In most boys the foreskin is non-retractile at birth. The age at which it may become retractable is very variable but this may not be until late childhood or peri puberty. A non-retractile foreskin (phimosis) is therefore normal or physiological for many boys.
Characteristically a healthy non- retractile foreskin will show pouting of pink inner layer mucosa at the preputial opening on attempted retraction, and on lifting the foreskin forwards the opening may appear larger and the skin is pliable and stretchy. A normal non-retractile foreskin may be associated with ballooning on micturition but if otherwise asymptomatic does not need referral or treatment unless persisting after 12 or 13 years of age.
In some boys a physiological non-retractile foreskin may be associated with symptoms of irritation, pain or episodes of balanitis (redness and swelling of the foreskin sometimes with a purulent discharge). If these are troublesome then treatment may be needed. In this instance treatment with topical steroids will often allow the foreskin to loosen and become more retractable. This could be offered in primary care prior to surgical referral. We would normally use 0.1% Betnovate, twice daily with gentle retraction. Treatment needs to be continued for up to 12 weeks to be effective and little change is usually seen until after 4 weeks. The foreskin may not become fully retractable, but if the opening is larger and symptoms have resolved that is an adequate response. It should be noted that whilst this treatment is Specialist recommended, it is not currently on formulary, however an application has been made to have this treatment included in the formulary.
Surgery in the form of either a circumcision or preputioplasty may be needed if steroids are ineffective or problems recur after they are discontinued.
Some boys may develop a phimosis secondary to Balanitis Xerotica Obliterans (BXO). This is usually not associated with ballooning and the preputial opening will show evidence of scarring with a white, thickened edge. In some cases this can cause severe difficulties with micturition and even bladder outlet obstruction. Circumcision is the recommended treatment for BXO.
FM, LS, JB Sept 22
Who to refer:
- Boys with a symptomatic non -retractile foreskin who did not improve after a course of topical steroid cream.
- Boys >12 years old with a non-retractile foreskin.
- A patient with suspected BXO, urgently if micturition difficulties.
Who not to refer:
Any boy with a non-retractile foreskin who is asymptomatic and younger than 12 years old.
How to refer:
Please refer via SCI Gateway
Referral Priority
- A child with an asymptomatic non-retractile foreskin will be triaged as a routine referral.
- A child with suspected BXO will be triaged as an urgent referral, especially if any micturition difficulty.
Surgical Priority
- Surgery (prepuceplasty or circumcision) for a non-retractile foreskin is classed as a non-urgent procedure.
Surgery for a boy with BXO is classed as an urgent procedure
Options for Management in Primary care
- Simple reassurance regarding the natural history for a non-retractile foreskin.
- Commence topical steroid cream as above for those boys with foreskin symptoms.
