Foreskin care

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This review is based on findings from a MEDLINE database search of the literature on care of the penile foreskin, foreskin complications, and their management. Articles were reviewed for relevance and quality of evidence is provided with the level of evidence in parentheses (Box 2). When available, we incorporated evidence from systematic reviews, relevant clinical guidelines, and randomized controlled trials. In the absence of high-level evidence, expert opinion on the topic is provided.

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Natural history of the foreskin and physiologic phimosis. The prepuce or foreskin is the retractile covering of skin over the glans penis. The foreskin is naturally adherent to the glans penis at birth, comprising outer and inner layers separated by dartos fascia.³ During infancy, it is advisable not to forcibly retract the foreskin, given the adherence of the inner foreskin to the glans penis by an epithelial lining, known as physiologic phimosis (level 2).^3-5 Forceful retraction of the foreskin causes microtears at the preputial orifice, leading to scarring and an eventual phimotic ring.⁵ Over time, reflex erections and the accumulation of smegma, a white exudate containing skin cells and keratin, facilitates the natural separation of epithelium from the glans penis.^3-6 Patients should be reassured that the accumulation of smegma is a normal phenomenon, aiding in separation of the foreskin from the glans. This process can continue into the late teens, and in most boys, physiologic phimosis will resolve with time (level 2).^5,6 The age at which physiologic phimosis resolves is highly variable. In 1949, Gairdner reported that completion of adhesion separation typically occurs by the age of 3 in about 90% of boys.⁷ In 1968, Oster found that approximately 4% of schoolboys aged 6 to 17 years have non-retractile prepuces.⁶ A 2006 study published by Hsieh et al reported that the incidence of normal foreskin, where the entire glans is visible after retraction of the foreskin, is 8.2% by age 7, 21.0% by age 10, and 58.1% by age 13 (Table 1).⁸ Therefore, counselling on when the foreskin becomes retractile should assume a patient-centred approach, focusing on education to avoid traumatic retraction, and pathologic signs requiring intervention rather than a strict age cut-off (level 3). We recommend reassurance that asymptomatic physiologic phimosis is normal in boys and typically resolves without any intervention. However, further discussion is warranted with parents of boys who have urinary tract abnormalities (antenatal hydronephrosis, high-grade vesicoureteral reflux, posterior urethral valves, and primary megaureters), as there has been a stronger effect of neonatal circumcision in prevention of urinary tract infections (UTIs) in this population.³

Circumcision rates and practices in North America. The decision to perform neonatal circumcision remains a personal parental choice, and both performing and not performing circumcision remain common. It has been estimated that circumcision rates in Canada in 1970 were between 51% to 67%, declining to current estimates of 31.9%, possibly due to changing parental beliefs and demographic patterns.^3,9 Given this decline in neonatal circumcision, there is a growing need for education on routine care and managing complications of the foreskin across the lifespan.

Routine neonatal circumcision has been a topic of debate for years. The Canadian Paediatric Society does not recommend routine neonatal circumcision (level 3).² In-depth analysis of this topic is beyond the scope of this review and has been outlined elsewhere.^2,3 The proposed benefits of circumcision include decreased risk of UTIs, HIV infection, human papillomavirus (HPV) prevalence, HPV incidence, herpes simplex virus infection, and penile cancer.³ However, given the low rates of these events in North America and the availability of non-surgical options to prevent infections (eg, condom use), routine neonatal circumcision remains unjustified based on the evidence available.³

Though generally considered safe, circumcision is not without complications. In a recent meta-analysis of 351 studies and more than 4 million males of all ages, the risk of complications requiring treatment was 3.84%.¹⁰ The risk increases when circumcision is performed for preputial disease.¹⁰ The most common complications are bleeding, device removal, infections, adhesions, and meatal stenosis.¹⁰

Adult circumcision is often performed for pain or discomfort from phimosis, recurrent paraphimosis, recurrent balanitis, or malignancy. Patients inquiring about the procedure often ask about pain and sexual function following circumcision. Pain following the procedure is mild to moderate, tempered with techniques such as intraoperative penile block. In a prospective observational cohort of adult patients undergoing circumcision, patient-reported severe pain was rare and almost always associated with infection or wound complications.¹¹ Time off work is variable, but 4 to 5 days for non–physically demanding activities and 7 to 14 days for physically demanding activities are recommended.¹¹ Regarding sexual function, studies suggest that circumcision has no adverse effect on sexual function, sensitivity, or sexual pleasure.^12-17 Nevertheless, to minimize the need for adult circumcision entirely, a potentially effective strategy may involve emphasizing the promotion of adequate foreskin care and hygiene, and fostering awareness among both patients and health care providers about common foreskin complications (level 3).

