Adult Section: Foreskin Tear, Circumcision Decision, and Testicular Position

**55. What causes recurrent foreskin tears?**

There are two main causes of foreskin tears: First, phimosis or paraphimosis, due to long-term chronic irritation from urine and smegma, can induce balanitis, causing edema, congestion, erosion, and tearing of the foreskin mucosa, leading to repeated cross-infection. Second, repeated friction during sexual intercourse can easily cause foreskin swelling, which becomes more pronounced during vigorous activity, and may even lead to paraphimosis, making tears and bleeding more likely during sexual intercourse.

Because of the foreskin fissures, residual urine often accumulates inside the foreskin along with shed cells, mucus, and bacteria, forming smegma in a warm, moist environment. If not thoroughly cleaned for a long time, this can irritate the glans penis, leading to balanitis, foreskin stones, and leukoplakia (white spots on the foreskin) due to pigment loss. If these conditions persist, they can cause inflammation, weakened immune function, and may even increase the risk of penile cancer. Furthermore, those who engage in unprotected sex are more susceptible to sexually transmitted infections such as gonorrhea and genital warts.

However, patients who experience foreskin tears shouldn't worry; circumcision is considered a minor urological procedure. Currently available circumcision techniques are quite advanced, generally achieving short procedure times, quick recovery, and good post-operative appearance, with minimal pain during and after the surgery. However, because the surgery is performed on a sensitive area, patients experience significant pain during pre-operative anesthesia, which is the main reason why some patients are reluctant to undergo the procedure. In reality, it's a very simple surgery that can be performed on an outpatient basis.

**56. Is surgery always necessary for phimosis?**

Phimosis refers to a condition where the foreskin covers the glans penis, preventing it from being fully exposed. If the glans can be exposed during erection, it's called pseudo-phimosis; if it cannot be exposed, it's called true phimosis. Paraphimosis, on the other hand, refers to a condition where the foreskin completely covers the glans, preventing it from being exposed at any time. Phimosis may not require treatment if the foreskin cavity is kept clean by regular washing; if recurrent infections occur, circumcision may be performed; while paraphimosis requires surgical treatment. Both phimosis and paraphimosis can easily lead to adverse effects such as infection, paraphimosis with edema, penile cancer, and premature ejaculation.

So, do all patients with phimosis need surgery? The answer is no.

It is generally believed that surgery should be avoided as much as possible for men under the age of 20, because regardless of who performs the surgery, there will be surgical scars, affecting appearance, but having little impact on function. In men still developing, excessive removal of the foreskin can affect penile erection, and may even cause pain or curvature. However, if it is phimosis, early surgical treatment is recommended, ideally before puberty.

For men over 20 years of age with fully developed penises, if recurrent balanitis occurs, partial foreskin removal can be performed to cure the inflammation. If the penis is fully erect but still covered by foreskin, partial foreskin removal can also be performed.

For patients with erectile dysfunction or premature ejaculation, unless it is primary, circumcision and penile dorsal nerve resection are not recommended, as these procedures can increase the patient's psychological burden, rendering the surgery ineffective and potentially worsening the condition. If it is functional, psychological adjustment should be the primary approach, rather than surgical treatment.

**57. What does it mean if one testicle is higher than the other?**

Some men may notice that their scrotum is asymmetrical, with one testicle higher than the other, while showering. Is this normal? What causes it?

Actually, it's normal for one testicle to be slightly higher than the other, with the difference being minimal; usually, the left testicle hangs lower. However, special attention should be paid when the following situations occur:

(1) The testicle hangs low, causing a feeling of heaviness and discomfort, and a worm-like mass can be felt in the scrotum. This phenomenon is often seen in "varicocele". Varicocele is a common disease in young men, usually seen on the left side, and is called primary varicocele. If some middle-aged and elderly men have varicocele, they should pay special attention to the possibility of retroperitoneal tumors (such as kidney tumors, lymphomas, etc.).

(2) If one testicle is positioned exceptionally high, is very soft, and sometimes cannot be felt, this is often seen in cryptorchidism. Testicles usually descend into the scrotum before the age of two. Cryptorchidism is a common congenital malformation caused by various reasons preventing the testicle from descending into the scrotum. Long-term cryptorchidism can lead to testicular atrophy and softening, resulting in impaired spermatogenesis and endocrine function, which can have lifelong effects. Therefore, if the above symptoms occur, a timely medical examination is necessary.

(3) One testicle enlarges rapidly in a short period of time. This should raise suspicion of testicular tumors. Usually, the affected testicle will enlarge rapidly in a short period of time and feel "heavy" to the touch. Testicular tumors can metastasize to pelvic lymph nodes in the early stages, so special attention should be paid when the testicle enlarges rapidly in a short period of time.