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Phimosis ~ Paraphimosis ~ Smegma ~ Fibrosis ~ Redundant Prepuce ~Frenulum Breve ~ Balanitis
Note that the foreskin (prepuce) will not retract off of the glans during erection. This is called "phimosis".
After infancy the foreskin should be loose enough to be drawn back so as to completely expose the whole glans (penis head) and to be pulled forward again without pain or difficulty. In the mature youth this action should be possible with the penis erect. If it cannot be retracted at all (phimosis), washing is not possible and smegma accumulates.
Phimosis in adults also makes sexual intercourse unsatisfactory and low deposition of semen in the vagina (as seman is often deposited inside the prepuce) may cause infertility. Occasionally the opening becomes so small that even urinating becomes difficult.
If a tight prepuce is forcibly drawn back (e.g. during intercourse) it may become trapped behind the glans and incapable of being pulled forward again (paraphimosis). In this painful condition the foreskin strangulates the glans and emergency treatment is necessary.
Phimosis may follow injury or inflammation (see below), or it may be a developmental abnormality. Parents are often surprised to learn that their teenager needs a circumcision, having been assured he was perfectly normal earlier in life. The explanation is that before puberty the opening in the prepuce was large enough to allow the glans to pass through but during the rapid growth of the penis after puberty only that part of the foreskin which covers the glans enlarges. In consequence, the tip of the prepuce which lies beyond the glans does not grow, the opening stays the same size and the much enlarged glans will no longer pass through.
A tight prepuce (foreskin) CANNOT BE CURED by stretching because small splits or tears which heal with scarring, make the condition worse than before. The only acceptable cure for a tight or phimotic foreskin is circumcision.
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A True Story of
I'm Vuk from Croatia and I'm 25 now. In my country there is no routine circumcision and the procedure is considered to be a religious act only. I'd been suffering from congenital phimosis combined with a short frenulum for so many years. I couldn't pull back my foreskin at all. In my childhood those problems were manifesting through itching, infections and burning feeling. Later I found out I'd been suffering from recurring balanitis. When I started going to elementary school a doctor told me to practice pulling the foreskin back and that the condition would cure by stretching. It didn't. When I started masturbating at the age of 12 another problems appeared. The foreskin, when penis was erect, due to friction during masturbation, tore several times. Those tears were small and healed quickly but were very painful, taking away the pleasure of masturbation. I couldn't clean my glans easily and couldn't pee if my foreskin was partially pulled back because the tight foreskin would "strangle" urethra. My frenulum was so tight it would turn white and would hurt if i tried to pull the foreskin. When I wanted to start having sex I was too afraid to approach any girl because of my problem. I thought that if masturbations could be so painful, how the actual sexual intercourse would hurt. So I was a virgin until my circumcision...
After recurring problems, I went to see a doctor who wanted to convince me to try some steroid creams combined with stretching rather than undergo circumcision. I, on the other hand, had decided to get rid of this damn foreskin of mine as soon as possible. I started my quest through the circumcision resources on the net, including the CIRCLIST site. I informed myself about the procedure and the benefits of being circumcised. Being in my situation, I couldn't understand those sites protesting against circumcision, knowing that my life would be much improved without the foreskin. So I pulled some connections in the local hospital and a surgeon scheduled my operation for the last day of previous April.
The operation itself gave me some jitters as it was the first I had had. I wasn't sure if I wanted to watch the procedure or not, but when I found out that I would be given general anesthesia I knew that I'd have to sleep it over. I was given some injections in my arm and the last thing I remember was the surgeon cleaning my penis with iodine. When I woke up, first I felt some itching, not painful though, and soon I saw, between my legs, the tip of my glans and the gauze around my penis. It didn't look too much sore. I got out of the hospital the same day but had to refrain from some activities for couple of days. There was some blood coming out from my cut (resected) frenulum the first evening, but other than that bleeding stopped. I was experiencing some pain for a week or so only during nighttime erections when the sutures were under strain. The glans was sensitive for a month, but I got used to that easily. I couldn't masturbate for 4 weeks, but after those had passed I experienced the nicest masturbation ever, finally being able to touch my glans.
Full healing took about 2-3 months, and since then my penis has the present appearance. I have no more problems with hygiene, pain, masturbation or sex. I've benefited from my circumcision physically, psychologically, sexually and medically. Now I lead a happy and normal life and I love my circumcised penis. I cannot talk from the angle of men with loose foreskin, but from the angle of phimosed men I recommend circumcision as the BEST and ONLY TRUE solution.
