Tight foreskin (phimosis): causes, treatment and when it is urgent

The foreskin is the thin layer of skin covering the end of the penis. In phimosis it is tight and difficult or impossible to pull back from the head of the penis. The NHS stresses that a tight foreskin is normal in babies and young boys: most boys' foreskins do not retract before the age of 5, and sometimes retraction is not possible until the age of 10 or older.

The end of a boy's penis may bulge or balloon when he pees, particularly if the foreskin is tight. The NHS says this happens as the foreskin starts to separate and should stop by itself; if it does not, it can be a sign of a tight foreskin. A tight foreskin is not usually a problem unless there are symptoms.

Never force a child's foreskin back, as this may be painful and cause damage that leads to problems later. Foreskin care in children should be gentle and led by a GP if there are concerns.

The NHS lists symptoms that suggest a tight foreskin is causing trouble: swelling and tenderness, pain when peeing or a weak flow of pee, blood in the urine, frequent urinary tract infections, bleeding or a thick discharge from under the foreskin or an unpleasant smell, and painful erections that make sex difficult. Swelling, tenderness, bleeding or discharge can also signal balanitis, inflammation of the head of the penis.

It advises seeing a GP if the foreskin is tight and swollen or painful, if there is bleeding around the foreskin when peeing, a thick discharge or an unpleasant smell, if there is pain or difficulty peeing, or if erections are painful. Adults can also be assessed in a sexual health clinic for balanitis, which the NHS says is usually not serious but needs a cause identified.

• Pain or difficulty passing urine

• Repeated infections of the foreskin or head of the penis

• Bleeding, tearing or thick discharge under the foreskin

• Painful erections or discomfort during sex

• Scarring or white patches on the foreskin, which can suggest conditions such as lichen sclerosus

If the foreskin is tight but not causing pain or bleeding, the NHS suggests washing the penis regularly with warm water or warm water and non-perfumed soap, and for adults only gently pulling the foreskin back as far as it will go to clean underneath, always re-covering the penis afterwards. It advises not using perfumed soap, talcum powder or deodorants on the penis because they may irritate.

Do not pull back the foreskin of a baby or young boy that is still attached to the end of the penis. If you are an adult doing gentle retraction, stop if it hurts, and never leave a retracted foreskin behind the head of the penis, because of the risk of paraphimosis.

The NHS says the foreskins of babies and young boys usually loosen with age so treatment is often unnecessary. When problems arise, options include steroid creams or gels to soften the foreskin, antibiotics if the foreskin or head of the penis is infected, and surgery: circumcision, or a procedure making small cuts in the tip of the foreskin so that it can be pulled back more easily, which the NHS says is usually only suitable for children.

A clinical page for GPs in Coventry and Rugby describes medical management of symptomatic phimosis in adults as use of a very potent steroid cream massaged into the tight part of the foreskin, combined with gentle stretching exercises, often for 2 months or more, with the aim of reducing frequency or potency as soon as it has worked. It says medical treatment is effective for more than 50% of patients and that phimosis may recur. It also notes that surgical options are preputioplasty or circumcision, usually under local anaesthetic, and that patients should be warned about paraphimosis. Do not use steroid creams on this basis alone; the exact product, strength and technique should come from your own clinician.

Circumcision is surgery to remove the foreskin. The NHS says it is only available on the NHS for medical reasons, such as repeated infections or problems caused by a tight foreskin, and is usually only offered when other treatments have not worked or it is the only option. It lists phimosis causing problems such as painful erections or difficulty peeing, an inability to pull back the foreskin, and scarring or tightness from conditions such as lichen sclerosus among the reasons.

The NHS says circumcision is usually done in hospital with the same-day discharge expected, normally under general anaesthetic but sometimes with a local anaesthetic or an anaesthetic that numbs from the waist down. The surgeon makes a circular cut below the head of the penis, removes the foreskin and uses dissolvable stitches, which should dissolve after 2 to 6 weeks. The procedure takes about 30 minutes.

Healing takes 4 to 6 weeks, although sometimes longer. Swelling, bruising and some minor bleeding for 1 to 2 weeks is normal, and the head of the penis is usually very sensitive. After a general anaesthetic someone needs to take you home and you should not drive for at least 24 hours. The NHS advises staying off work for a week, avoiding swimming, cycling, sport or heavy lifting for at least 2 weeks, and not having sex or masturbating for at least 4 weeks or until the wound has healed.

The NHS explains that if the foreskin is very tight it can get stuck when pulled back and cannot return over the end of the penis. The head of the penis can then become very swollen and painful. This is called paraphimosis and is a medical emergency, because immediate treatment is needed to avoid complications such as restricted blood flow to the penis.

Call 999 or go to A&E if the foreskin has been pulled back and cannot be returned, and do not drive yourself. A doctor may be able to return the foreskin to its normal position, and sometimes circumcision is later recommended. Always return the foreskin forward after cleaning, after sex or after medical examinations.

GPs assess most cases and can prescribe creams, treat infection and refer to urology or paediatric surgery. The NHS says circumcision is only available for medical reasons, and local policies may require that other treatments have been tried first, so be prepared to try creams before surgical referral unless there is paraphimosis, scarring or other clear indications.

Adults can also see a private urologist for assessment and surgery, and some choose circumcision for personal or religious reasons, which is generally not funded by the NHS. When considering a private route, ask about the anaesthetic planned, the surgeon's experience, the aftercare and what the overall cost includes, and request a written explanation of the risks.