What is phimosis?
Phimosis is when the foreskin is too tight to pull back (retract) over the glans, which is the head of the penis. It’s completely normal in babies and young boys, as the foreskin is naturally attached to the glans at birth and separates gradually as they grow. Most boys can retract their foreskin fully by the time they reach adulthood.
When a tight foreskin develops later in life or doesn’t loosen after puberty, it’s called pathological phimosis. This type is usually caused by scarring and often needs treatment, particularly if it’s causing pain, infections, or problems with sex or passing urine.
What causes phimosis?
Phimosis in adults is usually caused by scarring or inflammation that stops the foreskin from stretching properly. Common causes and risk factors include:
- Recurrent infections such as balanitis, which causes inflammation of the head of the penis and foreskin
- Lichen sclerosus, a skin condition that causes white, scarred patches and can tighten the foreskin over time
- The foreskin being forced back too early in childhood, causing small tears that heal with scar tissue
- Skin conditions like eczema or psoriasis affecting the penis
- Diabetes, as sugar in the urine can encourage infections under the foreskin
- Injury to the foreskin, including tears during sexual activity
In some people, a foreskin that was never fully retractable in childhood simply stays tight into adulthood.
What are the symptoms of phimosis?
Some people with phimosis have no symptoms at all and only notice it when they try to pull back the foreskin. Others find it causes:
- Pain or tightness when retracting the foreskin
- Pain during erections or sex
- Ballooning of the foreskin when you pass urine
- A weak or spraying urine stream
- Redness, soreness or swelling around the tip of the penis
- Small cracks or splits in the foreskin, which may bleed
- A white, shiny or scarred ring of skin at the opening of the foreskin
- Difficulty keeping the area clean, leading to smells or discharge from repeated infections
How is phimosis diagnosed and graded?
Phimosis is usually diagnosed with a simple physical examination. Your GP will look at your foreskin and ask how long it’s been tight and whether you’ve had any pain, infections or problems passing urine. You won’t normally need any tests, but you may be asked to provide a urine sample to check for infection or diabetes, or to have a swab taken if there are signs of infection. If there’s scarring that suggests lichen sclerosus, your GP may refer you to a specialist.
Doctors also grade phimosis by how far the foreskin can be pulled back. One commonly used scale runs from 0 to 5:
- Grade 0: The foreskin retracts fully with no tightness
- Grade 1: The foreskin retracts fully, but there’s a tight band behind the head of the penis
- Grade 2: Only part of the head of the penis can be exposed
- Grade 3: The foreskin pulls back just far enough to see the opening of the urethra
- Grade 4: The foreskin moves slightly, but neither the head of the penis nor the urethral opening can be seen
- Grade 5: The foreskin can’t be pulled back at all
Lower grades usually respond well to steroid creams and stretching, while higher grades with heavy scarring are more likely to need surgery.
What is the difference between phimosis and paraphimosis?
Phimosis means the foreskin is too tight to pull back. Paraphimosis is the opposite problem, where the foreskin has been pulled back behind the head of the penis and can’t return to its normal position.
With paraphimosis, the tight foreskin acts like a band, restricting blood flow to the penis and causing the head to swell which makes it even harder to move the foreskin forward. It’s a medical emergency and can cause serious damage if it isn’t treated quickly. People with a tight foreskin are more likely to develop paraphimosis, especially after sex, cleaning, or a medical procedure like having a catheter fitted.
If your foreskin is stuck behind the head of your penis and you can’t ease it back, go to A&E straight away.
Treatment for a Tight Foreskin
Most adults with phimosis can avoid surgery. The first-line treatment for phimosis is usually a steroid cream applied to the tight band of skin, used alongside gentle stretching to loosen the foreskin gradually.
Steroid Creams
Topical corticosteroids reduce inflammation and help the skin of the foreskin become thinner and more elastic, so it stretches more easily. Betnovate Cream, which contains the potent steroid betamethasone valerate, is often used for this.
You’ll usually apply a thin layer to the narrowest part of the foreskin once or twice a day for 4 to 8 weeks. A phimosis treatment cream works best when you combine it with gentle stretching, and most people notice the foreskin starting to loosen within a few weeks. Our prescribers will review your consultation to check that a steroid cream is suitable for you and advise how long to use it.
Gentle Stretching
Once you’ve been using the cream for about a week, you can start gently easing the foreskin back when you’re in a warm bath or shower when the skin is softer. Only pull it back as far as feels comfortable, and stop if it hurts, as forcing it can cause small tears that heal into scar tissue. Always return the foreskin to its normal position afterwards.
Treating Infections
If your tight foreskin is linked to an infection, it’s important to treat that too. Balanitis caused by a yeast infection is usually treated with an antifungal cream like clotrimazole, while bacterial infections may need an antibiotic.
What should I do if I have a tight foreskin and when should I see a doctor?
If your foreskin is tight but isn’t painful and doesn’t cause any problems, there’s no need to panic. Avoid forcing it back, keep the area clean and dry, and consider a steroid cream if you’d like to loosen it.
You should speak to your GP if:
- Your foreskin is painful, red or swollen
- You keep getting infections under the foreskin
- You notice white patches or scarring on the foreskin
- Passing urine is difficult or painful, or your stream is weak
- There’s blood in your urine
- Treatment hasn’t helped after 6 to 8 weeks
Go to A&E straight away if you can’t pass urine at all, or if your foreskin is stuck behind the head of your penis and won’t go back.
Our online clinic is for adults aged 18 and over, so if your child has a tight foreskin, speak to your GP for advice.
