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Phimosis
Scope
This guideline covers Phimosis in both adults and children.
Phimosis is the inability to retract the foreskin
True pathological phimosis is rare in those under 18 year old and must be distinguished from physiological adherence of the foreskin to the glans, which is normal.
The proportion of partially or fully retractable foreskin by age is at:
- Birth 4%
- 6 months 20%
- 1 year 50%
- 11 years 90%
- 12-13 years 95%
- 14+ years 99%
A non-retractile foreskin and/or ballooning of the foreskin during micturition in a child under two, do not routinely need to be referred for circumcision.
Pathological phimosis is more common in the adult population. This is due to scarring of the foreskin secondary to a wide list of conditions. The differential diagnosis includes recurrent balanitis, sexually transmitted diseases (STDs) and skin diseases such as eczema, psoriasis, lichen sclerosus, Zoons balanitis, carcinoma in situ, and frank squamous carcinoma.
Phimosis is a risk factor for penile carcinoma.
Cultural circumcision is not NHS funded within Devon – see circumcision commissioning policy
Parents and patients should be made aware of the risks and benefits of circumcision.
Phimosis (true or physiological) usually presents with one or more of the following:
- poor stream
- ballooning of foreskin on micturition
- 'spraying' or poor stream on micturition
- recurrent attacks of balanitis
- pain on intercourse in adults
- in severe cases, hydronephrosis
Phimosis
- Why has the patient presented at this time?
- What problem is the condition is causing?
Both patient and parental expectations should be explored and the options explained.
- If the issue is a non-retractile foreskin and/or ballooning during micturition in a child under two, a conservative approach should be taken as physiological phimosis which will usually resolve with time.
- Avoid forcible retraction of a congenital phimosis, as this can result in scar formation and an acquired phimosis.
- Personal hygiene is very important. Advise cleaning under a retractable foreskin and always reduce it to cover the glans after cleaning.
- Topical steroid application to the preputial ring to treat 'phimosis' has reported success rates between 33-95%.A prescription would not normally exceed three months and should have achieved maximal therapeutic benefit within this time. A topical steroid such as Betamethasone (0.025-0.1%) is commonly prescribed
Only a minority of children will have pathology and be subsequently listed for circumcision:
- N&E: "See topical corticosteroids"
Indications for referral for circumcision (circumcision commissioning policy):
Circumcision is routinely commissioned in Devon for:
- Physiological phimosis:
- In children approaching puberty and adults with persistent symptoms (discomfort, pain, difficulty with self-hygiene, recurrent paraphimosis) despite non-operative management (6-week course of topical corticosteroids).
OR - In children with a diagnosed abnormality of the urinary tract where circumcision is part of secondary management to reduce urinary tract infections.
- In children approaching puberty and adults with persistent symptoms (discomfort, pain, difficulty with self-hygiene, recurrent paraphimosis) despite non-operative management (6-week course of topical corticosteroids).
- Clinical diagnosis of pathological phimosis (balanitis xerotica obliterans / lichen sclerosus).
- Recurrent balanitis or balanoposthitis (3 or more episodes within 12 months despite treatment with topical corticosteroids).
- Acquired trauma where reconstruction is not feasible (e.g., following zipper trauma or dorsal slit for paraphimosis).
Referral Instructions
For adults
e-Referral Service Selection
- Specialty: Urology
- Clinic Type: Not Otherwise Specified
- Service: DRSS-Eastern-Urology- Devon ICB- 15N
For children
e-Referral Service Selection
- Specialty: Children's & Adolescents Services
- Clinic Type: Urology/Surgery – not otherwise specified
- Service: DRSS-Eastern-Child & Adolescent Services-Devon ICB - 15N
Referral Form
Pathway Group
This guideline has been signed off on behalf of NHS Devon.
Publication date: June 2020
Updated: February 2024
