What is the treatment for penis adhesions?

Treatment for Penile Adhesions

For post-circumcision penile adhesions, surgical lysis of adhesions (LOA) in the office is the most effective treatment, as conservative home management with daily retraction fails in approximately 64% of cases over 6 months, with most patients ultimately requiring LOA anyway. 1

Initial Assessment and Classification

When evaluating penile adhesions, document the following specific characteristics:

• Circumferential extent: Measure what percentage of the glans circumference is involved (less than 25%, 25-50%, 50-75%, or greater than 75%) 1
• Severity: Determine what percentage of the glans surface is covered by adhesions (less than 50% versus 50% or more) 1
• Type of adhesion: Distinguish between simple fibrinous adhesions versus well-formed skin bridges 2
• Timing: Note whether adhesions are early (within 3-4 months post-circumcision) or late presentations 2

Treatment Algorithm Based on Adhesion Characteristics

For Simple Fibrinous Adhesions (Early, Less Severe)

Conservative management may be attempted first only in highly selected cases:

• Adhesions covering less than 25% of the glans have the greatest likelihood of spontaneous resolution 1
• Adhesions covering less than 50% of the glans have higher success rates with home therapy 1
• Non-circumferential adhesions respond better to conservative measures 1

Conservative protocol when attempted:

• Apply topical corticosteroid (betamethasone 0.05% or clobetasol propionate 0.05% ointment) once daily to non-eroded areas if inflammation is present 3, 2
• Daily gentle retraction of the foreskin to prevent re-adhesion 3, 4
• Apply white soft paraffin (petroleum jelly) every 4 hours to maintain moisture and reduce friction 3
• Re-evaluate at 6 months, as this is the typical timeframe for determining success or failure 1

Critical caveat: Even with optimal conservative management, only 36% of patients achieve complete or substantial resolution, and 65% eventually require LOA 1

For Well-Formed Skin Bridges or Extensive Adhesions

Proceed directly to surgical lysis of adhesions:

• Well-formed skin bridges that develop 3-4 months post-circumcision require surgical adhesiolysis 2
• Circumferential adhesions covering more than 50% of the glans should undergo LOA rather than prolonged conservative management 1
• Multiple skin bridges always require surgical correction 2, 5

Office-based LOA technique:

• Apply EMLA cream (eutectic mixture of lignocaine and prilocaine) under an occlusive dressing for 60 minutes before the procedure 6
• Separate adhesions with a probe and gauze swab under local anesthesia 6
• This technique is completely pain-free in approximately 82% of boys 6
• Surgical excision under local or general anesthesia is required for thicker, more mature skin bridges 5

Post-Procedure Management

After adhesiolysis (whether conservative or surgical):

• Instruct parents to regularly retract the foreskin daily for at least 3 weeks to prevent re-adhesion 6
• Apply topical steroid if disease is still active to prevent Koebnerization and further scarring, particularly around the coronal sulcus 7
• Monitor for signs of infection: increased redness, warmth, purulent discharge, or fever 3
• Follow-up to ensure adhesions do not reform 1

Special Considerations and Red Flags

When to suspect underlying pathology:

• If adhesions persist despite adequate medical treatment, consider lichen sclerosus (present in approximately 3% of cases with persistent adhesions) 2
• Lichen sclerosus requires treatment with clobetasol propionate 0.05% ointment and may necessitate circumcision if phimosis develops 7
• Biopsy should be considered if there is concern for malignant transformation, as lichen sclerosus carries a 2-9% risk of penile carcinoma 7

When circumcision is indicated:

• Persistent phimosis despite medical management requires circumcision 7
• Subcoronal or transcoronal adhesions that persist despite adequate medical treatment need surgical treatment with concurrent circumcision 7
• If the disease is still active at the time of surgery, topical steroid is required postoperatively to prevent Koebnerization 7

Common Pitfalls to Avoid

• Do not pursue prolonged conservative management (beyond 6 months) in patients with extensive or circumferential adhesions, as this delays definitive treatment 1
• Do not apply topical corticosteroids to open wounds or erosions; use only on intact inflamed skin 3
• Do not fail to educate parents about daily retraction after adhesiolysis, as this is the primary cause of recurrence 6, 4
• Do not use dry dressings alone; occlusive/moist dressings significantly improve healing 3