Foreskin care. For patients presenting with foreskin concerns, proper physical examination by physicians is important. Ask the patient to retract the foreskin themselves if able. Smegma may be noted under the foreskin. Normal foreskin has no evidence of pale scarring at the preputial outlet. Examine the glans penis under the foreskin and note the location of the urethral meatus. If the foreskin cannot be retracted, it should never be forced, so as to avoid microtears at the preputial orifice. (Patient encounters for foreskin concerns provide an excellent opportunity to discuss foreskin care.)

The literature on proper foreskin care and hygiene is limited, and mainly consists of studies in a pediatric setting. In a comparative study of circumcised and uncircumcised adult men, uncircumcised men were found to be less likely to regularly wash the whole penis including retracting the foreskin.¹⁸ This finding is supported within our own practices, where many uncircumcised adults are unaware or uninformed about how to properly care for their foreskin. Inferior penile hygiene behaviour has been associated with increased risk of foreskin complications such as balanitis.¹⁸ Foreskin care should begin at birth, with regular genital hygiene. When the foreskin is retractable, the child can be taught to gently retract and clean it with water. Once dried, the foreskin should always be reduced back to cover the glans (level 3).^3,5,19,20 Soap and hygiene products can irritate the foreskin and urethral meatus.²¹ Counselling patients that gently retracting the foreskin and rinsing with a stream of water in the shower or rinsing while the penis is immersed in a bath is all that is necessary.

Continuing proper hygiene habits into adulthood is crucial. Regular retraction of the foreskin should be integrated into the long-term hygiene practices of uncircumcised patients, as it has been associated with reduced smegma accumulation, inflammation, pathologic phimosis, and adhesions (level 2).²² In a cohort study of 48 patients in the United States (age range 2 weeks to 52 years), it was found that cleansing the glans a minimum of 2 to 3 times per week with gentle retraction of the foreskin can decrease the incidence of common foreskin conditions such as phimosis.²³ Additionally, patients who washed while retracting the foreskin were less likely to have adhesions or phimosis than those who did not. Among the patients, 20 (41.7%) recalled being instructed by a physician or health care provider to gently attempt foreskin retraction when washing, 7 (14.6%) had been told to wash without retracting the foreskin, and 19 (39.6%) had never received any instructions. These findings identify a gap in preventive care and reinforce the need for proper foreskin care and hygiene in uncircumcised patients, as well as proper instruction from health care providers, to avoid complications later in life.

Treatment of physiologic phimosis. Asymptomatic physiologic phimosis does not require treatment and typically resolves with time. The Canadian Urological Association guideline on the care of normal foreskins in Canadian infants states there may be a role for topical corticosteroids if there is delayed retraction of the foreskin beyond 8 to 10 years of age.³ Topical corticosteroids thin the preputial skin and obliterate the stratum corneum, allowing gentle retraction over time, and are considered effective first-line treatment for physiologic phimosis (level 1).³ A recent Cochrane review of 14 randomized controlled trials (1459 patients up to 18 years of age) found that topical corticosteroids, compared with placebo or no treatment, may increase the frequency of complete and partial retraction of the foreskin after 4 to 8 weeks of treatment.²⁴ In addition, topical corticosteroids may also increase the probability of long-term resolution of phimosis at 6 or more months after treatment.²⁴ The most common corticosteroids used in the randomized trials were betamethasone and clobetasol propionate.²⁴ Penile lichen sclerosus, or balanitis xerotica obliterans, is typically resistant to topical steroid therapy, and referral for dermatologic and urologic assessment in these cases is warranted.⁵ Strict adherence to proper application of the medication is essential for the success of the treatment, and physicians should give clear instructions on how to do so.^3,25 We recommend rinsing the foreskin with water twice daily, drying the area, and then gently retracting the foreskin as much as possible without discomfort before precisely applying a thin layer of the topical steroid to the phimotic margin.^25-27 The prepuce should also be gently retracted several times daily once treatment begins, especially when voiding and during daily bathing.^25,27 In our practice, we prescribe 0.05% clobetasol twice daily for 8 weeks, and those whose symptoms do not respond are offered a second cycle of therapy if they are interested. Afterward, patients are reassessed, and we proceed with observation or discuss circumcision with patients depending on their preference.

Complications of the uncircumcised penis. There are several complications, including UTIs, pathologic phimosis, penile lichen sclerosus or balanitis xerotica obliterans, penile cancer, balanoposthitis, and paraphimosis.

Urinary tract infection: Neonatal circumcision has been shown to decrease the risk of UTIs; however, the overall risk of UTIs is low in infant males and decreases with age.³ The Canadian Urological Association does not recommend routine circumcision for UTI prevention (level 3).³

Pathologic phimosis: Pathologic phimosis and acquired phimosis are synonymous terms referring to the inability to retract the foreskin over the glans of the penis due to a tight or narrow preputial opening that develops from a secondary cause (Figure 1). Common causes of acquired phimosis include chronic inflammation, balanoposthitis, forceful foreskin retraction leading to scarring, lichen sclerosus, and diabetes mellitus.²⁸ Screening patients with acquired phimosis for diabetes should be considered, as it has been shown that a new diagnosis of diabetes may be found in up to 8% of those with acquired phimosis and no prior history of diabetes (level 2).²⁹

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Figure 1.

