From the Guidelines
Phimosis in adults should be treated with ultrapotent topical steroid ointment for 1-3 months, and if unresponsive, referral to an experienced urologist for circumcision is recommended. The treatment approach for phimosis in adults involves a combination of conservative measures and, if necessary, surgical intervention. 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.
The initial treatment involves the application of a topical steroid cream, such as clobetasol 0.05%, to the tight portion of the foreskin once daily for 1-3 months, along with the use of an emollient as a soap substitute and barrier preparation 1. It is essential to discuss the amount of topical treatment to be used, the site of application, and the safe use of an ultrapotent topical steroid with the patient 1.
If the disease has responded well to topical steroids, a further review 6 months later is recommended, and if disease remission has continued, the patient can be discharged 1. However, patients with active ongoing disease will require long-term follow-up, and any changes suggestive of premalignant or malignant changes should be biopsied and treated accordingly 1.
Surgical options, including circumcision or preputioplasty, may be considered if conservative treatment fails or if phimosis is severe 1. Patients should seek immediate medical attention if they experience severe pain, inability to urinate, or signs of infection such as redness, swelling, or discharge.
Key considerations in the treatment of phimosis in adults include:
- The use of ultrapotent topical steroid ointment as the initial treatment
- Referral to an experienced urologist for circumcision if unresponsive to topical treatment
- Long-term follow-up for patients with active ongoing disease
- Surgical options, including circumcision or preputioplasty, for severe or unresponsive cases
- Prompt medical attention for signs of infection or other complications.
From the Research
Treatment Options for Phimosis in Adults
- Conservative treatment options are available, including topical steroid application and the use of medical silicon tubes (Phimostop™) for gentle prepuce dilation 2
- Surgical approaches include circumcision, which is considered the gold-standard treatment, as well as preputioplasty and the use of in situ devices that crush the foreskin and create haemostasis 2
- Topical pharmacotherapy, such as topical steroids, may be effective in reducing the signs and symptoms of phimosis, but more research is needed to establish its true role and effectiveness 3
- Manual retraction therapy and topical steroid therapy have been shown to be effective in treating phimosis in boys, with response rates of 84.5% and 87% respectively 4
Cost-Effectiveness of Treatment Options
- Topical steroid therapy has been found to be the most cost-effective treatment option, with costs ranging from $758 to $800 per case 5
- Preputial plasty and circumcision are more expensive, with costs ranging from $2515 to $2580 and $3009 to $3241 per case respectively 5
- Surgical intervention should not be considered until topical therapy has been given an adequate trial, due to the lower morbidity, lower costs, and tissue preservation of preputial plasty 5
Surgical Treatment Options
- Circumcision is a common surgical treatment for phimosis, but it may not be necessary in all cases 6
- Preputioplasty and the use of in situ devices are alternative surgical options that may be effective in treating phimosis 2
- Laser circumcision has been shown to provide superior outcomes in terms of operative time and postoperative complication rate compared to traditional circumcision 2