If a foreskin is tight and unretractable, this is a phimosis. If it has already pulled back but will not go forwards again, this is a paraphimosis and should be reduced. If this is not possible in primary care, send to the Emergency Department.
If the phimosis is symptomatic, management is either medical or surgical. If it does not trouble a man, it can be left alone.
Medical management is with very potent steroid cream (Dermovate: Clobetasol 0.05%), massage a small pea sized amount of cream into the tight part of the foreskin (inside and outside).
After a week of treatment, the skin will be noticeably thinner. The man can then start stretching exercises on the foreskin, usually best by pulling the foreskin back until it feels tight (but not painful), and holding it back under tension for 10 minutes – usually after a bath or shower. Aim to do this twice a day. Warn about paraphimosis. Once wide enough, stretching can be done by easing apart with 2 fingers, again holding for 10 minutes at a time.
Often very potent steroid required for 2 months or more. Aim to wean either frequency of dosing or potency as soon as it has worked. Effective for >50% of patients. Phimosis may recur.
Surgical management is either preputioplasty or circumcision. These are usually done under local anaesthetic. Refer to urology