Pathologic phimosis in an uncircumcised elderly male exhibiting classic signs of penile lichen sclerosus, including white scarring and thickening of the foreskin

Indications for urologic consultation for phimosis include pathologic phimosis with evident scarring of the preputial ring or evidence of balanitis xerotica obliterans, recurrent episodes of balanitis, painful erections secondary to a tight foreskin, or recurrent UTIs (level 3).⁵ Characterizing phimosis as pathologic or physiologic remains a diagnostic challenge among physicians. Most referrals for phimosis in the pediatric setting have been shown to be physiologic upon urologic review, with only 14.4% proceeding to circumcision.³⁰ Referrals often cite “ballooning” of the foreskin, which can be alarming for patients. However, ballooning is a harmless phenomenon and is not associated with obstructed voiding; it is not necessarily a sign of pathologic phimosis or an indication for circumcision if it is the sole concern (level 2).^4,31

Penile lichen sclerosus (balanitis xerotica obliterans) and penile cancer: Penile lichen sclerosus is a chronic inflammatory skin condition involving the glans and foreskin.²⁸ It can lead to scarring of the preputial ring and pathologic phimosis.³² The exact cause is unclear and may involve history of traumatic injury or an autoimmune process.²⁸ Penile lichen sclerosus is a risk factor for penile squamous cell carcinoma (SCC) and urethral stricture disease. Penile SCC itself is rare in North America, with risk factors including tobacco use, chronic inflammation, balanitis, penile lichen sclerosus, phimosis, poor hygiene, absence of childhood circumcision, and sexually transmitted diseases such as HPV infection.³³ This further underscores the need for adequate penile hygiene and care. Studies have identified pre-existing penile lichen sclerosus in 28% to 50% of cases of penile SCC.^34-37 The average time for cancer to develop after the onset of lichen sclerosus is 10 to 34 years, and we recommend patients be counselled to perform regular self-examinations (level 3).^28,32

Balanoposthitis: Balanoposthitis refers to inflammation of both the glans penis and the foreskin. A diagnosis of balanitis has been shown to be more likely in uncircumcised patients than in those who are circumcised.¹⁸ The condition often occurs secondary to poor hygiene, and treatment consists of cleansing and application of antibacterial ointment (level 3).⁵ Recurrent episodes of balanoposthitis is an indication for urologic consultation as it can lead to scarring and pathologic phimosis.⁵

Paraphimosis: Paraphimosis is a condition where the foreskin, once retracted behind the glans of the penis, becomes trapped and cannot be pulled back to its original position. This results in swelling and constriction of the foreskin behind the glans, leading to potential complications such as impaired blood circulation, pain, and inflammation. Paraphimosis is considered a medical emergency and prompt intervention is necessary to alleviate the condition. Most cases can be reduced manually by applying steady pressure to the glans and constricted skin to alleviate edema, followed by using the thumbs to forcefully push the glans while the fingers pull the foreskin over the glans.⁵ If this is unsuccessful, a circumcision or dorsal slit procedure may be required for reduction of the foreskin. Patients should be counselled to always return the foreskin to its anatomic position covering the glans after retraction to prevent paraphimosis (level 3). Those who have recurrent episodes of paraphimosis should be referred to a urologist for consideration of circumcision as a definitive treatment option (level 3).

Foreskin care in special populations. Penile hygiene is a health priority over the entire lifespan of a patient. This becomes especially pertinent for special populations, including but not limited to residents of health care facilities, and those with intellectual or physical disabilities, dementia, Parkinson disease, or history of stroke. Awareness of proper penile hygiene for caregivers in these settings is also important. An Australian study involving care staff for patients with an intellectual disability identified a widespread lack of policy, training, and professional guidance for penile hygiene.³⁸ Patients in health care settings should be provided regular penile hygiene care by health care teams if unable to perform it themselves (level 3). It is recommended that nursing professionals and support workers cleanse the genitals of patients during routine hygiene care.³⁹ The foreskin should always be returned to its anatomic position (ie, reduced over the glans) after each hygiene session to avoid paraphimosis (level 3). Patients in long-term care facilities who require chronic bladder catheterization are at particular risk of paraphimosis, especially after cleansing of the penis when the foreskin may not be reduced properly.⁴⁰ Following catheter care, we recommend examination of the penis to ensure the foreskin has been reduced (level 3). For patients with catheters, any collection of smegma at the urethral meatus should be removed to prevent ascension of bacteria into the urethra.³⁹ Physicians should be conscious of individuals who may be at high risk of foreskin complications in these settings and advocate for routine penile hygiene practices.