Phimosis Treatment of Last Resort: Adult and Teen Circumcision

Do you know what phimosis is? If you're circumcised, you might not have heard of it. If you're not circumcised, you should know that phimosis is a condition in which a person's foreskin is too tight, making it difficult to retract comfortably.

Physiological phimosis is a naturally occurring condition in newborns and children. The foreskin can adhere to the penis head, or glans, for the first five or six years of life.

Pathological phimosis, however, occurs when the tight foreskin causes irritation, infection, scarring and other complications. It's most often seen in older boys and adult men who are past the typical age for physiological phimosis.

Diagnosis of phimosis typically includes a physical examination. Therapeutic approaches to treating phimosis—especially in the early years—include applying a steroid cream and gently stretching the foreskin to make it more pliable. Vigilance in keeping the area clean to prevent infection and irritation can help you avoid phimosis.

These approaches often work.

If all else fails, though, and phimosis and its complications persist, circumcision is almost always necessary. We'll look at what happens when an older child or adult gets a circumcision, as well as some factors that should trigger a visit to the urologist if someone has phimosis.

Adult and teen circumcision

Circumcision is traditionally performed shortly after a male is born, but adults and teens do undergo the procedure, whether for medical reasons or just as a personal preference. One study of 12,298 circumcisions performed on men between the ages of 18 and 64 from 2015 to 2018 found phimosis was the reason for 52.5 percent of the procedures.

For many people with phimosis, circumcision is often the option that's left after all the others have been exhausted.

"I'll use a higher dose of steroid cream in older kids who really don't want a circumcision, but I just find the effectiveness isn't as good," said Amanda North, M.D., the director of urology at the Children's Hospital at Montefiore in the Bronx, New York. "Either the steroid cream works or it doesn't. And when it doesn't work, most people end up with a circumcision."

Circumcision is an active choice almost as frequently as it's a last resort. For instance, many men who grow up in a part of the world where circumcision isn't as common and then relocate to the United States seek the procedure for themselves and their older sons.

"We have a lot of patients from other parts of the world where circumcision is relatively rare," North said. "But then when they come here and they have problems with their foreskin, they tend to get circumcised. You'd be surprised how many parents come in to get their kids circumcised, and part of their story is a brother who got circumcised at age 18 or a brother-in-law who had to have a circumcision when he was 30."

The procedure

Just as it is with newborns, the circumcision procedure is straightforward and low risk for teens and adults. The main difference is that it takes slightly longer, and most healthcare providers want the patient to be sedated.

"As a pediatric urologist, we don't do office circumcisions," North said. "But many adult urologists offer in-office circumcisions using only a local [anesthetic]. In older teens and adults, it can be done under sedation and local, and that's a very good combination."

Some parents are reluctant to sedate bigger kids, but North advises them to do so. Why? It's not a best practice "to take a sharp object to a baby's private parts when they're moving around," North said.

In reality, most people prefer to be sedated. In some cases, the sedation cocktail used in the procedure has other benefits besides just knocking you out.

"Sometimes they'll use propofol, which we call 'milk of amnesia' because it's a white drug," North said. "Sedation in most cases involves IV medication that makes you unaware of what's going on, but also those drugs are intended to also make you not really remember what happened."

In the hands of a skilled surgeon, a baby's circumcision procedure takes 10 to 15 minutes. An adult circumcision procedure might take 30 to 45 minutes. The patient is able to go home the same day and return to more or less normal activity within a couple of days—apart from strenuous activity and sex.

Other potential reasons for teen/adult circumcision

North mentioned a couple of other circumstances where families might consider circumcision for people with phimosis: neurodivergent kids and senior adults who are no longer able to care for themselves.

"I do get a lot of requests to do circumcisions on kids who are on the autism scale, especially if they're lower-functioning, because they're just not going to be able to take care of the foreskin themselves when they get older," North said. "It's one thing to help a 6-year-old to pull the skin back, but once that child has an adult-sized penis, it becomes a little more awkward."

Caring for men who are nearer to the end of life and have phimosis can be equally problematic if their caretakers aren't vigilant.

North shared the story of an older man with dementia who had phimosis and diabetes. During a medical procedure, a catheter was placed. The healthcare worker who took the catheter out forgot to put his foreskin back in place, so he was sent home with the foreskin trapped behind the penis head. Circulation to the penis head was cut off and gangrene developed.

"When men get older, and some of them end up with dementia or dexterity problems, phimosis can become a problem in ways that would be really surprising to the general public," North said. "I think if people thought more about those end-of-life issues, there would be more newborn circumcisions. It's not like a one-off thing we only see once every five years. [In] older men with foreskin problems who are losing mobility and perhaps memory, it's a real thing."

When to see a urologist

People who have tighter foreskins should understand that paraphimosis—foreskin trapped behind the penis head—is a medical emergency that requires immediate medical attention. Apart from that, you should probably consult a pediatric urologist on phimosis in kids if they reach about 6 years old and still can't retract their foreskin.

"If your kid's in kindergarten and he can't pull back his foreskin, it's time to see a urologist," North said. "I think anyone beyond that age, too, when you pull the skin back, you should see a mushroom head and then a shaft. If that mushroom head still has skin attached to it, or you can't pull the skin back enough to see the entire mushroom head of the penis, you really should see a urologist."

Conclusions

Phimosis, as with most medical conditions, has degrees of severity. Understanding that you can live with some tightness of the foreskin but not so much that it causes discomfort, irritation, infection and other downstream issues is key.

At the end of the day, if phimosis is causing issues, circumcision for older children or adults is a relatively easy, trauma-free option that's becoming more common.