Foreskin Issues and Circumcision

The foreskin is a thin layer of tissue that covers the head of the penis like a hood. The foreskin has approximately 20,000 sexually sensitive nerves and one of its functions is to keep the glans (head of the penis) moist, smooth and sensitive when required. The removal of the foreskin degrades the sensitivity of the glans by up to 75%. 

Not everyone with a penis has a foreskin. If you’re circumcised, your foreskin has been removed from its base near the middle of the penis shaft, typically at birth. You may even be able to see a band of ridged scar tissue around this area where the foreskin was removed.  Viafin-Atlas Ltd. (UK) carried out a survey over three years and the results proved that 76% of circumcised men were unhappy with their neo-natal circumcision which was carried out without their consent.

If you’re intact (uncircumcised), there are some health issues you can run into if you don’t take proper care of your foreskin. Some of these issues can be uncomfortable, and others require emergency medical attention to prevent long-term complications.

Keep in mind that you can still run into some of these issues if you don’t have a foreskin, but you’re at a much lower risk.

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Let’s dive into what the most common foreskin problems are, how each one is treated, and how you can prevent future issues.

When your foreskin is tight, it can be hard to move it without any pain or sensations of pressure. It’s usually a sign of phimosis In this condition, your foreskin can’t be pulled back, or retracted, from the head of your penis (glans penis).

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An unretractable foreskin is common in young, uncircumcised boys. It’s not a cause for concern in those cases. But your foreskin typically becomes retractable after the age of three. It should be fully retractable by the time you reach 17.

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Phimosis can be caused by:

• scarring that results from pulling a child’s foreskin back before it’s ready
• bacterial, viral, or fungal infections of the foreskin or glans penis
• inflammation of the foreskin or glans penis resulting from poor hygiene or irritation.

Here are some common treatments for tightness caused by phimosis:

• Oral or topical medication for infections. Your doctor will swab the infected foreskin tissue and send the sample to the lab for analysis. Based on your results, they may prescribe antibiotics for a bacterial infection, retroviral treatment for a viral infection, or antifungal lotions or ointments for fungal infections.

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• Daily, gentle retraction of the foreskin. Your foreskin may simply be tight due to your genetics. Pulling back your foreskin each day can help loosen the tissue so it becomes easier to pull back. A steroid ointment applied to the foreskin a few times a day can help with this process.

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• Circumcision. If no other treatments work, you may need to have your foreskin removed. In some cases, you may only need a partial circumcision. This may also be done if you have frequent infections or inflammation related to your foreskin.  Circumcision can cause more problems later in life, including  lack of sensitivity, abrasion of the glans (head of the penis), physical appearance and loss of self esteem to name a few.

Swelling of the foreskin tissue or of the penis glans can cause paraphimosis. When you have this condition, you can’t pull your foreskin back over the head of your penis after it has been retracted. It often leads to swelling of the head. It can also cut off the circulation. This is painful and a medical emergency.

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Most often, paraphimosis happens when your doctor or other healthcare professional doesn’t move your foreskin back after retracting it for an exam. It’s also caused by an infection, trauma, a tight foreskin. forcefully retracting the foreskin, or leaving the foreskin retracted for too long.

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Penis or foreskin swelling resulting from paraphimosis requires emergency treatment. It’s very important that you seek medical attention if this occurs. The foreskin can cut off blood flow to the end of your penis if it’s not moved back over the glans penis. This can result in complications like tissue death and, in rare cases, needing to remove part or all of your penis.

Seek emergency medical help if you notice any of the following:

• swelling and foreskin tightness
• changes in the color of your penis
• pain around your penis head or foreskin
• loss of sensation in the foreskin or the head of your penis

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If you can’t move your foreskin back over the head of your penis but don’t have these symptoms, it’s important that you see your doctor soon before they develop.

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There are over-the-counter (OTC) lubricants that can help. However, if you can’t move your foreskin, always see your doctor instead of trying to force it back to prevent any possible complications that can lead to changes in your penis function.

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Your doctor will reduce the swelling first and then move your foreskin back. This can be very painful, and your doctor may numb the area with local anesthetic before trying to move your foreskin.

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In rare cases, such as when there is a recurrent problem, circumcision could perhaps be the best treatment.

Several infectious agents can affect your penis and foreskin. Balantitis refers to inflammation of the foreskin and glans penis.

You might also notice:

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• small white spots around your glans and foreskin
• painful urination if the tip of your penis is swollen
• itchiness or soreness around your glans and shaft
• chunky, foul-smelling discharge

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 Postihiitis refers to inflammation of the foreskin alone. Balanitis usually leads to this if you’re uncircumcised. When both the glans and foreskin are inflamed, it’s called balanoposthitis.

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These conditions can be due to infection or other things that cause irritation.

Some common symptoms of posthitis that affect the foreskin include:

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• dryness
• pain or tenderness
• itchiness
• burning sensation
• thickened skin (lichenification)
• abnormal discharge from under the foreskin
• phimosis
• bad odor

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The most common infections that can lead to either balanitis or prosthetist include:

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• fungal infections
• gonorrhea
• herpes simplex
• primary or secondary syphilis
• trichomoniasis
• chancroid
• chlamydia
• human papillomavius
• yeast infections (this is the most common infectious cause)

The organism causing the infection has to be identified for successful treatment. Common treatments for balanitis and posthitis include:

• Applying creams or ointments to the affected area. Depending on the cause, antibiotics and antifungal treatments can help reduce symptoms and treat the source of the infection. Steroid cream may also be used. Talk to your doctor about which type will work best for your infection.

