Male foreskin problems: everything you need to know

Male foreskin issues can impact individuals at any stage of life, from infancy to adulthood. Understanding common foreskin issues, their causes, and available management options is essential for maintaining optimal male genital health. Leading consultant in sexual and reproductive health Dr Emily Lord explains everything you need to know about male foreskin problems.

What is the foreskin?

The foreskin is a fold of skin that covers the head of the penis (glans) and can be pulled back (retractile). Some men have their foreskin removed, for cultural reasons (usually in infancy) or because they have foreskin problems, which can occur in childhood, or later on in adult life.

Common foreskin issues

Balantitis: Balanitis refers to inflammation of the glans and foreskin, often caused by poor hygiene, bacterial or fungal infections, or skin conditions such as eczema. Symptoms include redness, swelling, itching, and discharge.

Uncircumcised men face a higher risk of developing balanitis, typically as a result of the buildup of microorganisms, debris, and secretions between the glans penis and foreskin. Other risk factors include morbid obesity, uncontrolled diabetes, long-term catheter use, poor hygiene. Additionally, it can occur when men have concurrent autoinflammatory conditions such as genital lichen planus and psoriasis.

Causes of balanitis can be separated into infective and non-infective:

Infectious causes

• Fungal infection
• Candida
• Bacterial infection
• Anaerobic bacteria
• Viral infection
• Herpes simplex virus (HSV)
• Varicella zoster virus (VZV)
• Protozoal
• Trichomonas vaginalis

Non-infectious causes

• Inflammatory conditions
• Circinate balanitis – as part of ‘Reactive Arthritis’ 
• Genital skin disorders, such as Lichen planus, Lichen Sclerosus, Psoriasis or Zoons balanitis.

Premalignant / malignant conditions (uncommon)

• Erythroplasia of Queyrat
• Bowen’s disease
• Squamous cell carcinoma (SCC)

Other causes

• Trauma
• Fixed drug eruption
• Contact dermatitis (irritant and allergic).

Clinical presentation

The presentation will depend on the cause, whether or not the man has been circumcised and also their skin pigment.

The way the presentation unfolds varies based on factors like the underlying cause, circumcision status, and skin pigment. Patients may describe a soreness, or an itch, or may have noticed skin changes such as redness, dryness, cracks or blisters. In some cases, the patient may struggle to retract their foreskin.

Specific presentations include:

Candida balanitis: This tends to cause red blotchy patches. The skin looks inflamed and dry, sometimes with cracks and tightening of the foreskin. 

Anaerobic infection: This often causes a smelly discharge that is trapped under the foreskin, sometimes associate with swelling and difficulty retracting the foreskin.

Herpes Simplex Virus (HSV): If this is the first time a man has developed HSV, then they may describe very painful wet ulcers on the head of the penis (or anywhere in the genital area). They are often associated swelling and the foreskin can again be difficult to retract. They may feel unwell with ‘viral’ symptoms and have painful swollen glands in their groin.

Circinate balanitis: As part of the ‘reactive arthritis’ presentation, the classic history is of a man who has a bacterial infection (e.g. an STI like chlamydia, or a bowel infection), which then develops into a swollen joint. In some cases, patients can have sore eyes (e.g. red and swollen), or develop a ‘ring-shaped’ rash on the head of the penis. 

Zoon’s balanitis: This is common in men over the age of 40, and is very rare in circumcised men. They present with a rash on both the glans penis, but also on the foreskin that covers that area – known as a ‘kissing lesion’. This often looks red and shiny, and can move around. Symmetric "cayenne pepper spots" and orange-glazed erythema on the glans penis.

Genital lichen planus: Men may present with purplish round papules and patches over the glans penis and scrotum; sometimes associated with fine white "Wickham striae" patches.

Genital Lichen Sclerosus: This condition causes tightening of the foreskin, and often there are white slightly thickened areas. Additionally, patients may experience patches of soreness, which may be red and ulcerate.

Complications

Phimosis: Phimosis occurs when the foreskin is too tight to retract over the glans, leading to difficulty in cleaning and potential discomfort during erection or sexual activity.

Paraphimosis: Paraphimosis may occur if a phimosis is not treated. It is the inability to return the retracted foreskin to its original position over the glans. This condition can cause swelling, pain, and restricted blood flow to the penis, requiring urgent medical attention.

Genital cancers: although very rare, in men with any inflammatory skin condition, such as lichen sclerosus, there is a small increased risk of developing genital cancers. It is really important to see your doctor for a diagnosis and treatment, and if things are not improving, you should be referred to a specialist for a biopsy.

Management and treatment options

Treatment of balanitis will ultimately depend on the underlying cause. Often swabs are taken to rule out infection. The mainstay of treatment is good hygiene, emollients for washing and usually a topical cream, which may contain steroids, antifungals or antibiotics (again, the choice is determined by the diagnosis). Very rarely will men be referred for a circumcision.

Male foreskin problems can greatly affect quality of life, impacting sexual function, and daily activities. By knowing the anatomy, common issues, and treatment options, individuals can maintain foreskin health. Seeking medical advice is crucial for effective management and to avoid complications.

If you would like to book a consultation with Dr Lord, do not hesitate to do so by visiting her Top Doctors profile today