What is phimosis?

Phimosis: Definition and Management

Phimosis is defined as the inability to fully retract the foreskin (prepuce) over the glans penis, which may lead to complications including painful erections, erectile dysfunction, and urinary issues. 1, 2

Types and Presentation

• Phimosis can be physiological (normal in children up to 3 years of age) or pathological (when it persists beyond this age or develops later in life) 3
• In adult men, phimosis commonly affects the prepuce, coronal sulcus, and glans penis, with the primary complaint being tightening of the foreskin 1
• The condition can result in erectile dysfunction, painful erections, and changes in urinary stream 1
• In children, phimosis most frequently affects the prepuce, with reported incidence in children with phimosis ranging from 14% to 100% 1

Causes and Risk Factors

• Lichen sclerosus (LS) is a significant cause of phimosis in both adults and children, with approximately 30% of phimosis cases in adults attributed to LS 1, 2
• Other causes include chronic inflammation, balanitis, penile trauma, and poor hygiene 1
• Phimosis may hinder proper inspection of the penis, increasing the risk of undetected conditions by 25-60% 1

Complications

• Untreated phimosis can lead to:
  • Painful erections and sexual dysfunction 1, 2
  • Paraphimosis (inability to replace a retracted foreskin) in uncircumcised men 1
  • Urinary flow interruption and potential urethral obstruction 1
  • In rare cases, renal failure following meatal obstruction in children 1
  • Increased risk of penile cancer (2-9% risk in patients with lichen sclerosus) 1

Treatment Options

First-Line Treatment: Topical Steroids

• Topical steroid therapy is recommended as the first-line treatment for phimosis, with circumcision reserved for cases that fail to respond to medical management 2, 4
• For adults: Apply clobetasol propionate 0.05% ointment once daily for 1-3 months, along with an emollient as both a soap substitute and barrier preparation 2
• For children: Apply betamethasone 0.05% ointment to the tight preputial ring twice daily for 4-6 weeks 2, 5
• Topical corticosteroids may increase complete resolution of phimosis after 4-8 weeks of treatment compared to placebo or no treatment 4
• Combining topical steroids with gentle stretching exercises has shown a 96% success rate in resolving phimosis 5

Surgical Options

• Circumcision is the gold standard surgical approach for phimosis that fails to respond to topical steroids 2, 6
• Alternative surgical techniques include preputioplasty and laser circumcision 6
• New medical silicon tubes (Phimostop™) for gentle prepuce dilation are emerging as conservative treatment options 6

Special Considerations

• Phimosis caused by lichen sclerosus may be less responsive to topical steroids and may require more intensive treatment or surgical intervention 2
• During erection, tight foreskin can cause significant pain, difficulty with sexual intercourse, and increases the risk of paraphimosis 2
• If circumcision is performed, the foreskin should always be sent for histological examination to exclude penile intraepithelial neoplasia 2

Common Pitfalls

• Many patients are referred for circumcision without an adequate trial of topical steroids 2
• Phimosis is often over-diagnosed, leading to unnecessary surgical interventions 7
• Always consider lichen sclerosus as a cause of phimosis, especially if resistant to treatment 2
• Circumcision does not always ensure protection against further flares of lichen sclerosus, with 50% of men requiring continued treatment 2