When will circumcision be needed for tight foreskin (phimosis) in adults or older men?

Male circumcision is rarely discussed, leading to insufficient information about foreskin conditions. This causes many conditions to go unnoticed, worsening one's health. One such condition is phimosis, where the foreskin is too tight to retract. Sometimes, it can fold back when the penis is relaxed but not when erect. This tightness causes minor damage during erections and sexual activity, leading to scarring. In adults, phimosis can be associated with infections like balanitis or sexually transmitted diseases.

Facts:

- Physiological phimosis in children often improves with age. The foreskin attachment breaks down, releasing a white material called smegma pearls. Most boys have a fully retractable foreskin by ages 10-12.

- Pathological phimosis is a medical condition caused by disease or scarring (BXO). It's important to distinguish it from a natural tight foreskin (physiological phimosis) as treatments differ.

Paraphimosis occurs when the foreskin gets stuck behind the penis head due to a tight ring. It requires immediate treatment, such as pulling the foreskin forward or preputioplasty to preserve it.

Causes:

- Skin conditions like BXO, Lichen planus, or Eczema.

- Infections: Circumcised men have lower rates of sexually transmitted infections, including syphilis, chancroid, and genital herpes (HSV-2).

- Scarring: BXO can cause severe scarring and phimosis.

- Potential cancer: There's a long-known link between un-circumcised men and penile cancer, especially in cases of phimosis history.

Non-surgical treatment:

Treatment for phimosis depends on age and severity. Options include:

- Steroid creams or ointments.

- Stretching exercises in early stages.

- Antifungal or antibiotic medications.

However, stretching scarred foreskin may cause more tearing and scarring. Scientific evidence is lacking for its effectiveness. Phimosis creams have had limited success in recent reports. Mild phimosis symptoms in adults can be managed by using condoms and lubricants during sexual activity.

Mild tight foreskin caused by fungal infection can be treated with antifungal medications and steroid cream. Adults with high blood glucose levels (diabetes mellitus) and phimosis may require circumcision due to recurring fungal infection or possible BXO. Tight foreskin (phimosis) in diabetic patients often requires circumcision and biopsy of the foreskin.

Surgical treatments:

- Frenuloplasty: A procedure that releases the frenulum, a small fold of tissue. It allows the foreskin to detach from the penis head.

- Preputioplasty: A procedure that expands the foreskin by an incision in front, enabling full retraction.

- Partial circumcision: Leaving part of the foreskin covering the penis head. It has long-term complications.

- Full circumcision: The standard surgical option with glue or stitches for tight foreskin, particularly for BXO phimosis, traumatic injury, or penile cancer.

If sexual activity is painful or uncomfortable due to phimosis, urgent treatment is needed. Home treatment includes daily cleansing, controlled stretching exercises, and clearing smegma. Infections with tight foreskin (balanitis) require antibiotic or antifungal treatment. It's essential to get examined for sexually transmitted diseases by a GUM clinic or a doctor.

In summary, there are various alternatives to full circumcision, such as medications, creams, frenuloplasty, preputioplasty, or a combination. These options should be discussed with a specialist or urologist. Full circumcision without any medical problems should be seriously considered as it is irreversible surgery.

PS: This information is for guidance only. This is not a replacement for professional medical advice. Please call Dr Khan for video consultation £150 advice at +447527314081 without any obligation.

Cracks on the foreskin

Cracked foreskin presents with mild burning, itching, swelling and red patches, and with tight foreskin (phimosis)

Cracks or fissures on the foreskin may be due to Inflammatory conditions of the foreskin (called posthitis) or head of the penis (balanitis) or both (balanoposthitis). These cracks could be painful and associated with fungal or bacterial infection, scarring conditions called lichen sclerosus (BXO), and tight foreskin (phimosis and Paraphimosis).

Fungal infections are usually responsible, most commonly involving the yeast called Candida albicans, which is associated with a bacterial infection. Foreskin yeast infection is generally called “candidiasis” or “thrush” and is not common in healthy individuals but in cancer, immunocompromised, and diabetic individuals.

Bacterial infections, especially Streptococcus organisms, are the second most common cause of balanitis. The sexual health clinic needs to exclude sexually transmitted infections (STIs). The most common STIs are Chlamydia trachomatis, genital mycoplasmas, and Neisseria gonorrhoeae. These can produce cracks and red foreskin.

Poor hygiene due to a tight foreskin can cause cracks on the foreskin and irritant balanitis.

Diabetic patients with uncircumcised men have a high (35%) prevalence of balanitis, which gives them cracks to the foreskin. Among men with an acquired tight foreskin, 26% had a history of diabetes. Tight foreskin (phimosis) in men with diabetes increases the risk of infection of the foreskin and glans.

Balanitis xerotica obliterans (BXO) is a chronic, progressive, and sclerosing inflammatory foreskin disease of unknown cause. BXO will produce scars and cracks.

Treatment of the cracks is medical (antifungal, antibiotics and steroids) and surgical (dorsal slit, preputioplasty or circumcision). Control of sugar in diabetes patients is critical to managing the above treatment.

