Definition

Inability to pull back a retracted foreskin forward over the glans. This is an emergency – reduce as soon as possible to avoid ischaemia/necrosis.

Symptoms

• Painful swollen glans
• Foreskin stuck behind the glans
• Discolouration of glans (dark red/blue)
• Tight constricting band of foreskin

Management

1. Manual reduction with suitable analgesia (oral/LA/lubrication)
2. If successful → discharge with advice not to retract foreskin for 1 week
3. If unsuccessful → call SpR → Dorsal slit
4. Consider circumcision electively after acute episode

Definition

Inability to retract foreskin over glans. This is usually not an emergency unless patient has retention.

Types of phimosis

1. Physiological – normal finding in children
   1. On gentle traction the foreskin will pucker and look pink and healthy (like a carnation flower)

Incidence of phimosis in various age-groups [3]

2. Pathological – usually seen in adults
   1. Commonly due to lichen sclerosus (also called balanitis xerotica obliterans (BXO)).

Note: Tight foreskin can be accompanied by tight (short) frenulum – patients will need a frenuloplasty to correct this if bothersome

Symptoms

• Ballooning of foreskin on voiding
• Recurrent UTIs if obstructive
• Recurrent infections (balanitis/balanoposthitis)
• Painful retraction attempts
• Cracking of the foreskin

Acute management (if urinary retention)

1. Dilate foreskin opening with small ISC catheters (start small 8Fr and go up)
2. Stretch gently with instruments under LA
3. Dorsal slit or circumcision if required

Non-acute management

1. General advice
   1. Hygiene – keep area dry and clean, dab foreskin after voiding to reduce irritation with urine
   2. Pay gentle attention to foreskin, but avoid forceful retraction
   3. Consider giving patient information leaflets
      1. Check and give local leaflets
      2. If no local leaflets available, then can use these:
         1. Paediatric patients - Alder Hey 4-Skin Health
         2. Adults – BAUS patient information page
2. Topical steroids – variable prescription practices, check local policy
   1. Example – Betnovate cream (Betamethasone 0.1% w/w) – apply to affected area BD for 3/52 then OD for 3/52, then stop
3. If conservative treatment fails → surgical options:
   1. Dorsal slit
   2. Circumcision
   3. Preputioplasty (if patient wishes to preserve foreskin and it’s not pathological)

Definition

• Balanitis – inflammation of the glans
• Balanoposthitis – inflammation of glans and foreskin

Causes

• Candida infection
• Poor hygiene / smegma accumulation
• Dermatitis (eczema, psoriasis)
• Bacterial infection
• Lichen sclerosus
• STI (HSV, trichomonas, etc.)

Symptoms

• Redness, swelling, discomfort
• Itching, irritation
• Foul smell or discharge
• Pain on foreskin retraction
• Dysuria

Treatment

1. Good hygiene + warm saline soaks - it is important to keep the foreskin clean and dry. Continuous exposure to urine causes irritation and Zoon's balanitis
2. Topical antifungal (clotrimazole) if candida suspected
3. Topical steroid (e.g., hydrocortisone 1%) if inflammatory/dermatitis
4. Oral antibiotics if bacterial (e.g., flucloxacillin or clarithromycin)
5. Avoid retracting foreskin forcefully
6. If associated with phimosis or recurrent episodes → consider circumcision
7. STI screen if appropriate

⚠️ If any lesion is seen on glans or foreskin - think malignancy!
This will require further review by SpR to decide if this needs a biopsy.

For more in depth reading see following article: Edwards SK, Bunker CB, van der Snoek EM, van der Meijden WI. 2022 European guideline for the management of balanoposthitis. J Eur Acad Dermatol Venereol. 2023 Jun;37(6):1104-1117.