Foreskin problems: an expert’s guide

Many men are concerned about their foreskin and thanks to the internet, they have access to information which is often misleading. Leading consultant urologist Mr Gordon Muir provides a comprehensive guide to foreskin problems, including the advantages and disadvantages of childhood circumcision, and the non-foreskin surgery options currently available.

Pros and cons of childhood circumcision

Generally, there are no medical benefits for circumcising a boy or man with a healthy foreskin. In fact, there are medical reasons to avoid it. While religious and socio-economic justifications exist, they're outside my expertise. Unless a healthy male child living in the western world has specific urological issues, there is no medical need for circumcision. A review on this can be found here.

Dissatisfaction with childhood circumcision often stems from a lack of consent and perceived bodily integrity violation, rather than botched procedures. But poorly done circumcisions can usually be improved, even in extreme cases where too much skin has been removed, or the head of the penis has been damaged.

Normal foreskin development

It is important to understand that many young boys may have a foreskin that doesn't retract. Forcing retraction in infants and toddlers can be harmful. Typically, foreskin retraction occurs naturally by around age 4, but if it doesn't, and the foreskin is tight, and the use of steroid cream before puberty will work to restore normal foreskin mobility in most boys . Beyond age 5, consulting an expert is advisable if the foreskin is tight, inflamed, painful, or non-retractile.

Children

For young boys whose foreskins don't retract or respond to steroid treatment, options such as preputial adhesion division, foreskin stretching, or preputial plasty can be successful for most cases. However, if a chronic scarring condition like lichen sclerosus et atrophicus (LSA), also known as balanitis xerotica obliterans (BXO), is present, circumcision is typically the only solution. Circumcision shouldn't be avoided when there's significant foreskin disease.

Adults

In adolescence and adulthood, dealing with a congenitally tight foreskin presents challenges due to limited scientific evidence on foreskin management. There's little financial incentive for pharmaceutical companies to invest in research, and societal and religious factors influence opinions on circumcision.

Equally, research funding for foreskin-related issues is minimal compared to other health concerns, As a result, the majority of the information presented here is from my personal experience of over 30 years of specialising in this area, and from my expert colleagues, as well as several case-series and reports.

Furthermore, for post-pubescent individuals with a tight foreskin, scarring plays a crucial role. Once scarring occurs, further tearing becomes likely, often leading to circumcision. However, diligent hygiene and steroid use may delay or prevent the need for circumcision. Recommendations include steroid application, maintaining hygiene, and avoiding contact with urine.

Stretching

For a man who can retract the foreskin when flaccid but not erect, stretching will often be satisfactory.

Finger stretching with a steroid such as betamethasone has been recommended, although scientific evidence is limited. Applying betamethasone daily and gently stretching the tight band for five minutes is advised, using moisturiser or baby oil as a lubricant. Consistency is crucial, but many patients struggle to adhere to the routine.

For me, previous stretching devices have been disappointing, but a new balloon dilatation device, Novoglan, shows promise in men without scarring. An Australian study reported an 80% success rate in avoiding circumcision after several months of daily treatment with Novoglan. Updates on real-world results will be provided as they become available, with steroids potentially unnecessary when using this device. The original Novoglan study can be found here.   

If there's no improvement after six weeks of stretching, surgery may be necessary. However, if progress is seen, continuing without the steroid for a couple more months typically results in a retractable foreskin during erection. It's important to aim for a foreskin that comfortably retracts behind the head of the penis during erection and stays there, retracting easily once the erection subsides.

Non-circumcision surgery

For men experiencing partial success with foreskin retraction, preputioplasty may be considered, a modified version of dorsal slit operation. However, it has a failure rate of at least 20%, making it less recommended as a first option. The frenulum, a small piece of skin beneath the penis, can cause issues if tight, split, or scarred. While circumcision was traditionally offered for a torn frenulum, frenuloplasty, a simple plastic surgery procedure, has shown to be effective in avoiding circumcision for 95% of men, with excellent results. Frenuloplasty should always be considered as an alternative if appropriate.

Circumcision

In cases where men have significant scarring, pre-malignant conditions, or persistent infections/inflammation, circumcision is often the most appropriate option. It can be performed under local anaesthesia with minimal pain. While concerns about sensitivity loss exist, many circumcised men report satisfactory function and sensitivity. Those who have delayed circumcision will typically experience improved function and sensitivity without the diseased foreskin.

Overall, while a circumcised penis may be slightly less sensitive than one without foreskin issues, the majority find improved sensitivity and comfort post-circumcision. For detailed circumcision techniques, you should refer to specific information sheets.

If you would like to book a consultation with Mr Muir, simply visit his Top Doctors profile today.