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• Focusing on hygiene. Wash your penis gently with warm water every day to reduce irritation and help keep your penis free of bacterial or fungal buildup that lead to infections. If you want to use soap, make sure it’s gentle and unscented.

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• Removing irritants from your daily routine. Chemicals or dyes in soaps, body washes, and clothing can all cause allergic reactions or irritation that may lead to balanitis or posthitis. For starters, use unscented, chemical-free substances to wash your hair and body and wear cotton underwear.

Balanitis, posthitis, and balanoposthitis can also be caused by injury or irritation from a variety of things.

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Ever caught your penis glans or foreskin in a zipper when you’ve pulled it up too quickly? It can hurt like crazy. The resulting injury can cause swelling or colour changes from inflammation as the tissue begins to repair itself. It can make wearing underwear or pants uncomfortable and sometimes unbearable.

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This kind of injury can also happen if your penis rubs against a rough underwear or clothing material for too long, resulting in irritation. Any injury or trauma to the penis can lead to these conditions.

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Using irritating products in the bath or shower can also inflame your foreskin. Some chemicals can cause allergic reactions that lead to inflammation. This is known as contact dermatitis, a type of ecxema. The pain and discomfort can feel very sharp and intense, especially if it’s near the tip of your penis. Common irritants are chlorine in a swimming pool and latex condoms.

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Other causes include:

• a tight foreskin
• psoriasis
• reactive arthritis
• balanitis xerotica obliterans (chronic balanitis)

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Common symptoms of foreskin inflammation include:

• rash or bumpiness
• sensitive or itchy skin
• dryness
• gray, brown, or red patches on skin
• patches of reddish, brownish, or grayish skin
• fluid-filled blisters
• thickened skin

If you know what’s causing the irritation, it’s easier to treat. Very mild symptoms, such as mild discomfort, can often be treated at home. However, if you don’t remove the irritant, your symptoms won’t go away.

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Try the following:

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• Use a cold compress. Apply a cold, damp, clean towel against the affected area for 20 minutes a day, several times a day, to relieve swelling and pain.
• Cover your penis with a bandage. If your penis or foreskin is scratching against clothing material or is injured, wrap your foreskin with a clean cloth or gauze and medical tape to protect the tissue from further irritation.
• Use OTC creams or ointments. Apply a cream that’s at least 1 percent hydrocortisone to relieve itching. Put it right on the area or apply it to a bandage and wrap it around the area.
• Take allergy treatments. Mild antihistamines such as diphenhydramine (Benadryl) or cetirizine (Zyrtec), can help with allergic reaction symptoms. Make sure the medication doesn’t cause drowsiness if you need to drive or be alert.
• Limit your exposure to irritants. If you notice that a certain hygiene product or clothing material causes inflammation or other reactions, stop using these products and switch to something with as few chemicals or irritants as possible. This usually cures the problem.

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Good hygiene is important to stop or prevent this condition no matter what the cause.

Get in to see a doctor if you notice:

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• split or bleeding skin
• trouble urinating
• scrotum swelling or pain
• bloody urine
• intense pain that lasts for more than two hours
• pain during sex

Dryness around or under your foreskin is often caused by a yeast infections also called thrush.

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Foreskin yeast infections are a result of overgrowth of a fungus known as Candida albicans. You can get it from having unprotected sex with someone who already has an infection. But it can also result from not cleaning your penis and foreskin regularly and thoroughly.

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Besides dryness, you may also experience:

• red or white bumps
• irritation or redness
• cottage cheese-like discharge from under your foreskin
• foreskin tightness

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Antifungal creams, lotions, and ointments like clotrimazole (Canesten) and miconazole (Desenex) are the best treatment for penile yeast infections. These can also be taken as an oral medication prescribed by your doctor

Here are a few tips to help you avoid painful or uncomfortable foreskin symptoms in the future:

• Clean under your foreskin regularly. Rinse the area daily with warm water, making sure to get under your foreskin.

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• Avoid scented or chemical-laden hygiene products. Artificial scents and chemicals can cause allergic reactions or dry out your skin. This can make you more susceptible to bacterial or fungal overgrowth. Choose soaps, body washes, and even shampoos with as few artificial ingredients as possible.

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• Change your underwear regularly. Dirty underwear can trap bacteria or moisture underneath the foreskin and cause it to build up, leading to inflammation, infection, or bad-smelling smegma. Put on a fresh pair at least once a day. If you prefer, wear loose boxers to allow the area to ventilate.

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• Wear protection when you have sex. Bacteria and viruses spread through unprotected sex. Even those not related to sexually transmitted diseases, can get underneath the foreskin and cause infections.

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Complications, methods of circumcision and their management will be reviewed here. Circumcision technique and its risks  are discussed.

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FREQUENCY OF COMPLICATIONS

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The rate of procedure-related complications during and after circumcision in the neonate is approximately 2 to 6 per 1000 . This rate increases 20-fold for those who are circumcised between one and nine years of age and 10-fold for those circumcised after 10 years of age. 

Inadequate training of clinicians contributes to complications as practitioners without formal training may not recognize congenital malformations (eg, congenital buried penis and penoscrotal webbing that are more likely to result in poor results when using routine conventional methods)

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Patients with these abnormalities should be referred to a pediatric urologist.

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The most common complications of male circumcision are bleeding and local infection, followed by unsatisfactory cosmetic results (too little or too much skin removed) and surgical trauma or injury. Rare but significant complications include life-threatening sepsis and meningitis, buried penis due to cicatrix formation, amputation of the glans, and necrotizing fasciitis. (Gangrene) .