HOW TO KNOW IF I HAVE PHIMOSIS - AND OF WHICH KIND IT IS

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​Can your foreskin (skin that covers the glans or "head" of the penis) be retracted? Can you easily move it behind the glans, and bring it back to the front without experiencing pain or discomfort, more or less as in this real example for adults? If not, you have phimosis ("muzzle" in Greek). Read on to better understand what this means, and find out whether your phimosis is physiological or pathological.
Babies are born with non-mobile and tight foreskins: this protects them from contamination. Left alone, most boys will make their first full prepuce retraction just before puberty[1]. By the time of adulthood, almost all men should already be able to retract it fully, even if not entirely comfortably.

IS IT POSSIBLE TO HAVE PHIMOSIS ONLY WHEN ERECT?

Yes. It is very common, especially during adolescence, that the foreskin can be retracted smoothly when the penis is flaccid, but exhibits some degree of phimosis during erections.

MECHANICAL CONDITIONS

But what exactly can prevent the retraction of the foreskin? There are two main mechanical conditions responsible for phimosis after puberty, either flaccid or erect:
  • ​PHIMOTIC RING: the narrower part of the foreskin (preputial ring, also called frenar band) is too narrow to pass around the glans penis. When this happens, the preputial ring is then called a phimotic ring. The technical name of this condition is preputial stenosis ("narrowing" in Greek).​
  • SHORT FRENULUM: the frenulum (a structure similar to the frenulum of the tongue, but which connects the foreskin to the ventral part of the glans) is too short to allow complete retraction. This condition is also called frenulum breve.​
These mechanical conditions may occur alone or in combination. It is not uncommon for phimosis to be a consequence of both a very tight opening of the foreskin and a short frenulum at the same time.
In general, however, a tight foreskin is the most frequent cause of phimosis. This is because the preputial ring (frenar band) near the opening is naturally less malleable than the rest of the skin, precisely to ensure that the glans remain protected and lubricated by the foreskin while the body moves during the most varied daily activities.

TYPES OF PHIMOSIS

Depending on the nature of the mechanical conditions causing phimosis, it can be classified into two kinds: physiological or pathological.

1 - PHYSIOLOGICAL PHIMOSIS

When the mechanical conditions responsible for phimosis are congenital (present from birth), it is called physiological. Physiological phimosis is, by far, the most common type of phimosis.

2 - PATHOLOGICAL PHIMOSIS

When the foreskin narrows or tightens due to some skin disease or injury, phimosis is called pathological or acquired. Its causes are mainly of inflammatory nature:
  • LS (BXO): lichen sclerosus (also known as balanitis xerotica obliterans) is one of them. This chronic inflammation of the skin is associated with the appearance of lesions that cause a stiffening of the preputial opening. In this case, the skin looks fibrous, lacerated and whitish.​
  • ​​POSTHITIS: tightening of the foreskin by acute or chronic inflammation of its mucosal surface due to infections caused mainly by bacteria and fungi. When, in addition to the foreskin, the glans is also inflamed, it is called balanoposthitis.
  • REPETITIVE INJURIES: chronic inflammation caused by recurrent injuries, such as urinary catheterization or frequent forced retraction of the foreskin, can also cause phimosis as they generate lacerated and scar tissue, which is much stiffer than uninjured skin.​​​
  • ​​​​DIABETES: untreated diabetes can also generate phimosis because of the presence of glucose in the urine, which can infect the foreskin causing it to stiffen.
Worried? Relax. The good news is that physiological phimosis can almost always be resolved with non-invasive or conservative (without tissue removal) methods. In addition, a large proportion of posthides and balanoposthides respond well to treatment with antibiotics or fungicides[2], and LS in some cases can be reversed with the application of ultra-potent steroid cream[3]. So if your skin disease is soon diagnosed as unmanageable by a general practitioner or urologist, finding a good dermatologist for a second opinion may be a good idea.
But, whatever is the cause of your phimosis, what's your score?

REFERences

  1. Thorvaldsen MA, Meyhoff H (2005). Phimosis: pathological or physiological? Ugeskr Læger, 167(17):1858-62.
  2. Edwards S, Bunker C, Ziller F, Meijden W (2014). 2013 European guideline for the management of balanoposthitis. International J of STD & AIDS, 25(9):615-626.
  3. Neill SM, Tatnall FM, Cox NH (2002). Guidelines for the management of lichen sclerosus. British J. of Dermatology, 147:640-9.