Vuk (Croatia)
Click the images below for larger viewing.
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Circumcised Freehand Sleeve Resection, Frenulum Removed (below) |
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Obviously all males need to have a fully retracting foreskin by age 16 or soon after if procreation is to be possible! By this age 10% of uncircumcised boys have non-retractable foreskins if they have never attempted to peel and wash them. However, this is not 'normal' (in the statistical sense) since 90% of boys do NOT suffer from this problem! Obviously someone who has reached teenage years with phimosis needs help and I'm not at all suggesting that instructing them in safe stretching techniques is disastrous.
What I am saying is that advising children or parents of children to leave phimosis untreated is wrong and dangerous. Once the penis matures:
1) The risk of paraphimosis and possibly catastrophic trauma increases substantially
2) The extent and amount of stretching required to rectify the situation increases greatly because the glans is so much larger and more difficult (stretching often results in tears to the foreskin, further complicating the situation.)
3) Circumcision becomes more of a problem (erections, larger blood vessels, etc) (and more expensive).
Therefore if the problem is diagnosed before puberty it is much better to treat it with circumcision before puberty. Phimosis that has persisted beyond age 8 is outside the 'normal' range and the safest and most sensible approach is to treat it. As I said before (and have said many times) stretching is certainly a appropriate tactic for those who wish to keep their foreskin. However several studies have shown that circumcision has a lower failure rate and fewer complications and therefore is to be preferred where preserving the fore-kin is not an issue.
James Badger
It is a myth put out by the anti-circ lobby that a baby cannot suffer from phimosis.
Phimosis is defined as "a foreskin that is too tight". It is not just "a foreskin which cannot be retracted". In the infant the foreskin is too tight if the baby has difficulty passing urine. This causes the foreskin to balloon up painfully and also puts a back pressure on the bladder and kidneys which can do permanent harm.
In the older child or adult the foreskin is too tight if ballooning occurs when urinating OR if the foreskin cannot be retracted fully and freely over the coronal rim because it is not elastic enough to stretch that much.
Vernon (UK)
Uncircumcised male with foreskin retracted, presents with large accumulation of smegma (sometimes called 'cock cheese'.) Smegma is thought to be the cause of numerous penile and female urinary/genital infections. The male penis begins producing even greater quantities of smegma during puberty, and care must be taken to wash the penis regularly, from childhood throughout adult life if the male is not circumcised, to prevent the accumulation of this foul smelling substance. The male with phimosis (above) who is unable to retract the foreskin even when flacid (soft) must be circumcised to prevent the accumulation of smegma. Younger males should be regularly checked to ensure no phimosis exists and that no smegma has been allowed to collect under the foreskin or behind the glans.
But do only uncircumcised men have a problem with smegma? No. I was loosely circumcised at birth: I have a long inner foreskin remaining (about 2 inches), which spends most of the day folded up behind the glans. If I am sitting it usually covers the corona (rim of the glans). The inner foreskin secretes smegma, and, especially in the hot weather, there is a noticeable odor, as well as moistness. Although I do not produce anywhere near the amount of smegma that an uncut man does, I produce an amount which, during the summer at least, is inconvenient and unwanted. I think that the problem would have been obviated had I received a slightly tighter job: if the doctor had removed either more of the inner foreskin (possibly another inch or so) or if he had removed more of the shaft skin, resulting in a high-and-tight.
I had a room-mate some years back who had a low-and-tight cut, with very little inner skin, and a very smooth shaft. He never produced any smegma whatsoever.
The moral is, circumcision cures smegma-problems, but some styles (high and/or tight) cure it better than others.
Brad (USA)
Before I was circumcised (at age 30) I tried for
years to eliminate the smell from my penis. I was scrupulously clean, and tried
everything I could think of, but I never got rid of the smell completely.
There was always at least a slight but noticeable odor for the first few seconds
each time I got an erection, and this could be within half an hour of getting
out of a bath or shower where I had pulled the foreskin right back and washed
with soap.
Apart from washing, I was very careful to pull the
foreskin right back when urinating, and for the last few years before being
clipped I trained the skin to stay back all the time. But there was still the
same odor when I got an erection. I used to think it was very unfair of life
that, although I was very turned on by the equivalent smell of a female, I never
found a woman who liked the smell of my penis.
