Types of Phimosis – Suggested Surgery for Each Level

Phimosis is a condition of the penis in which the foreskin (the retractable fold of skin covering the penis glans) cannot be pulled back or retracted over the head of the penis. Phimosis can occur due to a multitude of reasons and isn’t necessarily a problem on its own. As long as phimosis is asymptomatic, it does not require any surgical intervention. 

However, severe cases may require surgical intervention, such as circumcision surgery. In this blog, we will discuss what are the different types of phimosis, its different levels of severity, and what treatment method may be best suited for you. 

Types of Phimosis

There are primarily two types of phimosis:

1 – Physiological Phimosis

Sometimes referred to as primary phimosis, physiological phimosis is one of the most common types of phimosis. Physiological phimosis occurs naturally at birth and generally resolves on its own. Almost all newborns are born with a tight foreskin that loosens up on its own over time. In some cases, though, the condition can persist until teenage. In such cases, non-surgical methods such as steroid creams may be effective in treating physiological phimosis. If the condition seems to persist thereafter, your urologist may recommend circumcision surgery.

2 – Pathological Phimosis

Pathological phimosis is also known as secondary phimosis. Pathological phimosis is a type of phimosis that occurs due to factors such as scarring, infection, or inflammation of the penis caused by an injury. Pathological phimosis can occur irrespective of age and usually requires surgical treatment.  Some of the common phimosis causes in adults include:

• Poor hygiene
• Skin conditions
• Formation of scar tissue
• Balanitis
• Balanoposthitis
• Injuries

Grades of Severity of Phimosis

The severity of phimosis is divided into 5 different levels. Depending on the severity of your condition, the best-suited method of treatment for your condition may vary as well.

• Level 1: Level 1 phimosis is characterized by full retraction of the foreskin but tightness behind the glans. The foreskin opening at this level is around 34mm. Level 1 phimosis is considered to be mild in nature and can be treated with non-surgical methods such as phimosis creams. You can also leave it untreated as long as it does not cause you any symptoms. While rare, this level of phimosis could also lead to paraphimosis. 
• Level 2: Level 2 phimosis is characterized by only a partial exposure of the glans. In this case, erection may be painful and cause discomfort. However, the level of severity is generally treatable with phimosis creams and gentle foreskin stretching exercises. The foreskin opening in level 2 phimosis can be from 26mm to 34mm. 
• Level 3: Level 3 phimosis is characterized by partial retraction of the foreskin with the meatus barely visible. There might be little or no retraction when erect. The foreskin opening in level 3 phimosis is about 18mm to 26mm. This level of severity generally requires surgical intervention, such as circumcision, for effective treatment. 
• Level 4: Level 4 of phimosis is characterized by slight retraction of the foreskin but no visibility of the meatus or the penis glans. This level of severity is considered to be serious and likely exhibits symptoms such as pain during erection, pain during intercourse, recurrent infections, and difficulty urinating. Additionally, you could discover that your glans are quite sensitive to physical contact. The foreskin opening in level 4 phimosis is 5mm to 16mm. Circumcision is generally considered to be the only effective treatment for this severity. 
• Level 5: Level 5 phimosis, sometimes referred to as pinhole phimosis, is the most severe stage of adult phimosis. Pinhole phimosis is characterized by complete inability of the foreskin to be retracted and requires circumcision for effective treatment. Symptoms of pinhole circumcision include swelling and tenderness, pain when urinating, ballooning, blood in urine, and painful erection. The foreskin opening in level 5 phimosis is just 4mm. 

How is Phimosis Treated?

Surgical Treatment

Circumcision is generally considered to be a safe and effective treatment for all severity levels of phimosis. In a circumcision procedure, the foreskin is cut and removed from the penis. There are primarily 3 methods of performing a circumcision surgery:

• Laser Circumcision: A laser circumcision is an advanced and minimally invasive surgical procedure that is performed to remove the foreskin. As the name suggests, laser circumcision uses a medical laser to cut and remove the foreskin along a predetermined incision line. Compared to traditional methods, laser circumcision is an extremely precise procedure and does not involve any risk of deep cuts or excessive bleeding. Laser circumcision is generally performed on an outpatient basis and has proven to provide patients with quicker recovery and better postoperative quality of life. 
• Stapler Circumcision: Stapler circumcision is another alternative method of foreskin removal that your urologist may recommend. A stapler circumcision procedure uses a stapler device, an advanced and disposable surgical tool, to remove the foreskin. This stapler device fits snugly over the penis glans and, once fired, removes the foreskin in a quick motion. A stapler device is also fitted with a silicone ring that wraps itself around the incision wound as soon as the foreskin is cut. This silicone ring helps prevent excessive bleeding and promotes better healing. Once the incision wound has healed (which generally takes around 10-14 days), the silicone ring will fall off on its own.
• Open Circumcision: Open circumcision, medically referred to as the open-dorsal slit technique, is a traditional form of phimosis surgery. In an open circumcision procedure, the foreskin is cut and removed with the help of a scalpel and surgical scissors. The operation generally begins with an incision being made along the upper length of the foreskin from the tip of the corona to expose the penile glans. While considered safe and effective, open circumcision is more invasive in nature and requires more recovery time. Due to its invasive nature, it also carries a significant risk of complications and infection as well. However, such cases are very rare.

