GROIN AND GENITAL AREA
Phimosis in children
Difficulty or inability to retract the foreskin, the skin that covers the glans.
Phimosis
Phimosis in children is the difficulty or inability to retract the foreskin, the skin that covers the glans.
In young children, some difficulty in retracting the foreskin may be physiological and may not necessarily require treatment. In other cases, however, phimosis may be related to a more marked narrowing or to the presence of a scar-like ring.
Symptoms and signs to look out for
The signs that most often lead to a consultation are:
Causes or associated factors
In younger children, difficulty retracting the foreskin may be linked to the normal anatomical development of the foreskin and does not necessarily represent a problem that needs immediate treatment.
However, phimosis may also be scarring, meaning that it is caused by the formation of rigid, narrowed tissue. This condition may appear after inflammation, local infections or be associated with skin conditions such as lichen sclerosus.
It is important to avoid forced retraction of the foreskin, as this may cause small injuries, pain and scarring, worsening the narrowing.
When to book a consultation
It is advisable to request a paediatric surgery or paediatric urology consultation when:
In younger children, in the absence of infections, pain or scarring signs, immediate treatment may not be necessary. The purpose of the specialist assessment is precisely to distinguish physiological situations from those that require treatment.
A common concern is whether the foreskin should already retract during the first years of life: it is not always necessary for the foreskin to be fully retractable in young children, unless there are local infections, urinary tract infections, pain or scarring signs. It is instead important to avoid forced retraction and request an assessment if there are any doubts.
Assessment and diagnosis
Diagnosis is made through a specialist consultation. The paediatric surgeon assesses the appearance of the foreskin, the possibility of retraction and the presence of any scarring signs, inflammation or suspected lichen sclerosus.
When lichen sclerosus is suspected, the definitive diagnosis may require histological examination of the foreskin, meaning a biopsy or analysis of the tissue removed during surgery, according to specialist indication.
During the consultation, information is also collected about any infections, urinary symptoms, pain or difficulties reported by the child or parents.
How it is treated
Treatment depends on the child’s age, the type of phimosis, the presence of symptoms and any suspicion of scarring phimosis or lichen sclerosus.
Not all children with difficulty retracting the foreskin need surgery. In younger children, if there are no infections, pain or scarring signs, observation or follow-up over time may be indicated.
When phimosis is symptomatic, scarring or persistent, the possible surgical options are:
- circumcision, meaning surgical removal of the foreskin;
- preputioplasty, meaning a procedure to widen the foreskin, when indicated;
- preputial frenulotomy, meaning division of a short preputial frenulum, in cases where the problem mainly involves the frenulum.
The choice of treatment is discussed with the family based on the clinical picture, the child’s age and the specialist indication.
When surgery is needed and what it involves
Surgery may be indicated at any age in case of urinary tract infections, recurrent balanoposthitis or balanitis xerotica obliterans caused by lichen sclerosus.
It may also be indicated in boys over the age of 11 if phimosis persists, or in case of painful erections.
Circumcision consists of the surgical removal of the entire foreskin. It is usually performed under sedation and local anaesthesia, as a day surgery procedure.
Division of a short preputial frenulum is generally advisable after the age of 12. When the indication concerns only the frenulum, the procedure may also be performed while the patient is awake, under local anaesthesia, as an outpatient procedure.
In cases where lichen sclerosus is suspected, the removed tissue may be sent for histological examination according to specialist indication.
Recovery and useful instructions
After surgery, instructions may vary depending on the type of procedure and the individual case.
In general, Dr Rapuzzi advises:
In cases of lichen sclerosus, long-term urological follow-up is indicated to monitor the development of the condition and any involvement of the external urethral opening.
Parents’ most common questions
No. In young children, it is not always necessary for the foreskin to retract completely. In the absence of local infections, urinary tract infections, pain or scarring signs, early intervention is often not needed.
No, it should not be forced. Forced retraction may cause pain, small injuries and scarring, worsening the narrowing. If there are any doubts, it is better to request a specialist assessment.
The foreskin should be retractable before the beginning of sexual activity. Before then, the need for treatment depends on the presence of symptoms, infections, pain, scarring phimosis or a recommendation from the paediatrician or specialist.
A consultation is useful if local or urinary infections occur, if there is pain, a whitish scar-like ring or if phimosis persists as puberty approaches.
Lichen sclerosus is a skin condition that may affect the foreskin and cause chronic inflammation, scarring and narrowing. In some cases, it may also involve the external urethral opening.
No. Not all cases require surgery, and surgery does not always necessarily mean circumcision. In some cases, preputioplasty may be indicated, if compatible with the clinical picture.
According to the doctor’s indication, the foreskin should be retractable before the beginning of sexual activity. Before then, the need for treatment depends on the presence of symptoms, infections, pain or scarring signs.
Note: the information on this website is provided for guidance only and does not replace a specialist medical assessment. In case of acute symptoms, significant pain or a worsening general condition, you should contact a doctor or go to the emergency department.
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