Foreskin diseases: phimosis, paraphimosis, and paraphimosis
The skin of the penis is thin and movable. At the tip of the penis, the skin folds into a double layer, covering the glans. This skin covering the glans is called the foreskin. Under normal circumstances, in children under 7 years old, the foreskin is relatively long and can completely cover the glans. As the penis grows and lengthens during puberty, the foreskin can no longer cover the glans, exposing it. However, in some adults, the foreskin still completely covers the glans, even when the penis is fully erect, and the glans cannot be fully exposed; this is called phimosis. If the foreskin opening is too small or too tight and cannot be retracted to expose the glans, this is called paraphimosis. If part of the foreskin becomes trapped in the penile sulcus due to penile erection, causing local swelling and pain, it will form paraphimosis. When the foreskin is too long, it is easy for dirt to accumulate, leading to balanitis; when dirt accumulates under the foreskin for a long time, it can form stones, which can be felt as hard lumps under the foreskin. Some diabetic patients experience repeated balanitis, leading to scarring and thickening of the foreskin, narrowing of the foreskin opening, and a tendency for the foreskin to become trapped in the penile sulcus behind the glans. In terms of treatment, if the foreskin is wide and too long, it should be frequently retracted and cleaned; surgery is unnecessary. However, if balanitis recurs frequently, or if the foreskin is too narrow or the opening is too small, circumcision may be performed.
Phimosis refers to a condition where the foreskin completely covers the glans penis and the urethral opening, but can be retracted to expose the glans. If the foreskin is regularly retracted and cleaned, the foreskin will naturally shorten, usually without the need for circumcision. Paraphimosis, on the other hand, refers to a condition where the foreskin opening is too narrow, preventing retraction to expose the entire glans. In infants under one year old, the foreskin is relatively long compared to the penis, and there are epithelial adhesions between the foreskin and the glans; this is considered physiological phimosis. As children grow older, the foreskin gradually develops and separates from the glans, and most cases of phimosis disappear. Surveys show that approximately 27.28% of preschool children aged 5-7 years have phimosis. Whether it's phimosis or redundant foreskin, the foreskin constantly covering the glans increases the temperature and humidity inside, creating a favorable environment for bacterial growth. If the area is not cleaned promptly, inflammation can easily occur. Over time, adhesions between the foreskin and glans can form, affecting development and causing painful intercourse. Chronic irritation caused by long-term phimosis is often an important factor in the development of penile cancer. Clinical data shows that men with phimosis, especially those with paraphimosis, have a higher incidence of penile cancer. Therefore, men with phimosis who are unwilling to undergo surgery should regularly retract their foreskin and clean away smegma. Clinical observations suggest that some men with phimosis do not actually have an excessively long foreskin; they simply find it difficult to tolerate the discomfort caused by friction between the glans and underwear, and are therefore reluctant to retract the foreskin. It is recommended that the foreskin be retracted to the coronal sulcus to expose the glans; this discomfort will quickly disappear.
From an embryological perspective, congenital phimosis is rare; it is mainly caused by acquired local inflammation. Therefore, from childhood, parents can help children by regularly retracting the foreskin and cleaning smegma to prevent phimosis. For adults with phimosis or redundant foreskin, circumcision is recommended. For children under 7 years old, whose penises have not yet developed and may not be too long, surgery is not necessary; simply helping them retract the foreskin and clean it regularly is sufficient.
Because the foreskin opening is tight, forcibly retracting it upwards without timely and complete repositioning can cause the foreskin opening to become constricted at the coronal sulcus, obstructing blood and lymphatic return from the distal foreskin and glans penis, leading to local congestion, edema, and pain. If not treated promptly, the foreskin and glans penis may ulcerate or even undergo extensive necrosis. Early manual reduction can be performed. First, disinfect with a 1‰ benzalkonium bromide solution, apply paraffin oil locally, grasp the foreskin with the middle and index fingers of both hands and gently pull downwards, while simultaneously using both thumbs to push the glans penis back into the foreskin. This should achieve repositioning. If manual reduction is difficult, the swollen foreskin can be punctured with a needle to allow tissue fluid to drain. After the edema subsides, repositioning can be attempted, which usually succeeds. For severe cases of paraphimosis, under local anesthesia, a 2-3 cm longitudinal incision must be made between the skin and deep fascia of the dorsal foreskin of the penis before repositioning, followed by transverse suturing of the incision. If necessary, circumcision should be performed after the inflammation subsides. The inner foreskin layer about 0.5cm from the coronal sulcus should be removed in a distal circular motion. The frenulum should be preserved. After careful hemostasis, the inner and outer foreskin layers should be symmetrically sutured. Postoperative care should be taken for local care.
Balanitis refers to acute or chronic infection of the foreskin and glans penis, mainly caused by phimosis or redundant foreskin, which easily leads to the accumulation of smegma or foreskin stones composed of sebaceous gland secretions and epithelial debris under the foreskin, which is not cleaned in time. In the acute phase, symptoms include redness and swelling of the foreskin and glans penis, pain and tenderness, dampness accompanied by intense itching. In severe cases, superficial ulcers and foul-smelling discharge may occur, even necrosis of the glans penis, swelling and pain of the inguinal lymph nodes, fever, and chills. After the inflammation subsides, adhesions may occur between the foreskin and glans penis, or urethral meatus stenosis may develop. Treatment: In the acute phase, effective antibiotics are administered, and the foreskin is retracted and cleaned locally. For phimosis, a dorsal incision and drainage is performed, followed by soaking in a 1:5000 potassium permanganate solution. Circumcision can be performed after the inflammation subsides. If urethral meatus stenosis is present, dilation or urethral meatus reconstruction may be performed.