Non-surgical Treatment

Depending on the severity of your phimosis, your urologist may recommend non-surgical alternatives. Though, it is to be noted that non-surgical treatment for phimosis is generally effective in treating only level 1 and level 2 phimosis. Severe stages of phimosis will likely require circumcision. Some non-surgical alternatives that your urologist may recommend to treat mild cases of phimosis are given below:

• Antibiotics: Some cases of phimosis can be caused due to bacterial or fungal infection. In such a condition, treating the underlying infection would result in relief from phimosis itself. Some commonly prescribed antibiotics that your urologist may recommend include: Mupirocin 2%, Amoxicillin, Flucloxacillin, etc. 
• Steroid Creams: Another effective alternate treatment for phimosis is topical corticosteroids in the form of creams, ointments, or gels. Using these steroid creams for phimosis about 6-8 weeks improves the condition of phimosis in most cases.
  
  Topical steroids work by reducing inflammation and loosening the foreskin. This makes it easier to retract the foreskin without experiencing severe pain or discomfort.Some commonly prescribed topical steroids for level 1-2 phimosis include betamethasone valerate (Betnovate), Temovate, Elocon, Novoglan, and Hydrocortisone.

 

• Foreskin Stretching: Symptoms of mild to moderate cases of phimosis (Level 1 and level 2) can usually be managed by simple stretching exercises that may be recommended by your urologist. Gently and slowly pulling the top of your foreskin using just 2 fingers may ease some of the symptoms you are facing. 
• Good Hygiene: Maintaining good genital hygiene is always crucial. Regularly and thoroughly washing the penis glans can significantly reduce your chances of developing phimosis and may even help you relieve symptoms of phimosis. Using mild soap to clean your foreskin is a great way to maintain your genital hygiene and avoid excessive buildup of any bacteria or smegma.
• Retracting Exercises: Retracting the foreskin over the penis glans regularly may also encourage better stretching of the foreskin. It is important to use extra caution during such exercises and avoid forcefully stretching the foreskin. It is also advisable to use coconut oil when performing such exercises.

Why Choose Circumcision for Phimosis?

Most urologists recommend undergoing circumcision surgery to treat phimosis due to its ability to remove the foreskin itself completely.

As a result, the chances of phimosis recurrence after circumcision surgery are almost zero. While non-surgical alternatives to circumcision may provide you with good initial results regarding level 1-2 phimosis, they may not be long-lasting. It is also possible for phimosis to reoccur once you have stopped the application of prescribed phimosis creams.

Alongside, circumcision may also provide you with some additional benefits, such as:

• Easier Penile Hygiene: As the foreskin is removed, it becomes easier to maintain good genital hygiene. Make sure to regularly clean your penis and wash away any excess bacteria or smegma that may have accumulated over the penile glans. 
• Decreased Risk of Urinary Tract Infection: Urinary Tract Infection or UTI is an infection that can occur in any part of the urinary system. Compared to uncircumcised men, circumcised men are found to be at a reduced risk of contracting UTIs.
• Decreased Risk of Sexually Transmitted Diseases: Some studies suggest that uncircumcised men are at a lower risk of contracting STDs of any kind. However, such protection is considered modest, and safe sexual practices should be followed and encouraged.
• Reduced Risk of Penile Cancer: While penile cancer itself is a rare condition, it is even less common in circumcised men.
• Effective Treatment for all Levels of Phimosis: Regardless of severity, circumcision surgery is considered to be a safe and effective treatment for phimosis and various other foreskin issues such as balanitis, posthitis, and paraphimosis.

What Happens if Phimosis is Left Untreated?

If left untreated for a long time, phimosis can lead to serious complications such as recurrent infections, gangrene, penile cancer, permanent damage to the penis, or in some severe cases, loss of your penis.

If you struggling with a severe case of phimosis that is exhibiting symptoms such as:

• Redness or discoloration
• Swelling
• Inflammation
• Soreness.
• Pain while urinating
• Pain with erections or with sexual activity.

It is highly advisable to contact your healthcare provider as soon as possible. Timely treatment of phimosis can help treat the symptoms you may be facing and prevent chances of any further complications. 

FAQs

How long does phimosis surgery take?

Phimosis surgery is generally performed on an outpatient basis, meaning you will likely be able to go home on the same day of surgery. Phimosis surgery itself lasts for only 10-15 minutes. However, you should expect to spend at least a couple of hours at the hospital.

How long does it take to recover after phimosis surgery?

On average, recovery time after a laser circumcision surgery usually takes anywhere from 7-10 days. You will likely be able to return to work in just 2-3 days. Depending on some factors, however, such as your overall health, method of surgery, and quality of postoperative care, the exact duration of your recovery period is likely to vary.

Can I have sex if I have phimosis?

You can have sex when you have phimosis, but it might be painful or not feel good. Sexual activity might cause the foreskin to rip. It’s important that you use a condom and lubrication in order to avoid any irritation and minimize the chances of skin tear.

Can I cure phimosis at home?

While some simple stretching exercises may help you relieve some of the symptoms caused by mild cases of phimosis, they cannot cure it. Some simple stretching exercises you may be able to perform to manage some of your symptoms are: 

• Gently and slowly massage the foreskin so it’s easier to retract. It is recommended to use topical steroid creams to help soften the foreskin tissue.
• Using just 2 fingers, slowly massage and stretch the top of the foreskin. Avoid any forceful movements. 
• If stretching causes excessive pain or skin tear, it is important to stop immediately. Consult your urologist, and don’t wait too long to get medical help.

What are some complications that are associated with phimosis surgery?

Complications of any kind after phimosis surgery are rare. However, as is the case with any other type of surgery, they can still happen. Some complications that are associated with phimosis surgery are given below:

• Excessive bleeding.
• Infection.
• Having a foreskin that is too long or too short.
• Excessive pain.