Foreskin problems

Also called Balanitis, Phimosis, Paraphimosis, Tight foreskin

Soreness, tightness and inflammation. A foreskin retracted and stuck behind the head of the penis is an emergency.

What it is

A group of common problems affecting the foreskin.

**Balanitis** is inflammation of the head of the penis and foreskin, causing soreness, redness and discharge. Causes include irritation from soap, poor drying, thrush, bacterial infection, lichen sclerosus, and, importantly, undiagnosed diabetes. **Recurrent balanitis in an adult should prompt a blood glucose test**; it is a recognised presenting feature.

**Phimosis** is a foreskin too tight to retract. In young boys this is normal: the foreskin is naturally non-retractile and usually separates on its own by around ten, sometimes later. **Forcible retraction causes scarring and is harmful**, and it remains widely and wrongly advised. In adults, new tightness is usually scarring, often from lichen sclerosus, and needs assessment.

**Paraphimosis is the emergency.** A retracted foreskin that cannot be pulled forward again swells and constricts the head of the penis, cutting off its blood supply. It is a common consequence of catheterisation or examination where the foreskin is not returned to position afterwards, and it needs immediate reduction.

In children, ballooning during urination and occasional inflammation are common and usually need nothing but reassurance and gentle care.

Signs you might notice

Balanitis: redness, soreness, swelling, itching, discharge, and pain on passing urine.

Phimosis: a foreskin that will not retract; ballooning during urination; discomfort with erections or sex in adults; spraying or difficulty passing urine.

Paraphimosis: a foreskin stuck behind the head of the penis, with increasing swelling and pain, and the head becoming dusky. **This is a 999 or A and E emergency, immediately.**

Also urgent: inability to pass urine; spreading redness with fever; or any ulcer, lump or persistent white patch, which needs assessment.

In an adult with recurrent balanitis, ask for a blood glucose test.

How it can affect day-to-day life

The single most useful piece of advice for parents is: do not force it back. Clean gently on the outside only, and leave the foreskin alone. Generations of children have been harmed by well-meant retraction.

For adults, plain water washing and thorough drying prevents most balanitis; soap, shower gel and antiseptics make it worse.

After any catheterisation or examination, the foreskin must be returned to its normal position. This is the commonest avoidable cause of paraphimosis, and it happens in hospitals and care settings regularly. It belongs on the checklist.

Lichen sclerosus is a common and under-diagnosed cause of adult phimosis, and it responds to strong topical steroid, which can avoid circumcision.

Circumcision is not the automatic answer; topical steroid and gentle stretching resolve many cases of phimosis, and preputioplasty preserves the foreskin.

Recurrent problems in an older man should prompt a look for diabetes and for penile cancer, which is rare but presents this way.

Supporting someone well

Never force a child's foreskin back. Clean the outside gently; that is all that is needed.

Wash with water and dry thoroughly; avoid soap, shower gel and antiseptics on the area.

Always return the foreskin to its normal position after washing, catheterisation or examination.

Treat paraphimosis as an emergency and go straight to A and E.

Ask for a blood glucose test after recurrent balanitis.

Ask about topical steroid for phimosis before agreeing to circumcision.

Get any ulcer, lump or persistent white patch assessed.

Use a condom and get sexual health testing where relevant.

Add foreskin position to the care checklist for anybody being catheterised or given personal care.

Where to get help

999 or A and E immediately for paraphimosis.

A GP practice for balanitis, phimosis and recurrent problems; urology for surgical options.

A sexual health clinic where a sexually transmitted cause is possible.

British Association of Dermatologists publish patient information on lichen sclerosus and genital skin conditions.