Causes

Primary or congenital phimosis occurs in young children — infants and it is normal to have it into the teenage years. Primary or congenital phimosis is physiological but does not cause any side problems, such as urinary obstruction, hematuria, or preputial pain. It is possible child suffers from congenital phimosis because of a history of recent catheterization or of parents forcibly retracting the foreskin in an attempt to clean the glans.

Secondary or acquired phimosis also has several possible causes: it most often occurs because of a history of poor hygiene, chronic balanoposthitis, but forceful retraction of a primary phimosis is also possible. This is why parents should never try to force the foreskin back as it can be very painful for their son and can also lead to small injuries, causing scarring which can make it even harder to pull the foreskin back. This type of phimosis is known as acquired or pathological phimosis. Secondary or acquired phimosis is often followed by hematuria or preputial pain. Acquired phimosis is typical for both children and adults.   

Secondary or acquired phimosis, caused by poor hygiene and/or chronic balanoposthitis can eventually lead to paraphimosis. Typical of paraphimosis is pain and edema of the uncircumcised or improperly circumcised penis. Even vigorous sexual activity has been reported to predispose one to paraphimosis.  Paraphimosis is a urological emergency in which the retracted foreskin of an uncircumcised male cannot be returned to its normal anatomic position. Clinicians must recognize paraphimosis promptly, as it can result in gangrene and amputation of the glans penis.

Care Of The Uncircumcised Penis

No special care is required for the foreskin in infancy — the foreskin should not be forcibly retracted, however gentle retraction is acceptable. The main goal of gentle retraction is cleansing underneath the foreskin during diaper changes or bathing. This type of gentle retraction will result in progressive retraction over time. After the retraction, the foreskin should be pulled back over the head of the penis and returned to the normal position. The foreskin doesn’t have to be pulled back completely to be able to keep the penis clean. Washing it from the outside is enough. Under no circumstances should objects such as cotton swabs be used to clean the space between the foreskin and the glans. [7]

Treatment

The need for treatment will depend on the child’s age, the extent of the problem, and what is causing it [7]:

• If phimosis persists but doesn’t cause any problems, you can wait until after about the age of three before going to see a doctor about it.
• After the age of three there are three treatment options available: 
  • “Wait and see” if the phimosis will go away on its own.
  • Use a steroid cream to help stretch the foreskin.
  • Have surgery to partially or completely remove the foreskin (circumcision).

The main aim of treatment is to enable the boy to wash his penis properly and urinate without any difficulties or pain. Erections shouldn't be painful either.

Some men simply accept the chronic irritation and the red, swollen foreskin. They sometimes complain of phimosis and visit the doctor only when there is pain or an odorous discharge. However, the treatment of phimosis depends on the type of phimosis. 

Congenital phimosis should be left alone: only the usual cleaning without any forceful retraction is recommended. Proper foreskin hygiene is also suggested to patients with acquired phimosis. Use of steroid creams as a noninvasive effective treatment for acquired phimosis is recommended (treatment for repeated phimosis may involve application of a steroid cream to the foreskin up to three times a day for about a month to loosen the adhesive ring) or the use of nonsteroidal ointments has also been reported to be of benefit in the treatment of acquired phimosis. 

If phimosis is causing urinary obstruction, seek medical attention from a specialist (urologist). In cases like this, it is often necessary to perform circumcision or other plastic surgical technique to enlarge the opening without actually removing tissue. As said, either antibiotics may control the infection, sometimes hot soaks may help separate the foreskin from the glans, but if they fail, a small incision is made to release it.

In some cases, circumcision is advised, which is done when the inflammation clears [8]. Circumcision is performed under general anesthesia. The foreskin is pulled back as far as it will go: it is slit along its upper surface and then all around so that it can be removed.

The raw edges of the inner and outer layers are stitched, and then a dressing is applied. The patient usually goes home the same day. Pain is present until the healing is complete, but it can be controlled with painkillers. After the circumcision, the patient may find that the appearance of the penis has changed considerably.

All causes of potential infection must be kept away (for example urine). Urination may also be painful.

For a couple of days, a patient should avoid tight clothes or any excessive movement, especially sexual activity. After few days there should be no more pain and stitches should be healing. 

In paraphimosis, after emergent reduction, referral to a urologist for eventual circumcision is obligatory since the condition is likely to recur. Treatment for paraphimosis may involve lubricating the foreskin and tip of the penis and then gently squeeze the tip of the penis while pulling the foreskin forward. If this shows to be ineffective, a small incision to relieve the tension may be performed. However, generally, circumcision is performed. Of course, complications (gangrene of the glans, inflammation of the prepuce) are possible, but if appropriate treatment is followed they are not likely to occur.