Why Do Some People Develop Tight Foreskin (Phimosis)?

Many parents and caregivers have questions about how to care for an uncircumcised penis. One common question is — how far back should the foreskin go? 

You should be able to pull back the foreskin so it uncovers the head of the penis. Phimosis is the term for when the foreskin cannot be easily pulled back. While this may sound concerning, it can actually be completely normal. Other times, it can be a sign of something more serious that needs treatment. Here’s when you can “wait-and-see” and when you should get help for tight foreskin.

What is phimosis?

Phimosis is the medical term for the inability to retract the foreskin covering the head of the penis. Phimosis is divided into two types: physiologic and pathologic. 

Physiologic phimosis

Physiologic phimosis is completely normal. The term describes the fact that when babies are born, they have tight foreskin that does not retract. That’s because the foreskin is stuck to the head of the penis. These are called adhesions. And in babies, it’s just the way the penis develops. 

As children get older, the foreskin becomes easier to pull back. The adhesions disappear and the foreskin separates naturally from the head of the penis. This happens during early childhood. Most of the time, physiologic phimosis disappears by the time a child is 5 to 7 years old. But it can take longer — up to 3% of older teens still have tight foreskin.

Occasionally, some children develop foreskin or bladder infections from physiologic phimosis. 

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Pathologic phimosis

Pathologic phimosis describes a situation where previously retractable foreskin is now tight and won’t move back. It isn’t normal and needs to be treated.

Pathologic phimosis can develop at any age. But it is uncommon overall, especially in children. Pathologic phimosis develops when the foreskin becomes tight because of scarring. Anything that causes inflammation of the head of the penis or the foreskin (balanitis) can lead to pathologic phimosis. 

The most common reasons pathologic phimosis develops include:

• Infections: Infections of the head of the penis or foreskin can happen to anyone who is uncircumcised if bacteria or fungus gets caught underneath the foreskin. Pathologic phimosis can also develop from sexually transmitted infections. 

• Skin conditions: Skin conditions like eczema, psoriasis, and lichen planus can affect the foreskin. This will cause inflammation and can lead to scarring. 

• Trauma: Trying to forcibly retract tight foreskin causes inflammation and makes the situation worse. 

What are the symptoms of phimosis?

 Symptoms of physiologic phimosis include:

• Foreskin tightness: In phimosis, the foreskin doesn’t pull back completely (or at all). The foreskin might look like it forms a band around the head of the penis. But the foreskin should look normal. 

• Ballooning foreskin: Because the foreskin is tight, it may expand (balloon) during urination. The foreskin should “deflate” after urination and this should not cause pain.

• Smegma: Smegma is a collection of skin cells that forms between the foreskin and the head of the penis. It looks like a white material and washes off easily. 

With pathologic phimosis, symptoms are much more bothersome. You may notice redness, pain, and swelling of your foreskin or the head of your penis. This can lead to:

• Pain with urination or trouble urinating

• Painful erections and pain during sex

• Bleeding and scarring of the foreskin or head of the penis

How do you treat phimosis?

Treatment for phimosis depends on whether a person has physiologic or pathologic phimosis.

Treatment for physiologic phimosis

Most of the time, children with physiologic phimosis don't need any treatment. 

Over time, the foreskin will start to naturally retract. You should wash your child’s penis and foreskin with soap and water, just like the rest of the body. Make sure you teach other caregivers (and older children) that they shouldn’t try to forcibly retract the foreskin. It’s okay to pull the foreskin back as far as it naturally goes but don’t pull back any further. Forcible retraction can lead to scarring and pathologic phimosis. 

If your child’s physiology phimosis is causing trouble with hygiene or infections, they may need treatment with a steroid cream. Steroid creams used to treat phimosis include:

• Betamethasone 0.05%

• Triamcinolone 0.1%

• Fluticasone propionate 0.05%

A pea-sized amount of cream gets applied to the tip of the penis and gently rubbed around the foreskin twice a day for 2 months. You can stop using the cream once the foreskin can be pulled back. 

Treatment for pathologic phimosis

If you have pathologic phimosis, remember that you should not try to force the foreskin back yourself. This can lead to painful fissures on the inside of the foreskin. 

Pathologic phimosis will not go away on its own — so you need to see a healthcare provider to start treatment. Treatment will stop symptoms, like foreskin pain, trouble urinating, and pain with sex and erections. Treatment will also prevent long-term problems, like cancer of the penis.

If you don’t have a lot of scarring around your foreskin, you might be able to try treatment with steroid creams. But if you do have a lot of scarring, you may need surgery. Surgical options include:

• Preputioplasty: This is a surgical procedure that allows you to keep your foreskin whole. With a small incision the foreskin is widened, making the foreskin less tight around the penis.

• Circumcision: Circumcision is a surgical procedure that removes the foreskin. And it definitively cures pathologic phimosis.

Why trust our experts?

Written by:

Ronald W. Dworkin, MD, PhD

Ronald W. Dworkin, MD, is a board-certified anesthesiologist who has been practicing anesthesiology in a community hospital for 30 years. He has taught in the honors program at George Washington University for over 10 years and works as a senior fellow at the Hudson Institute.

Edited by:

Patricia Pinto-Garcia, MD, MPH

Patricia Pinto-Garcia, MD, MPH, is a medical editor at GoodRx. She is a licensed, board-certified pediatrician with more than a decade of experience in academic medicine.

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