Ever so often I see a client for massage who has a tight foreskin. Sometimes with oil lubrication, the foreskin will retract but for some men even this won’t enable them to pull back the foreskin and usually this has been the situation for them since they were first getting erections. For those of us who have retracting foreskins or those who are circumcised this may not seem problematic but in reality the means that these guys have a very different experience of both masturbation and penetrative sex.
More about having a tight foreskin or Phimosis
At birth, the inner layer of the foreskin is sealed to the glans penis. This attachment forms “early in fetal development and provide[s] a protective cocoon for the delicate developing glans.”The foreskin is usually non-retractable in infancy and early childhood. This remains the situation until early adolescence when most boys first experience a retraction of foreskin with erection. A Danish survey found that the mean age of first foreskin retraction is 10.4 years.
There are three mechanical conditions that prevent foreskin retraction:
- 1. The tip of the foreskin is too narrow to pass over the glans penis. This is normal in children and adolescents.
- 2. The inner surface of the foreskin is fused with the glans penis. This is normal in children and adolescents but abnormal in adults.
- 3. The frenulum is too short to allow complete retraction of the foreskin (a condition called frenulum breve).
Pathological phimosis (as opposed to the natural non-retractability of the foreskin in childhood) is rare and the causes are varied. Some cases may arise from balanitis (inflammation of the glans penis), perhaps due in turn to inappropriate efforts to retract an infant’s foreskin.
It has been put forward that unusual masturbation practices, such as thrusting against the bed or rubbing the foreskin forward may cause phimosis. Patients are advised to stop exacerbating masturbation techniques and are encouraged to masturbate by moving the foreskin up and down so as to mimic more closely the action of sexual intercourse.
Lichen sclerosus et atrophicus (thought to be the same condition as balanitis xerotica obliterans) is regarded as a common (or even the main) cause of pathological phimosis. This is a skin condition of unknown origin that causes a whitish ring of indurated tissue (a cicatrix) to form near the tip of the prepuce. This inelastic tissue prevents retraction.
Phimosis may also arise in untreated diabetics due to the presence of glucose in their urine giving rise to infection in the foreskin.
Phimosis in older children and adults can vary in severity, with some able to retract their foreskin partially (relative phimosis), and some completely unable to retract their foreskin even when the penis is in the flaccid state (full phimosis).
Physiologic phimosis, common in males 10 years of age and younger, is normal, and does not require intervention.[Non-retractile foreskin usually becomes retractable during the course of puberty.
If phimosis in older children or adults is not causing acute and severe problems, nonsurgical measures may be effective. Choice of treatment is often determined by whether the patient (or doctor) views circumcision as an option of last resort to be avoided or as the preferred course.
- Topical steroid creams such as betamethasone, mometasone furoate and cortisone are effective in treating phimosis and may provide an alternative to circumcision. It is theorized that the steroids work by reducing the body’s inflammatory and immune responses, and also by thinning the skin.
- Stretching of the foreskin can be accomplished manually, with balloons or with other tools. Skin that is under tension expands by growing additional cells. A permanent increase in size occurs by gentle stretching over a period of time. The treatment is non-traumatic and non-destructive. Manual stretching may be carried out without the aid of a medical doctor. The tissue expansion promotes the growth of new skin cells to permanently expand the narrow preputial ring that prevents retraction. In a study, 86% of individuals were cured and could retract their foreskin in 6 weeks, by applying a cream and skin stretching twice daily.
- Beaugé treated several hundred adolescents with unusual masturbation habits and techniques, such as thrusting against the bed or rubbing the foreskin forward. He advised them to masturbate by lightly grasping the shaft of the penis and pulling it back and forth. Retraction of the foreskin was generally achieved after four weeks and he stated that he never had to refer one for surgery.
Surgical methods range from the complete removal of the foreskin to more minor operations to relieve foreskin tightness:
- Circumcision is sometimes performed for phimosis, and is effective.
- Dorsal slit (superincision) is a single incision along the upper length of the foreskin from the tip to the corona, exposing the glans without removing any tissue.
- Ventral slit (subterincision) is an incision along the lower length of the foreskin from the tip of the frenulum to the base of the glans, removing the frenulum in the process. Often used when frenulum breve occurs alongside the phimosis.
- Preputioplasty, in which a limited dorsal slit with transverse closure is made along the constricting band of skin can be an effective alternative to circumcision. It has the advantage of only limited pain and a short time of healing relative to circumcision, and avoids cosmetic effects.