Circumcision removed the odor completely, as well as
looking better and giving me more enjoyable sensations.
Daniel (UK)
I still uncircumcised and I have the same problem - even more so during warm weather. I find I have to wash with soap and rinse seven times a day over the sink before the smell goes away. When anti-circers claim that adequate hygiene can be achieved in a couple of seconds each day in the shower it makes me laugh sometimes. Trouble is, you have to be careful when using soap as in my case I can get a reaction to the soap which then makes matters worse. The best thing I find is to try retraction for a while to let everything dry out and this keeps the smell at bay for a while.
For info to those cut when young etc. who may not have experienced these hygiene problems, in my experience when I was little I used to get curds of smegma quite a lot but this disappeared when I reached my mid-teens. Possibly due to the fact that I masturbated more and took more care over personal hygiene (having discovered sex). However, even today despite having a bath most mornings or a shower I still find that at the end of the day I am moist beneath the foreskin. The hygiene problem really pisses me off and I envy all you lucky roundheads. I'm just posting this so we are all hopefully better informed. You cut guys have given me a fantastic amount of useful information for which I am extremely grateful, this is one of my contributions in return.
Peter (USA)
I have a friend who is up on medical matters he says to get rid of the smell you must dissolve a half teaspoon of cooking salt (NOT table salt) in a glass of warm water. Bathe your penis in the solution for about five minutes, making sure your foreskin is fully retracted. Do not dry it off. You will observe the waste products suspended in the water. Repeat three times weekly or until the condition improves. My personal advice is get yourself circumcised as soon as practical, I had mine at 40 and have never looked back, it is the best thing that could happen to a guy.
Neville (UK)
An Irritation has caused the foreskin of the penis to swell. It is
now retracted behind the head (glans) of the penis and cannot be returned to its normal
position covering the head. This condition is known as paraphimosis, and must be corrected
quickly to restore full circulation to the head of the penis.
Definition:
The inability to pull the retracted foreskin (in an uncircumcised male) over
the head of the penis.
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Causes, incidence, and risk factors:
Paraphimosis is caused by inflammation and narrowing of the foreskin. The
inflammation may be caused by infection and possibly associated with poor personal
hygiene; it may occasionally develop after direct trauma to the area, which results in
swelling. Uncircumcised males and those males who may not have been appropriately or
completely circumcised are at risk.
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Prevention:
Circumcision of infant boys prevents the possibility of developing this
condition.
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Symptoms:
*an inability to pull the retracted foreskin over the head of
the penis
*a painful swelling at end of penis
*penis pain
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Signs and tests:
A physical examination confirms the symptoms. See a Urologist immediately
if you think you have this condition.
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Treatment:
Compression of the head of the penis while applying forward traction on the
foreskin may reduce the paraphimosis and circumcision can be scheduled in the near future.
If the application of pressure fails to allow the foreskin to return over the
glans, prompt surgical intervention (circumcision) is necessary.
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Expectations (prognosis):
The probable outcome is excellent if the condition is diagnosed and treated
rapidly.
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Complications:
If the condition is not relieved rapidly, gangrene or permanent damage to the
penis may occur.
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Calling your health care provider:
Call your health provider if this condition occurs.
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There has been some discussion on the list concerning the Sunday Times article about a 3 year old boy taken to St George's A & E with paraphimosis. The real purpose of that article was to demonstrate how bad the NHS is. The article ended by saying that the boy was now fine. Circumcision as a remedy at the time or as a future requirement never seems to have been mentioned.
But there was another article in the Observer on 28 May about another case of paraphimosis, this time in a boy of 8. The hospital had great difficulty in reducing the swelling and getting the foreskin back into position. In the end, they had to give the boy a general anesthetic. Since the boy was going to have to have a general, the surgeon offered to circumcise the boy at the same time, saying he would certainly have to be circumcised at some point and did the mother want it done now so that he would not need another operation. The mother was about to agree, but then decided against. The rest of the article was then about circumcision, how the boy's father and step-father, both uncircumcised, had been horrified that the boy might have been cut, how the boy's GP had said the condition could be kept under control for now with creams etc.
