Foreskin is the piece of skin that covers the top of the penis. Foreskin problems such as tightness, ballooning, redness are very common. It can affect boys of all ages. Inadequate or incorrect information can cause confusion and anxiety to both patients and parents. This article will help parents to get some understanding on common foreskin problems in boys.

Tight Foreskin or Phimosis

In boys, tight foreskin, also called as phimosis is very common. Because of the tightness, Sometimes the foreskin balloons at the time of passing urine. At birth, the foreskin is normally tight (Figure 1). However, as the boys get older, fluid is produced from the undersurface of the foreskin and makes it freely mobile. By the time the boys are around 10 years of age, the foreskin is completely free and mobile. Beyond the age of 10 years,if foreskins are not freely mobile, treatment is usually recommended.

Figure 1: Normal tight foreskin    Figure 2: Flower appearance

Although tight foreskin is very common in young boys,it can also be seen after infection or inflammation of the foreskin. In a normal tight foreskin (physiological phimosis), pulling the foreskin back will show a flower like pink inner foreskin at the tip, as shown in Figure 2. However, if infection is present (pathological phimosis) the foreskin tip is flat and flower appearance is not seen.

Inflamed Foreskin

Inflammation of the tip of the penis and foreskin (balanitis) are usually caused by chemical irritation, bacterial or fungal infection. The tip of foreskin becomes red, swollen and painful (Figure 3). After some time the inflamed foreskin becomes tight – as shown in Figure 4. Antibiotic and antifungal creams can be applied, along with regular warm sitz (antiseptic) bath and it usually works well.

Figure 3: Balanitis         Figure 4: Inflamed & tight foreskin                                                 

BXO

Infected or inflamed foreskin should always be watched carefully, as they can result in a tight scar formation (BXO -Balanitis xerotica obliterans) (Figure 5). Steroid creams applied over the foreskin may improve the tightness, but not in all patients. In many patients, the tightness comes back immediately after stopping the cream applications. Most patients need circumcision (Removing the foreskin) which will cure the patient.

Very rarely, the infection from the tip and head of the penis can spread into the whole penis. The whole penis appears swollen and red (Figure 6)and this condition is called balanoposthitis. Oral antibiotics (tablets and syrup) are usually not enough. Antibiotics given via the veins (intravenous) will reduce the redness and swelling quickly.

Figure 5:BXO         Figure 6:Balanoposthitis                                

Paraphimosis

Sometimes boys forget to pull the foreskin forward (back to normal) after cleaning or passing urine. The foreskin becomes red,swollen and appears like a balloon around the head of the penis (Figure 7). This is called paraphimosis and it is an emergency requiring surgery. If noticed early, the foreskin can be gently pulled forward to normal position under anaesthesia, otherwise the foreskin may need to be removed – circumcision.

Figure 7: Paraphimosis.   Figure 8:Foreskin cyst

Cysts in the foreskin are very common. The most common cysts are white in color and move along with the foreskin(Figure 8). They are not painful at all but can cause lot of anxiety. The normal fluid produced from the foreskin and glans (smegma) is trapped under the foreskin and forms a cyst. These cysts resolve on its’ own and do not need any surgery.