One of the most frequently misdiagnosed conditions of the foreskin is phimosis. The reason for this misunderstanding is because the very paper that ended circumcision in England in 1949, recognizing that the attachment of the foreskin to the glans at birth is normal, also incorrectly said that the separation of the two structures is complete by the age of 3.

Physiologic phimosis: Today we know the attachment of the foreskin and glans is normal in infancy and childhood, and that the average age of foreskin retractability is 10.4 years. One to two percent of boys are born with a fully retractile foreskin and one to two percent of adult males live to old age with a problem-free non-retractile foreskin. These are variations on a theme. Retraction is unique to each boy, and the first person to retract a boy’s foreskin should be the boy himself. If the process isn’t complete by puberty, the hormones of puberty—and the increased interest in the organ at hand—generally complete the process. Most males can fully retract their foreskins by the time they’re 25.

During the developmental process, the foreskin and glans may begin to separate, while the opening of the foreskin is not yet lax enough to allow retraction. This can cause the foreskin to “balloon” as the boy urinates. I love the story of an elderly Irishman who tells how, as a boy, he and his friends lucky enough to have a foreskin that ballooned: would stand in a row, urinate, and then squeeze the balloon to see who could “shoot” the farthest. As the preputial opening widens, most boys decrease their chances of winning the game but increase their ability to retract their foreskins.

Pathologic phimosis: Unlike physiologic phimosis, pathologic phimosis is an abnormal condition. Proper care for the intact penis is simple and helps to prevent pathologic foreskin conditions. The foreskin should be left alone until the prepuce demonstrates an ability to retract easily and naturally. Again, the boy should be the first person to retract his own foreskin. If the foreskin does not yet retract, there is nothing to “clean under”; its forcible retraction by a parent, doctor, or anybody other than the boy himself (it is highly unlikely that a boy will cause himself the pain of forced foreskin retraction) can result in scarring, infection, or inflammation—common causes of pathologic phimosis. Excessive use of bubble baths, soaps or shampoos in the bath, or chlorinated swimming pools can also cause the foreskin to close down to protect the underlying urinary opening (meatus). Symptoms may include redness, itchiness, and stinging or burning with urination. The foreskin will return to normal when the offending substances, which kill normal bacteria and cause yeast overgrowth, are removed from the boy’s environment. The healing process can be helped with “bacterial replacement therapy,” applying liquid Acidophilus culture (the active ingredient in yogurt) or other probiotic to the foreskin six times a day for three days.

Inelastic scar tissue caused by premature retraction may also prevent the foreskin from retracting. Gentle stretching of the remaining tissue will allow retractability over time in most boys. In others, a y-v or z-plasty can realign the tissue and widen the opening. If the male is not in pain, this surgical treatment should be used as a last resort and not until the end of puberty (25 years). And, finally, a condition of unknown etiology, previously called balanitis xerotica obliterans (BXO) and now more commonly referred to by the name used for the same condition in females, lichen sclerosis, is identified by change in the color of tissue to white and the closing down of the foreskin. A pharmacist has suggested a treatment that works well. Apply 1% clotrimazole cream and 1% hydrocortisone cream (both over-the-counter medicines) to the tissue three times a day. Improvement is generally noted within the first week, and the foreskin is usually restored to health in 6 to 8 weeks.

Keeping one’s foreskin should be a high priority. So, in sum, if somebody tells you your baby or child has “phimosis” and needs to be circumcised, remember that physiologic phimosis is normal and doesn’t need to be “treated.” And if you or another adult you know is diagnosed with pathologic phimosis, remember that there are several less drastic, effective treatment alternatives to circumcision, alternatives that will preserve both the protective and sexual functions of a most important body part.