Conservative Treatments

Patient-Friendly Alternatives to Circumcision

Last updated on 12th April 2010

Please contact Dr Peter Ball if you need any help with the stretching techniques described on this page, or if your Doctor insists that circumcision is the only answer.

NORM-UK estimates that at least 9 out of 10 patients undergoing circumcision in British hospitals do not need to be there 1 2. Conservative, non-surgical treatments for common foreskin problems are much easier, cheaper and far less likely to cause long-term harm to the patient 3. Unfortunately many doctors are unaware of these. Others are uninterested in preserving the patient's foreskin for religious, personal or even financial reasons.

It is important that doctors keep up to date and ensure that any decisions to undertake an invasive procedure are based on the best available evidence. Therefore, to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate. [The law & ethics of male circumcision - Guidance for Doctors, BMA, March 2003]

Stretching a tight foreskin

The vast majority of tight foreskins can be suitably loosened within a month or so by persistent stretching twice daily.

When possible start by warming the penis. Use baby oil, Vaseline intensive care hand and body lotion, Nivea or any bland cream as a lubricant. Pull the foreskin forward away from the body several times then pull it back as far as it will go onto the glans (head of the penis} and hold it in this stretched position for several minutes. If done with an erection the stretching will be even more effective. Do this several times a day.

When stretching begins to make the glans (head of the penis} visible, grip the glans between thumb and fingers and roll the foreskin forward over the glans and thumb. Thus providing a larger platform on which to stretch. Hold it in this position as long as you can at a time - say 5 minutes. Repeat as often as you have the time and enthusiasm for. Later you will find there is room for two or more fingers to insert into the tight ring of the foreskin to stretch it further.

The glans is often uncomfortably tender to touch when exposed for the first time. This can be cured by deliberately handling it under water and frequently changing your grip. It will soon become less tender and reach a normal level of sensitivity.

It may become apparent that further retraction of the foreskin is held up by a short frenulum (banjo string - the tongue of skin in the mid-line underneath the glans) This is called a Frenulum Breve and can be cured by a small operation under a local anaesthetic called a frenuloplasty.

Take care to avoid trapping the foreskin behind the glans (Paraphimosis) when it becomes loose enough to happen but tight enough to be difficult to bring forward again. Seek medical advice early if you fail to return the foreskin to cover the glans.

If you are unable to see the glans or make any headway stretching, consider buying a glansie (NORM-UK members can get a 10% discount) to bring the foreskin to the stage when the above methods can apply.

Attempt to retract your foreskin every time you pee.

Development

The foreskin and the glans develop as one structure. Natural separation of the two structures occurs gradually during childhood. The age at which the foreskin becomes retractable differs for each child. It may take until the age of 17 or beyond. This is normal. Forcing the foreskin to retract may cause pain, bleeding, scarring, infection, and adhesions. Therefore, the foreskin of a child should be retracted only by the child himself when he is ready to do so.

Steroid creams

Steroid creams should be used next if no significant progress has been made after a month. The cream you need is called Betamethasone 0.05% sold in 30 G tubes. It is sold in the UK as Diprosone. It is a prescription-only medicine which means you will have to ask your doctor for a prescription. The cream should be massaged into the tight part of the foreskin inside and outside 2-3 times a day for at least a month combined with further stretching. As the foreskin widens it may become apparent that the frenulum is restricting retraction. This can be remedied by a small operation called a frenuloplasty performed under a local anaesthetic.

Preputioplasty (Dorsal Relieving Incision)

A preputioplasty should be able to cure any tight foreskin where stretching and steroid cream application have failed. This is an operation in which a cut is made through the tight ring that is limiting foreskin retraction, in an up and down direction and then sewn up in an across direction. Once this has healed (2-3 weeks) the foreskin can usually be retracted fully and the only change in appearance is a notch that becomes visible in the skin as it is retracted. Make sure that you agree with your surgeon how far you will allow him to cut through the foreskin.

Short frenulum

A short frenulum may be the cause of a foreskin not retracting behind the glans, or pulling the glans downwards as soon as retraction begins. If stretching the frenulum fails, as it usually does, it can be freed by a minor operation called a Frenuloplasty. This can usually be performed under a local anaesthetic.

Ballooning of the Foreskin

Ballooning of the foreskin while urinating can be a normal phase of development during childhood. It is not an indication for circumcision. Ballooning is a temporary phenomenon that arises when the foreskin begins to separate from the glans. It speeds the process of separation and disappears when the process is complete.

Phimosis

Phimosis is a name given to the condition where the foreskin is unretractable. We must distinguish normal (physiological) unretractability from abnormal (pathological) unretractability. Physiological unretractability of the foreskin is found in nearly all new-born infants, and becomes increasingly uncommon with advancing age. It is not an indication for circumcision.

Pathological phimosis is scarring and obstruction of the opening of the foreskin. This is rare and may be found in diabetes, and in a localised skin condition called lichen sclerosus which is often referred to as "balanitis xerotica obliterans" (BXO) when it affects the penis. In this condition the skin is thickened, white, and hard. Circumcision is a treatment option for lichen sclerosus of the foreskin when it is refractory (unresponsive) to conservative treatment. Circumcision will not however cure or prevent outbreaks of lichen slerosus elsewhere on the penis.

The medical literature contains many reports showing that most cases of phimosis can be treated effectively by topical steroid applications or by conservative surgery.

"True" phimosis --- better termed "preputial stenosis," because "phimosis" has so many different definitions it now is devoid of any useful meaning --- occurs in less than 2% of intact males.

Of these 2%, 85-95% will respond to topical steroids. Of those who fail this, at least 75% will respond to stretching under local anesthesia, either manually or with a balloon. The arithmetic is simple: At the very most 7 boys in 10,000 may need surgery for preputial stenosis. No wonder the Canadian Paediatric Society calls circumcision an "obsolete" procedure! [What is 'phimosis'?, Van Howe R, CIRP]

Further information

Further information on the conservative treatment of foreskin problems can be found on CIRP.

References

1 - What is 'phimosis'?, Van Howe R, CIRP (further references on CIRP page)

2 - Rickwood AMK, Kenny SE, Donnell SC. Towards evidence based circumcision of English boys: survey of trends in practice. BMJ 2000;321:792-793.

3 - Sivakumar B, Brown AA, Kings L. Circumcision in 'buried penis' - a cautionary tale. Ann R Coll Surg Engl. 2004; 86(1):35-7.

Medical professionals should also refer to the Phimosis Clinical Guidelines page and accompanying references