What is phimosis?
At birth, almost all boys have a foreskin that is attached to the head of the penis and does not pull back. This is physiological (normal) phimosis. As the child grows, smegma collects under the foreskin, and erections and hormones help the foreskin gradually separate.
- At 1 year of age, in about 50% of boys,
- at 3 years, in about 90%, the foreskin retracts partly or fully.
In some children this process continues until adolescence, and that is also normal.
Pathological phimosis is a narrowing of the tip of the foreskin into a scarred, white, firm ring. The most common causes are lichen sclerosus (balanitis xerotica obliterans) and tears caused by forcing the foreskin back.
When is it a problem?
Treatment is needed in these cases:
- recurrent balanoposthitis (inflammation of the foreskin),
- recurrent urinary tract infection in a child with a urinary tract anomaly,
- difficulty urinating, a thin urine stream and pain when urinating,
- a white, scarred appearance of the foreskin,
- pain and cracking of the foreskin during erection in an adolescent.
Why should it never be forced back?
Forcing the foreskin back creates tiny tears in the skin. These tears heal with scarring, and as a result normal physiological phimosis turns into true, scarred phimosis. In addition, a foreskin that has been forced back may not return and can cause paraphimosis.
For daily hygiene, it is enough to pull the foreskin back gently only as far as it goes easily and rinse with water.
Treatment
Steroid cream
This is the first-choice treatment. A mild steroid cream is applied to the narrow tip of the foreskin 2 times a day for 4–8 weeks, while the foreskin is pulled back very gently. In 80–90% of children the foreskin widens. If the foreskin is not gently retracted regularly after treatment, the narrowing may come back.
Surgery
If the cream does not help or there is scarring of the foreskin:
- Circumcision is the most reliable treatment, especially in lichen sclerosus.
- Preputioplasty: for families who want to keep the foreskin, the narrow ring is cut and widened.
When to seek urgent care
If any of the following is present, do not wait for a routine appointment: call the doctor or go to the nearest emergency department.
- The foreskin has been pulled back and will not return, and the head of the penis is swollen (paraphimosis)
- Unable to urinate
- Pus from the tip of the penis, redness and fever
Note for pediatricians and family doctors
Physiological phimosis is normal in infancy and early childhood; ballooning, smegma 'pearls' and mild adhesions do not require treatment. Indications for treatment: recurrent balanoposthitis, recurrent urinary tract infection in a child with a urinary tract anomaly, pain on erection in an adolescent, white, firm, scarred skin (lichen sclerosus/BXO). The first choice is a 4–8 week course of topical corticosteroid. Forced retraction should not be performed.
What happens at the visit?
- The appearance of the foreskin, how far it retracts, and whether there is scarring are assessed.
- We ask about symptoms (infection, difficulty urinating, pain).
- When needed, the cream treatment is explained; rarely, surgery is planned.
Frequently asked questions
The foreskin balloons up like a balloon when he urinates. Is it dangerous?
If the urine flows normally and the child feels no pain, this is normal in young children and goes away as the foreskin widens.
White, pearl-like lumps are visible under the skin.
This is smegma: natural dead cells that collect under the foreskin. It is harmless and comes out on its own as the foreskin opens. There is no need to squeeze it or try to clean it out.
Is the cream treatment safe?
Yes. A small amount of a mild steroid cream is applied only to the tip of the foreskin for a short time and is not absorbed into the body to any significant degree.
Related topics
Sources
- EAU Guidelines on Paediatric Urology, 2025: Phimosis.
- Moreno G et al. Topical corticosteroids for treating phimosis in boys. Cochrane Database Syst Rev, 2014.
This page is for education. Decisions about your child’s treatment are made together with the doctor after an examination.