If cracks of freoskin are associated with tight foreskin (phimosis)

The treatment of phimosis depends on several factors, including age and the degree of tightness. Here are the available options:

1. Steroid Cream or Ointment: These reduce inflammation and improve foreskin elasticity.

2. Stretching Exercises: Beneficial, especially in the early stages of Phimosis.

 3. Stretching Rings (Phimostretch): Devices that aid gentle foreskin stretching.

If cracks of freoskin are associated with diseased freoskin (BXO)

We provide circumcision, dorsal slit or preputioplasty at our centre
Please get in touch with us for professional and expert advice by calling the mobile number below to the doctor directly.

Please call us at +447527314081 to discuss this further and get advice from our specialist team.

• Dr Nkwam: Consultant Urologist

• Dr Sanndher: Consultant Urologist

• Dr Khan: Paediatric Surgeon/Urologist

• Dr Safdar: Experienced Surgeon

London Circumcision Centre, Leyton and South Woodford Clinics, London

Aftercare Instructions for Glue Circumcision

How do I look after a circumcision treated with skin glue?

Skin glue is a special medical adhesive gel that is applied to the circumcision wound edges. It can be used on its own or with stitches. It takes only 3-5 minutes to dry and set, forming a thin layer over the wound. It forms a waterproof coating over your circumcision wound. Glue circumcision is the best method. 

How does skin glue work on circumcision wounds?

The inner and outer foreskin have edges that can be easily joined together with medical liquid glue using a special technique. 

Will glue get separated during the erection of the penis? 

No, glue is strong enough to stay on the skin during your erection in our unique technique of glue circumcision.

Why is the skin glue used in circumcision?

This will give a waterproof seal, less pain, less risk of infection, and better results than stitches. 

Can glue be used to redo or revise circumcision?

Yes, redoing or revision circumcision with glue gives the best outcome of the previous scar. Glue revision circumcision is the best method.

How long does glue stay on the circumcision wound?

The glue usually comes off itself within 5-15 days 

Will I feel pain after glue circumcision?
For the first few days, you may feel pain and use simple pain relief medication. Take simple over-the-counter painkillers for a few days. Glue circumcision is less painful than circumcision with stitches only. The head of the penis (glans) remains very sensitive after circumcision; you can apply a small amount of Vaseline or olive oil only to the glans penis. Sensitivity may last many weeks or months.

How do I care for a circumcision treated with skin glue?

Please follow the aftercare advice from Dr Khan

• Wash your hand before you touch/change the bandage 

• Only wear tight underwear with the head of the penis upwards toward the belly button. 

• Avoid soiling the bandage with urine

• Do not touch the glue for four days 

• Keep the circumcision wound dry for the first four days

• Keep the bandage for four days and take showers after four days. Afterwards, change the bandage daily for seven days after applying Fucidin cream only on the stitches

• No bath for 15 days to prevent soaking the wound

• Wrap the circumcision wound with cling film if you would like to take a shower for four days. 

• If the circumcision site gets wet, pat it dry. Don't rub the glue site, and do not apply cream or an antiseptic solution to it.

• If the wound edges join together securely and the glue is still in place after 15 days, you can remove it in the shower.

• Apply bio-oil on the wound for 2-3 months after four weeks to decrease the scarring.

What are things to avoid during the healing of the circumcision with glue?

• Do not scratch, rub, or pick at the glue; doing so may loosen the film before the wound fully recovers.

• Do not soak or scrub your wound for 15 days.

• Do not swim until the adhesive film (glue) has fallen off naturally

• Do not apply liquid, ointment medications, or any other product to the wound while the glue is in place. It could loosen the glue film before the wound is fully healed

• Do not do any heavy lifting, gym or exercise for two weeks

• Do not do any sexual activities for 4-6 weeks

How long will swelling or bruising settle down? 

The shaft of the penis will have swelling for 4-6 weeks, and bruising of the glans and shaft of the penis will settle within four weeks. 

How long frenulum is will heal? 

If you have frenuloplasty with glue circumcision, we put a few stitches covered by glue at the frenulum, which will take longer (about four weeks) to heal. Apply Fucidin cream after changing the bandage. The frenulum area will heal later than the circumcision site.

When should I get help from the Doctor?

Most circumcision wounds are sealed with skin glue and heal normally with excellent results. You should get medical help from our specialist doctors if: 

• Your wound gaps open or start to bleed

• You think your wound may be infected

What are the symptoms of wound infection?

• The circumcision wound looks redder or swollen

• The pain in the wound gets worse after three days

• Discharge of pus or blood comes from the circumcision wound

• You have a fever of 38C (100.4F) or more 

• Wound edges get separated by bleeding

Please get in touch with our doctors for medical advice if you have any questions.

Written by a patient at Leyton Clinic, London, February 2020

“I got circumcised by Dr Khan using the glue method and I can only praise both the surgeon and the technique. He was extremely friendly and approachable. I had a long list of question before the procedure which he happily answered over the phone. Booking an appointment was very easy and hassle-free. On the day of the operation, Dr Khan asked me about all my wishes and preferences and gave me personalised suggestions. The operation itself was virtually completely painless. I kept talking to Dr Khan and his lovely nursing assistant throughout the procedure. Having followed his post-operative care plan to the letter, my recovery was very quick and uneventful. I only needed to take simple over-the-counter painkillers (paracetamol and ibuprofen) for 2 days. The pain was completely gone after that. The swelling settled in about a week. As I'm writing this review, I am only 4 weeks post-op and it feels like I have been circumcised forever. The glue method achieved an excellent cosmetic result. I cannot recommend Dr Khan highly enough.”

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