During the hot summer months, men should be wary of balanitis!
Many men with phimosis or paraphimosis develop balanitis due to a lack of attention to penile and foreskin hygiene in response to seasonal temperature changes. This causes significant pain and adds to family discomfort. Especially in the hot summer, bacteria can easily proliferate in the smegma, leading to balanitis. Therefore, we remind men with phimosis or paraphimosis to pay extra attention to penile and foreskin hygiene during the summer months, washing daily to maintain local cleanliness; consuming cool and refreshing foods and drinks; and if balanitis develops, seeking treatment at a reputable hospital's specialist clinic. Circumcision may be performed when convenient to relieve the discomfort caused by balanitis.
In children with phimosis, urine accumulates between the foreskin and glans, and combined with secretions and shed skin, excessive smegma forms, frequently irritating the inner foreskin and glans, which can cause balanitis and urethritis. In severe cases, it can lead to ulcers on the foreskin and glans or the formation of stones. Some children may have curd-like discharge during urination or experience difficulty urinating. Therefore, children with congenital phimosis who do not show significant improvement by age 3-4, especially those with frequent redness and inflammation, must undergo circumcision to prevent retrograde infection caused by repeated foreskin infections and redness, leading to urethritis or cystitis. Furthermore, long-term balanitis is also a significant risk factor for penile cancer.
For infants with congenital phimosis, parents should regularly clean and care for the external genitalia. When cleaning, the mother can gently pinch the middle of the penis with her right thumb and forefinger, and gently push the foreskin back towards the child's abdomen to fully expose the glans and coronal sulcus. Then gently wash with warm water. Because the glans of a young child is usually covered by the foreskin, the mucous membrane is very delicate and highly sensitive to external touch. Therefore, use a towel soaked in warm water to gently wash; the water temperature should not be too high, and the pressure should not be too strong, otherwise it will cause discomfort. After washing, be sure to return the foreskin to its original position to prevent paraphimosis.
If the foreskin opening is too tight to be retracted, or if it is acquired phimosis, circumcision may be considered. The surgery is best performed between 5 and 6 years of age, as this allows us to determine if the foreskin can retract spontaneously. Children who have started school generally can only have the surgery during holidays, and this time constraint may sometimes delay treatment. Early surgery is generally not recommended because young children may not cooperate, and there is a possibility of spontaneous retraction. However, if there are recurrent infections, scarring, or paraphimosis, age is not a limiting factor. Circumcision is relatively simple and generally not very risky; it can be performed under local anesthesia in an outpatient setting. Younger children should be hospitalized because they often cannot cooperate well and must be put to sleep with systemic medication before the surgery. This surgery should be performed in the pediatric surgery department of a reputable large hospital to ensure success. Improper surgical treatment can lead to complications such as penile curvature and painful erections, increasing the child's physical and psychological suffering. It is worth emphasizing that if a child with complete phimosis is left untreated, it will affect their sex life as an adult; moreover, due to the irritation from inflammation and smegma inside the foreskin, the probability of developing penile cancer will also be greatly increased.
The reasons for circumcision are usually based on hygiene and health considerations, or the requirements of certain religious rituals, such as the requirement for circumcision for believers in Judaism and Islam; in some ethnic groups, circumcision for young boys signifies adulthood. From a medical perspective, circumcision should be considered if there is obvious phimosis accompanied by recurrent balanitis or urethritis. However, should all foreskins be circumcised? In the 19th century, some reports suggested that penile cancer was more common in uncircumcised men; other studies suggested that cervical cancer in women was more common in women who had sexual relations with uncircumcised men. However, research since the 1880s has shown that there is no absolute relationship between circumcision and any type of cancer. Furthermore, the foreskin has a protective function for the penis, preventing direct external injury to the glans. If daily hygiene habits are good, even without circumcision, the probability of urethritis is not necessarily higher than in circumcised men. Moreover, there is no evidence that circumcision is related to sexual function or ability.
Circumcision is a simple procedure, usually taking only 30-40 minutes, performed under local anesthesia with minimal bleeding. After the surgery, as long as you avoid strenuous contact, you generally don't need special rest and can resume normal activities and even work. Possible postoperative complications include: bleeding from the local wound; excessively tight bandaging leading to ischemia and cyanosis of the glans, causing extreme pain. If any of these occur, you should immediately return to the hospital for treatment. Additionally, during sleep at night, the penis may experience physiological erections, which can pull on the wound and cause pain. Usually, applying pressure to the area and waiting for the erection to subside will relieve the symptoms. The wound generally heals in about one week; during this time, it should be kept clean to avoid infection. Sexual activity can be resumed after 2-3 weeks, once the wound has healed well.
To reiterate, not every man with phimosis needs circumcision. Usually, as long as the foreskin is pulled back and cleaned during showering to prevent the accumulation of smegma, balanitis will not occur, and the glans can continue to have this protective "outer layer".