Phimosis – is it normal ?

Q: When my 33 month old baby boy urinates his penis literally blows up like a balloon and looks as though its going to burst? His urine flows freely and he doesn’t seems to be in pain when he pee. His penis will inflates at the end of his wee. Mom told me he never see anything like this before when she raised threes of my brothers up. Is this normal ? (Michelle )

( CLICK HERE for Bahasa Melayu version of this article )

A: Dear Michelle, this is a manifestation of a condition called phimosis.
The prepuce ( foreskin ) is redundant skin about 1 cm from the glans penis. It covers the glans penis (head of the penis). It is normal for the skin to be attached to the glans penis making it non-retractile (unable to pull the skin to expose the entire glans penis ) . This attachment will slowly detach naturally over time with development of the inner skin via keratinisation and enzymes that promotes detachment.  Until then, it is normal for the foreskin to be non-retractile. This is seen in almost all newborn males.

There is quite a wide range of age for this natural retraction to be achieved, with studies showing age ranging from infancy to teenage/adulthood. It does very much increase in incidence/possibility as one grows older. Most achieved it by 2-5 years old. Certain analysis described that 2% of normal males continue to have non-retractability throughout life even though they are otherwise normal.

Do not forcefully retract it with the intention to resolve the condition as such forceful retraction will cause injury to the inner skin due to trauma and the scarring that follows could lead to pathological phimosis, as it is unlikely the skin will be able to naturally be retracted in the future.

Why the balloon effect ?
Due to the adhesion and non-retractibility, there is only a small but unscarred opening in the foreskin. Thus with high velocity urine stream coming from the urethral opening in the glans penis, there will be a temporary collection of urine in the space between the penis and the foreskin due to the small opening via the foreskin. This produce the temporary ballooning effect.

Parents may find this weird and even frightening. Please be assured that this is most of the time a benign condition and with increasing retraction of the foreskin, this will not happen anymore. However, please note that if the boy appear to be straining with need to apply extra manual pressure, then this is a sign of obstruction and would need to seek treatment.

Is it always normal ? 
Natural incidence of phimosis with natural resolution, without causing any problems to the child is known as physiological phimosis. However, phimosis is not always normal. There are incidences in which we call pathological phimosis. This meant that the foreskin is truly not retractable due to scarring of the foreskin against the glans penis. This happen due to trauma ( when forcefully retract the skin before natural detachment occur), and infection. In pathological phimosis, the child will have problems with painful or bloody urination, painful during erection and recurrent infection of the penis (balanoposthitis). It is also not normal for a boy to get phimosis again after natural retraction was achieved (secondary non-retractibility). In such condition, you need to seek a doctor’s treatment.

What can I do ?
The important thing is to note whether the phimosis is associated with painful and difficulty urination, or recurrent infection of the penis. This is not normal and treatment need to be sought. On the other hand, most cases are normal (physiological) so parents ought to be assured and wait for natural detachment of the foreskin to happen, thus enabling retraction to be achieved.

Treatments available for pathological phimosis includes circumcision, prepuceplasty (surgical refashioning of the foreskin without circumcise) as well as non-surgical options like stretching exercise with steroid cream application.

( CLICK HERE for Bahasa Melayu version of this article )

( answered by Dr Foo Chee Hoe )