From the Guidelines
Phimosis treatment should start with topical steroid creams, and if unresponsive, referral to an experienced urologist for circumcision is recommended. According to the British Association of Dermatologists guidelines for the management of lichen sclerosus, 2018 1, adult male patients with phimosis caused by lichen sclerosus who do not respond to an ultrapotent topical steroid after 1–3 months should be referred to an experienced urologist for circumcision.
Key Considerations
- Topical steroid creams like clobetasol propionate 0.05% (CP 005%) ointment applied once daily for 1–3 months can be effective in treating phimosis caused by lichen sclerosus 1.
- Gentle stretching exercises of the foreskin during bathing can help improve retraction, and good hygiene is essential, including regular cleaning beneath the foreskin as far as possible without forcing retraction.
- If conservative treatments fail after 1–3 months or in severe cases causing pain, difficulty urinating, or recurrent infections, surgical options may be necessary, including circumcision or preputioplasty.
- For children, treatment is often delayed until age 5-7 unless complications occur, as physiologic phimosis commonly resolves naturally, but those unresponsive to topical steroids may require referral to a urologist for circumcision 1.
Surgical Options
- Circumcision is a common surgical option for treating phimosis, especially in cases where topical steroid creams are ineffective 1.
- Preputioplasty, a partial incision to widen the opening, is another surgical option, but its effectiveness and safety compared to circumcision are not well-established in the provided evidence.
Follow-up and Management
- Patients with phimosis caused by lichen sclerosus should be followed up regularly to assess the response to treatment and to monitor for potential complications, such as urinary symptoms or signs of malignant change 1.
- Those who undergo circumcision should be reviewed after surgery to assess residual disease and to provide further treatment with topical steroids if necessary 1.
From the Research
Phimosis Treatment Options
- Topical steroid therapy is a effective alternative to circumcision for the treatment of phimosis in boys younger than 3 years 2
- Topical steroids can resolve phimosis effectively in boys younger than 3 years, with a success rate of 74% after 1 month of treatment with betamethasone 2
- Manual retraction therapy, topical steroid therapy, and preputioplasty are effective alternatives to circumcision, with the goal of retracting the foreskin without removing it 3
Success Rates of Topical Steroid Therapy
- A study found that 82% of boys with phimosis were successfully managed with topical steroid therapy, with 12 having full retraction, 26 having moderate retraction, and 12 having partial retraction 4
- The success rate of topical steroid cream was 69.4% and 63.9% at 3 and 8.3 months, respectively, with no side effects associated with the treatment 5
Treatment Options for Adult Phimosis
- Conservative treatment options for adult phimosis include topical steroid application and the use of medical silicon tubes (Phimostop™) for gentle prepuce dilation 6
- Surgical approaches for adult phimosis include circumcision, laser circumcision, preputioplasty, and the use of in situ devices, with patient satisfaction rates, complications, and impact on sexual function varying depending on the treatment chosen 6
Factors Affecting Treatment Outcome
- Scarring on examination was observed to negatively impact outcome, with a success rate of 92% in boys without scarring compared to 67% in boys with scarring 4
- The objectivation of the phimosis grade did not predict the outcome of topical steroid treatment, with no significant difference in success rates between different grades of phimosis 5