From the Guidelines
Phimosis caused by lichen sclerosus should be treated with an ultrapotent topical steroid for 1-3 months, and if unresponsive, referral to an experienced urologist for circumcision is recommended. This approach is based on the most recent guidelines from the British Association of Dermatologists, which emphasize the importance of early treatment to prevent complications and improve quality of life 1. The guidelines suggest that adult male patients with phimosis caused by lichen sclerosus should be offered an ultrapotent topical steroid, such as clobetasol propionate 0.05% ointment, once daily for 1-3 months, with an emollient as a soap substitute and as a barrier preparation.
If the patient does not respond to topical steroid treatment after 1-3 months, circumcision should be considered. This is because persistent phimosis can lead to complications such as urinary tract infections, painful erections, and increased risk of penile cancer 1. The guidelines also recommend that patients with urinary symptoms due to lichen sclerosus should be referred to a urologist for further investigation and management of lower urinary tract symptoms.
In addition to topical steroid treatment and circumcision, patients with lichen sclerosus should be followed up regularly to monitor for disease recurrence and progression. This includes regular review of symptoms, particularly urinary and sexual function, and biopsy of any suspicious areas suggestive of penile intraepithelial neoplasia or squamous cell carcinoma 1. The guidelines also recommend that patients with active ongoing disease should be offered long-term follow-up and treatment with topical steroids as needed.
Overall, the management of phimosis caused by lichen sclerosus requires a multidisciplinary approach, involving dermatologists, urologists, and primary care physicians. Early treatment and regular follow-up are essential to prevent complications and improve quality of life. The guidelines provide a framework for the management of lichen sclerosus, and healthcare professionals should be aware of the latest recommendations and guidelines to provide optimal care for patients with this condition 1.
Some key points to consider when managing phimosis caused by lichen sclerosus include:
- The use of ultrapotent topical steroids, such as clobetasol propionate 0.05% ointment, for 1-3 months
- Referral to an experienced urologist for circumcision if the patient does not respond to topical steroid treatment
- Regular follow-up to monitor for disease recurrence and progression
- Biopsy of any suspicious areas suggestive of penile intraepithelial neoplasia or squamous cell carcinoma
- Long-term follow-up and treatment with topical steroids as needed for patients with active ongoing disease.
From the Research
Definition and Diagnosis of Phimosis
- Phimosis is defined as the inability to retract the foreskin and expose the glans 2
- Differentiating between physiological phimosis and pathological phimosis is important, as the former is managed conservatively and the latter requires surgical intervention 3
Treatment Options for Phimosis
- Topical steroid therapy is an effective alternative to circumcision for the treatment of phimosis in boys younger than 3 years 4
- Conservative treatment, including topical steroid application and the use of medical silicon tubes (Phimostop™) for gentle prepuce dilation, is an option for adult phimosis 2
- Surgical approaches, such as circumcision, preputioplasty, and laser circumcision, are also available for the treatment of phimosis 2, 5
- Topical steroids have been shown to be effective in treating phimosis, with an overall efficacy of 87% in one study 6
Age-Related Considerations
- Physiological phimosis is common in male patients up to 3 years of age, but often extends into older age groups 5
- Topical steroid therapy has been shown to be effective in boys younger than 3 years 4
- The choice of treatment for adult phimosis depends on the grade of phimosis, results, complications, and cost-effectiveness 2
Referral and Diagnosis
- Referrals of patients with physiological phimosis to urology clinics may create anxiety regarding the need for surgery amongst patients and parents, while unnecessarily expanding the waiting list for specialty assessment 3
- Many physicians continue to face difficulties in distinguishing physiological phimosis from pathological phimosis, leading to unnecessary referrals 3