Phimosis in adults: causes, topical steroid treatment and when circumcision

In newborns and small children the foreskin is naturally adherent to the glans and cannot be retracted; with age it separates spontaneously, and forcible retraction is harmful. This physiological phimosis needs no treatment. The situation in an adult man is different: if after puberty the foreskin still cannot be retracted and the opening of the foreskin is narrowed or a white, firm, scarred ring can be seen, we speak of pathological phimosis, and it usually needs medical assessment.

Characteristic of pathological phimosis are narrowing and loss of elasticity of the skin at the tip of the foreskin, whitish or grey skin of altered texture, splitting on stretching, recurrent inflammation under the foreskin and sometimes adhesions to the glans. In many adults the foreskin was initially mobile and narrowed over time. So in an adult who previously retracted the foreskin without difficulty and suddenly cannot, the cause of the changes needs to be sought.

The most important cause of foreskin scarring in adults is lichen sclerosus, also called balanitis xerotica obliterans, BXO, when it affects the penis. It is a chronic inflammatory skin disease that causes whitening, thinning and stiffening of the skin of the foreskin and glans, and in an advanced form narrowing of the urethral opening. The second group is recurrent inflammation of the glans and foreskin (balanoposthitis): fungal (most often yeast), bacterial, and inflammatory in skin diseases such as psoriasis or eczema. The third is injury and forcible retraction of the foreskin, which cause microtears and scars.

Diabetes promotes phimosis in two ways: a high glucose level in the urine and tissues makes yeast and bacterial infections under the foreskin easier, and recurrent inflammation leads to scarring. In addition, drugs of the SGLT2-inhibitor class, which increase glucose excretion in the urine, were associated in the cited study with about a 2.7-fold higher risk of genital infections and conditions such as balanitis, and even phimosis in men, compared with DPP-4 drugs. This is an observational study, which does not prove that the drug is the cause of phimosis in a particular patient, and it is not an argument for stopping the drug without consulting the treating doctor; it only shows that a man with diabetes, particularly over 60, should pay attention to hygiene and report recurrent balanitis.

These numbers require correct interpretation. A relative risk of 15.5 means that squamous cell carcinoma of the penis occurs in men with lichen sclerosus far more often than in the general population, but penile cancer is a rare disease, so the absolute risk in an individual man remains low. The practical conclusion concerns not panic but surveillance: lichen sclerosus has to be recognised (this often requires assessment by a dermatologist or urologist and, if the picture is equivocal, a biopsy), treated and monitored, and any new change on the glans or foreskin — an ulcer, a lump, a persistent patch, bleeding — reported to a doctor without delay.

The evidence for adults is much weaker. A systematic review of pharmacological treatment of phimosis or lichen sclerosus in adults (Lygas and Joshi, 2022) found that there is little research and it is heterogeneous; it suggests the probable safety of topical steroids and some potential to reduce the signs and symptoms of lichen sclerosus, but good-quality trials with patient-reported outcomes are lacking, so a cure rate cannot be reliably given. In turn, in a small review of boys with lichen sclerosus (Folaranmi et al., 2018; 6 studies, 89 patients) steroids avoided circumcision in 31 of 89 (35%), with short follow-up. Topical steroids can therefore be regarded as a reasonable first attempt for phimosis without serious scarring, but not as a method of proven effectiveness in adults.

In practice the regimen (type of steroid, strength, duration, possible combination with antifungal treatment) is set by the doctor according to the diagnosis: different management applies in lichen sclerosus (usually potent steroids to a defined schedule, with follow-up) and in post-infectious phimosis. Usually a thin layer is applied to the narrowed part of the foreskin for several weeks, with gentle stretching within the limits of pain; this does not replace assessment of the cause. Side effects include skin thinning and fungal superinfection with overuse, so one should not extend or increase treatment on one's own or reach for potent steroids without a prescription.

When steroids do not help, phimosis recurs, the foreskin is heavily scarred or adherent, there is recurrent inflammation of the glans, or lichen sclerosus involves the glans and the urethral opening, surgery is considered. There are two main techniques. Circumcision consists of removing the foreskin and is the most definitive, and the removed tissue can be examined histologically, which matters if lichen sclerosus or premalignant changes are suspected. Preputioplasty involves cutting the constricting ring and suturing it in a transverse direction, which widens the foreskin but preserves it; it is an option for men who wish to keep the foreskin, and is used when the lesion is limited.

The choice depends on the extent of scarring, the diagnosis, the patient's preference and the surgeon's experience. Preputioplasty is suitable mainly for limited narrowing without active lichen sclerosus; with extensive scarring or active disease circumcision is usually regarded as more certain, although comparative data for adults are lacking. The procedures are usually performed under local anaesthesia or brief general anaesthesia, as day cases. Possible complications include bleeding, haematoma, infection, slow healing, changes in sensation and scars; in lichen sclerosus narrowing of the urethral opening may need additional assessment. We give no figures for complications or recurrences here, because the cited sources contain no comparative data for adults.

Paraphimosis is a situation in which a foreskin retracted behind the glans cannot be pulled back and tightens like a ring behind the coronal sulcus. Swelling of the glans and foreskin develops, which increases the constriction, and in extreme cases ischaemia and necrosis. It most often follows forgetting to return the foreskin after an examination, catheterisation, procedure or intercourse, and also forcible retraction of a narrowed foreskin. Pain, swelling, discolouration or a change of colour of the glans and inability to urinate are symptoms with which you must go to the emergency department.

Several treatment methods have been described in the literature: manual reduction (with pressure and local anaesthesia), osmotic methods (intended to reduce swelling), puncture and aspiration of fluid, and surgical incision of the constricting ring; a penile nerve block technique has also been described (Little and White, 2005). The choice of method belongs to the doctor. Do not use force or wait until morning in the hope that the swelling will subside by itself; delay increases the risk of ischaemia. After the episode, treatment of the cause of the phimosis, often surgical, is usually recommended to prevent recurrence.

Phimosis in an adult is a signal to establish the cause, not a reason for embarrassment or for self-treatment by force. The key steps are: diagnosis (including recognising lichen sclerosus and diabetes), a trial of conservative treatment under medical supervision, and surgery when conservative treatment fails. The certainty of the evidence for steroid treatment in adults is low, so decisions rest on clinical assessment and the patient's preferences. Paraphimosis is the one situation in which you must not wait.