What are the stages of phimosis?

From the Guidelines

Phimosis is a condition that progresses through several stages, beginning with physiologic phimosis, and can be classified into five grades based on the degree of foreskin retraction and glans exposure, as noted in various studies 1. The stages of phimosis can be summarized as follows:

• Grade 1: Full retraction with a visible stenotic ring
• Grade 2: Partial glans exposure
• Grade 3: Partial retraction exposing only the urethral meatus
• Grade 4: Slight retraction without meatus visibility
• Grade 5: No retraction at all Treatment options vary by severity, starting with gentle stretching and topical steroid creams for mild cases, as recommended by the British Association of Dermatologists' guidelines for the management of lichen sclerosus 1. For cases of phimosis caused by lichen sclerosus that do not respond to ultrapotent topical steroids after 1-3 months, referral to an experienced urologist for circumcision is recommended, as stated in the 2018 guidelines 1. It is essential to note that early intervention is crucial to prevent complications, including balanitis, urinary tract infections, and, in rare cases, penile cancer in adulthood, as highlighted in the review of the literature and current recommendations for management of lichen sclerosus 1. Some key points to consider in the management of phimosis include:
• The role of surgery, such as circumcision, in the treatment of penile lichen sclerosus with symptoms due to persistent phimosis or meatal stenosis, as supported by large studies documenting satisfactory results 1
• The importance of sending all tissue removed at circumcision or meatotomy in the pediatric population for pathological review to diagnose potential lichen sclerosus, as recommended by the review of the literature and current recommendations for management of lichen sclerosus 1

From the Research

Stages of Phimosis

• Phimosis is a condition where the prepuce cannot be retracted over the glans penis, and it can be classified into different stages, including:
  • Severe phimosis: the prepuce is unretractable to evaluate the meatus 2
  • Moderate phimosis: the prepuce is retractable to less than 50% glanular exposure 2
  • Mild phimosis: penile adhesions are present 2
• Physiologic phimosis is common in male patients up to 3 years of age, but it can extend into older age groups 3

Treatment of Phimosis

• Topical steroid therapy is a highly efficacious, safe, and well-tolerated treatment for phimosis, with a success rate of 84.5% to 87% 2
• Manual retraction therapy and preputioplasty are also effective alternatives to circumcision 3, 4
• Surgical approaches, such as circumcision and laser circumcision, are also available, but they should not be considered until topical therapy has been given an adequate trial 4, 5

Histological Alterations in Phimosis

• Histological alterations in the prepuce, such as an increase in collagen type III and a reduction in the volumetric density of elastic fibers, can be observed in patients with failed topical treatment 6
• These alterations can affect the success rate of topical treatment, with a success rate of 85% reported in one study 6