplied by: Dr Darren Katz, Men’s Health Melbourne.
Why is foreskin hygiene important?
Bacteria and smegma (collection of dead skin cells and oily secretions) can collect under the foreskin. To help with genital hygiene, the foreskin should be gently pulled back and cleaned daily, but not with strong soaps or chemicals. Keeping the foreskin clean helps to prevent inflammation of the glans penis that is sometimes caused by infection.
During a genital examination, the doctor should check under the foreskin for signs of infection. If there is an infection, the doctor may prescribe antibiotics or antifungal medication. In severe cases of inflammation or infection, circumcision may be recommended.
The foreskin should not be pulled back using force as this can cause bleeding and injury, and sometimes scarring. This scarring can cause ongoing problems with retracting (pulling back) the foreskin, making it hard to keep the inside of the foreskin clean.
For more information on related topics, see:
What is balanitis?
Balanitis is a very common inflammation of the glans penis that can affect males at any age. Balanitis is twice as common in men who are not circumcised compared to circumcised males.
What are the symptoms of balanitis?
Men with balanitis may have the following symptoms:
- not able to pull back the foreskin
- itchiness or rash
- sore or tender glans penis
- redness or swelling
- discharge from the penis.
What causes balanitis?
Balanitis can happen when the foreskin is not pulled back, or is unable to be pulled back due to scarring, and the inside of the foreskin is not kept clean. Inflammation caused by a bacteria or fungus is common. Balanitis can also be caused by irritation from chemicals in soap, clothing, washing powder and latex in condoms, allergies to certain medicines, viruses such as human papilloma virus (HPV), and diabetes.
In adults balanitis can be a sign of diabetes. After urinating, if urine gets trapped under the foreskin, the moist area and the glucose in the urine can lead to bacterial growth. If you have balanitis and it keeps happening, ask your doctor about a test for diabetes.
How is balanitis treated?
Treatment for balanitis depends on the cause. Usually, washing the penis and the inside of the foreskin with soap and warm water will help. Antibiotic or antifungal ointments/creams can treat balanitis caused by infection. If balanitis keeps happening, circumcision may be advised.
What is balanitis xerotica obliterans (BXO)?
Balanitis xerotica obliterans (BXO, also known as lichen sclerosis) is not the same as balanitis. BXO is a far less common condition where scar tissue forms in the foreskin. A ring of white tissue develops at the tip of the foreskin making the foreskin tight so that it is difficult to pull back (phimosis). BXO may very occasionally spread to the glans penis.
Speak to your doctor if you are concerned about white scarring of your foreskin. BXO gets worse over time and is usually treated by circumcision.
Both balanitis and BXO increase the chance of developing penis cancer; however penis cancer is uncommon (less than 1 in 100 of all male cancers) and happens almost only in uncircumcised men.
Phimosis & Paraphimosis
What is phimosis?
Phimosis is when the foreskin is too tight, or the tip of the foreskin narrows and is unable to be pulled back to expose the head of the penis.
What are the symptoms of phimosis?
Severe phimosis can cause pain when urinating, urinary retention, urinary tract infections and the skin on the penis can become infected. Older men with severe phimosis have a higher risk of developing cancer of the penis. Phimosis can cause severe pain with erections and sexual intercourse, causing injury to the foreskin with minor bleeding and infection. In these situations circumcision is usually necessary.
What causes phimosis?
Phimosis is often seen in children or young adults (called primary or congenital phimosis), most commonly before puberty. Phimosis can also happen after injury that causes the foreskin to tear (called secondary or acquired phimosis). As the tear heals, scar tissue makes the foreskin less able to stretch far enough to pull back. The scarring from BXO can also cause phimosis. Phimosis can happen after infection or as a result of inflammation (balanitis).
How is phimosis treated?
Phimosis can be treated with steroid creams applied once or twice daily for a couple of weeks. Studies have shown that the creams have a good rate of success (more than 85 per cent) and the treatment works better if the foreskin is gently stretched at the same time as applying the cream.
If steroid creams do not work or phimosis is severe, circumcision may be the best option. Adult men with phimosis should be checked for balanitis, diabetes and penis cancer.
What other condition can cause problems with retracting the foreskin?
Frenulum breve, or a short frenulum, is where the frenulum of the penis (a band of tissue on the underside of the glans penis that connects to the foreskin), is too short and restricts the movement of the foreskin. This can cause pain during sexual intercourse.
How is a short frenulum treated?
A frenuloplasty is an operation where a cut is made in the frenulum so that it can be stretched to make it longer and the cut is then stitched closed. It usually takes about four weeks to recover from the operation and normal sexual activity should then be possible.
What is paraphimosis?
Paraphimosis happens when the foreskin has been retracted behind the head of the penis and cannot go back to its original position. If the foreskin stays in this position, it can cause pain and swelling and can stop blood flow to the penis. This is a serious medical problem and must be treated immediately or there can be long-term damage to the penis, including gangrene.
What causes paraphimosis?
Paraphimosis can happen at any age, and can be caused by injury to the head of the penis. It can also happen to infants if a parent pulls back the foreskin and either does not, or is unable to, pull it forward again.
How is paraphimosis treated?
It is important to apply ice to lessen any swelling and then try to move the foreskin forward, using lubricant gel, to its usual position. Other ways to lessen foreskin swelling include injecting certain medicines. If the foreskin does not go back to its normal position, a surgeon may have to cut the foreskin to release it, or an urgent circumcision may be needed.
What is circumcision?
Circumcision is the surgical removal of the foreskin. For thousands of years, male circumcision has been a part of religious practices and cultural rites of passage; in some traditions circumcision still remains an important part of a boy’s life.
Why are circumcisions done?
In Australia, circumcision of infant males was once very widespread but has now declined to around one in seven infant boys (10-20%). Most infant circumcisions are now done for health reasons, family tradition, or religious or cultural traditions.
Circumcision in older boys or men is usually only done to treat a medical condition (such as balanitits, phimosis, paraphimosis or BXO), although some men choose to be circumcised for personal reasons.
Circumcision can lower the risk of repeated urinary tract infections, infections under the foreskin, tearing of the foreskin, and sexually transmissible infections (STIs) such as HPV, genital herpes and HIV. Circumcised men also have a very low risk of penis cancer (an uncommon cancer that affects up to 1 in 1,000 uncircumcised men during their lifetime).
What are the risks of circumcision?
Circumcision in an older boy or man is a more complex operation than when done on infants, although it is usually successful. About 3 in 200 circumcisions have some complication, although serious complications are rare. The most common problems are inflammation, bleeding and infection and these can usually be treated easily. There is some pain both during the operation and for some time afterwards. To help lessen pain, the doctor uses either a local anaesthetic or, if the boy is old enough, a general anaesthetic may be used.
Good sexual function and sexual pleasure are experienced by both circumcised and uncircumcised men.
What are some things to think about?
Circumcision is a legal procedure in Australia and parents may make the choice to have their baby boy circumcised. If a doctor recommends circumcision of a young child to treat a medical condition, parents will be given information on the procedure and the possible risks and benefits of the operation.
If an adolescent or adult man needs a circumcision for a medical reason (or chooses to have a circumcision for other reasons), the doctor will provide information on the risks and benefits so he can make an informed decision.