All About The Tight Foreskin

Today, we are going to talk about a topic which is rather sensitive, but really important to all boys and men, which is phimosis.

Phimosis is the tightness of the foreskin that prevents the foreskin from naturally sliding down to expose the head of the penis. In milder forms of phimosis, the foreskin can still slide down to expose the head partially, but in more severe forms of phimosis, the foreskin cannot slide down at all.

One common complication of phimosis is something called paraphimosis. What happens is the foreskin slips down behind the head of the penis and it cannot go back up. Then what happens is the tightness of the foreskin strangulates the head of the penis, and this can compromise blood flow to the head itself. This is actually a medical emergency and a lot of patients end up in A&E just to get this fixed. The other complication that more severe forms of phimosis can lead to, will be infections. So can you imagine for a person with a tight foreskin, after urination a lot of the urine and the dampness is then trapped underneath the foreskin next to the head.

This is a very good environment for different fungus and bacteria to grow, and this can lead to infection of the foreskin as well as the head of the penis. This condition is known as balanitis and this can be very severe in people with conditions that can affect their immune system strength for example, people with diabetes.

The two commonest causes, the first would actually be diabetes. In fact, for a lot of my patients, and in a case study we will discuss a bit later, a tight foreskin is actually the first presenting sign of diabetes.

So, what happens in diabetes is a patient's immune system gets compromised and the urine that's trapped under the foreskin forms an environment for fungus to overgrow. This leads to what we call a fungal balanitis, a fungal infection of the foreskin. Now this leads to the foreskin thickening and hardening, and eventually leads to phimosis.

The other common problem we see in adults who develop phimosis is this problem called lichen sclerosis, or in a fancier term, it's called BXO (Balanitis Xerotica Obliterans).

We don't really know the cause of this problem, but what happens in patients with these issues is, the foreskin gets pale, gets hard and gets tight, and if it's not dealt with quickly, this tightness and this hardening can actually spread to the head of the penis and even the urethra, which is the urinary tube within the penis and can get extremely complicated to treat.

For less severe forms of fibrosis, we actually try prescription or medicated creams first and with luck, this can actually soften the skin, allowing it to stretch enough to fix the problem. Unfortunately, for the majority of patients, they end up needing a surgical circumcision. The surgeons would have to sit you down and discuss with you the need for circumcision and also the kind of aesthetic look you want to achieve at the end of it because different patients have different preferences. Some would like more skin removed, some would like less and you need to see an experienced surgeon who will be able to cater to your different aesthetic demands.

Let me tell you a story about one of my patients who suffered from phimosis and came to us for treatment. Let's call him Mr. T. Mr. T was a 45-year-old man who developed pain and cracks in his foreskin. So, he never had any issues with his foreskin previously, but over the last few months, what happened was when he tried to retract his foreskin, it was split and it was extremely painful and it was getting swollen.

You could tell that it was obviously a fungal infection of the foreskin. So, what we did was we did a quick sugar test for him and unfortunately the sugar level was higher than what was expected. We went on to more confirmatory testing and he was subsequently diagnosed with diabetes. So, with this background, then we could confirm the cause of his phimosis was actually a fungal balanitis that was secondary to the uncontrolled blood sugar level caused by diabetes.

First, we had to get the diabetes under control. And that's with diabetic therapy and of course lifestyle changes. And we also had to treat the fungal balanitis with antifungal medications and cream and because he had to go on the medication to control his diabetes that works by making him urinate out sugar, these are risk factors for him getting a fungal balanitis yet again.

So, after much discussion with him, the decision was made for a more confirmatory kind of treatment and that would be a surgical circumcision.

Phimosis is a very common problem that affects men and boys of all ages. If you do think you suffer from phimosis, please don't suffer in silence. Come look for me and I will be very happy to talk to you and try to solve your issues together.