Uncircumcised? Know the Causes and Symptoms of Phimosis

Penises may sometimes seem like more trouble than they're worth. You have your unscheduled erections, your annoying post-pee dribbles, your nocturnal emissions and more.

Add an intact foreskin to the picture and a whole new set of issues arises for your penile health and hygiene. Uncircumcised penises are no dirtier than circumcised ones, but being uncircumcised does require extra work for regular penile maintenance.

It can also mean dealing with extra complications, such as phimosis.

What is phimosis?

Phimosis is defined as a condition in which the foreskin of an uncircumcised person can't be retracted. It means the foreskin is unusually tight or adhesions are connecting the inside of the foreskin to the penis head, making retraction of the skin uncomfortable or impossible.

Many uncircumcised people live with some degree of phimosis. It becomes a problem only if it causes symptoms, according to Cleveland Clinic.

In practice, the term phimosis may get overused.

"Phimosis is one of those garbage terms that can mean anything from having extra foreskin to having a foreskin that won't retract," said Amanda North, M.D., the director of urology at the Children's Hospital at Montefiore in the Bronx, New York. "It is kind of used for everything because a lot of medical terminology is driven by billing codes, and the diagnosis code for 'redundant foreskin' and 'foreskin that won't retract' are one and the same. So anyone who doesn't like their extra foreskin gets categorized as phimosis, even if the foreskin retracts all the way, easily, without any problem."

It's normal for young, uncircumcised children to not be able to pull back the foreskin because male babies are born with adhesions connecting the tissue of the foreskin to the penis head beneath it. These adhesions generally resolve on their own over time, and by age 6, 92 percent of boys have retractile foreskins. By the time they turn 16, 99 percent of boys can retract their foreskins.

Causes and types of phimosis

It's difficult to pin down a cause of phimosis. In its purest sense, the term refers to a normal condition of the uncircumcised penis of a newborn or, in older children and adults, something that's simply a genetic anomaly—one that's fairly common.

Pathological phimosis is a different matter. This term refers to tightness of the foreskin that causes other complications.

The typical type of phimosis is the kind that affects newborn boys who remain uncircumcised.

"That's physiologic phimosis," North said. "So a newborn is going to have a foreskin that doesn't retract, and that's considered physiological and normal. In a newborn, the foreskin is actually kind of closed. It's open enough for them to urinate, but it's normal for a newborn's foreskin not to be able to retract."

Newborns have two foreskin conditions. One, the skin is tight and doesn't retract. Two, there are adhesions between the foreskin and the penis head.

"Over time, those two things should both improve. First, the skin should open, and second, the foreskin should separate from the head of the penis," North added.

Then there's pathologic phimosis, which occurs when the foreskin gets chronically irritated and/or the area gets repeatedly infected, causing a buildup of scar tissue. These conditions can lead to certain diseases that further damage the skin.

A common underlying cause of these situations occurs when someone has a particularly tight and less retractable foreskin and tries to pull it back too forcefully, damaging it and causing scar tissue to build up.

The tightness can also lead to near-constant contact with urine when it becomes trapped under the foreskin after urination, a major irritant that can also lead to scar tissue developing.

"As kids get older, sometimes the skin gets damaged," North said. "And it's not just that the skin won't retract. Sometimes there can be scarring in the skin, and that can lead to all sorts of problems, including lichen sclerosus, which is a skin disease where the skin is permanently damaged."

Risks and symptoms of phimosis

Some of the major symptoms of phimosis include the following:

• Redness or discoloration, especially when the foreskin becomes infected
• Swelling or inflammation
• Soreness
• Cracking and bleeding skin
• Pain while urinating
• Painful erections

The risks are nothing to ignore. We're talking about a whole lot more than just having a mildly irritated penis from time to time.

For starters, all the irritation, possible infections, exposure to urine and potential secondary infections cause scarring, which makes it even more difficult to retract the foreskin. It can get so bad that the foreskin can't be moved at all.

"In those kids, even in the operating room, we can't pull the skin back," North said. "We have to cut it to clean under it, whether that's because of someone forcing it back and causing it to rip, and it heals with a scar, or because of repeated infections or because it's been repeatedly exposed to urine because of urine trapping. The cause isn't always clear, but in my patient population, it's not as uncommon as you might think."

North related a story of a boy who presented at the emergency room with blood in his urine, a symptom that turned out to be an unexpectedly phimosis-related one.

"He was 8 to 10, in that age range, and he went to the ER with blood in his urine," North explained. "And I thought, 'Oh, we better get a renal and bladder sonogram,' until I examined him. His foreskin was scarred and cracked, and the skin was bleeding. He could barely pee. I got him on my OR schedule within the week because he just needed a circumcision. Once the skin is permanently damaged, the patients are better served with circumcision."

All this damage due to pathologic phimosis can lead to even bigger trouble later.

"It can mean the skin is permanently damaged, and it can even be a risk factor for later having penile cancer," North said.

Understanding the risks and the differences

The main takeaway in learning about phimosis should be to understand when it's a problem and when it's normal.

One seemingly common situation North alluded to is people getting worried when their small child's foreskin doesn't retract due to normal physiologic phimosis, even before they reach the appropriate age for it to do so. It's even possible that some parents may cause well-intentioned damage by trying to force it back.

On the other end of the spectrum, the 8-year-old boy with pathologic phimosis whose foreskin was so damaged that it was cracked and dripping blood into his urine was clearly a situation that should never have gone on as long as it did.

Not to be overdramatic, but recognizing the difference can save a person a lot of discomfort and also save lives, considering phimosis is a risk factor for penile cancer.

Is phimosis becoming an issue for you? See a doctor. If for any reason you're looking for a new doctor, Giddy telehealth takes the difficulty out of the search. The easy-to-use online portal provides access to hundreds of healthcare professionals who have expertise across the full scope of medical care. Many of them specialize in men's health and offer same-day video visits.