I had always thought that paraphimosis was a definite medical indication for circumcision. Someone on the list has already speculated as to how the 3 year olds foreskin got pushed back, and similar thoughts arise about the six year old. Both may have been cases of over anxious mums making sure the foreskin retracted properly. The two cases led me to speculate about the development of the foreskin up to puberty.
Obviously as the body and penis grows, so does the foreskin and the size of the opening. (The adult glans would not go through a foreskin opening the size of a baby's.) But I would have thought that, as the glans develops, it is likely to grow more in proportion than the foreskin opening. In other words, if a boy has a genuine phimosis in childhood (I use the word genuine to mean an inability to retract the foreskin through narrowness of opening rather than adhesions), that is unlikely to correct itself as he grows. So it would follow that any boy suffering one bout of paraphimosis is very likely to suffer another, particularly after puberty when the penis expands fully during erection and it is likely to happen at a very embarrassing time when the boy is masturbating or making love.
Paraphimosis is of course serious because the constriction must be reduced quickly otherwise the blood supply can be cut and permanent damage ensue. I feel particular sympathy for the surgeon in the case of the 6 year old. The boy's penis was already going to be traumatized by the reduction process. He was already having to undergo a general anesthetic. A circumcision would probably have been as quick to perform and the boy would have suffered no more discomfort than he did through the paraphimosis. And almost certainly at some stage the boy is going to be back in hospital with another bout, this time circumcision will be done, NHS resources will have been wasted and the boy will have been put through another traumatic experience which would have been unnecessary had the mother agreed to circumcision the first time.
But perhaps I am wrong and a foreskin with a tendency in childhood to get stuck behind the glans develops out of this at a later age? I realize that all such trouble would have been prevented by an Routine Infant Circumcision (RIC). But that is not the point here. What I am really asking is, for those parents who want to eave their son intact, what are the medical indications for them nevertheless to agree to a circumcision being performed.Ivan (UK)
Q. A friend of mine who was circumcised a few weeks ago because of a tight, unretractable foreskin. He told me that the urologist reported that he did not have "true" phimosis, but rather "fibrosis." What is the difference?
A. Phimosis is tightness of the foreskin - it may be congenital or acquired. Fibrosis is the growth of tough, fibrous tissue where there shouldn't be any. It's normally a secondary condition and the only medical records I recall associating it with phimosis was for secondary phimosis acquired after an improperly performed (usually too loose) circumcision. (If circumcision is done in such a way that the actual scar can move over the glans this is a common and disastrous complication - for this reason a loose circ should be either very high [away from the glans and closest to the body] or performed with a Plastibell or Tara KLamp to keep the healing scar tissue away from the glans.)
Since you don't mention that your friend had been previously circumcised it is likely that his fibrosis resulted from tearing and scarring associated with a pre-existing phimosis and/or lack of hygiene in caring for the glans.
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| The photos above exemplify the redundant, overhanging prepuce. A redundant prepuce can simply overhang the glans just a little, or be grossly redundant as seen in the photo at the far right above. In any case a full circumcision should be considered to improve both hygiene and sexual relations. | ||||
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| The photos in the above set show the erect penis with a redundant prepuce. Note the foreskin does not automatically retract on these men, and must be manually 'skinned back' for washing and sexual relations to occur. Most uncircumcised men with a redundant prepuce also have what is referred to as a 'weighted tip' which is a somewhat, if not fully, restrictive frenar band at the mouth of the foreskin. This ring of thicker, heavier tissue disrupts the natural foreskin retraction process that should occur upon erection. It is estimated that 30% of uncircumcised men and boys have a redundant prepuce and weighted tip. | ||||
| The photos to the right show an 18 year old male with a short, restrictive frenulum. Even skinned back as shown far right, you can note that the foreskin is unable to lay smoothly back on the shaft during erection. |
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| The photos to the right show a 24 year old male with an even more restrictive frenulum, which when combined with the extremely tight frenar band (weighted tip), is good cause for an immediate emergency circumcision. Most physicians would diagnose this male with phimosis because of this dual condition. Even if the frenar band was removed, the remaining foreskin would not be able to properly retract and would tear during intercourse or masturbation. A full circumcision is highly recommended for this individual. |
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Short frenulums, long foreskins, weighted tips (frenar bands), and other issues common to the uncircumcised male often end up causing diseases of the penis including cancer and balanitis. Balanitis is so common and so much information exists on this problem of the uncircumcised male, that we have had to place it on its own page. Click here for a complete discussion of balanitis.
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