(386) Rethinking Phimosis Management: Conservative and Surgical Alternatives to Circumcision

Abstract Introduction Phimosis is a common urological condition characterised by the partial or complete inability to retract the foreskin, which can cause genital pain and sexual dysfunction. The condition may be classified according to its severity and underlying aetiology, both of which guide clinical decision-making. Whilst circumcision remains the conventional surgical treatment, it is a radical intervention associated with inherent risks. These include not only surgical complications but also a notable risk of medico-legal litigation, compounded by the procedure’s perceived simplicity and the subjective nature of cosmetic outcomes, resulting in an average claim of approximately $175,000 in the United States of America. Furthermore, cultural and religious beliefs often influence patients' attitudes toward circumcision. In recent years, there has been a shift towards less restrictive therapies that preserve the prepuce, with advances in surgical innovation having expanded the range of treatment options for phimosis. As these novel approaches gain traction, it is essential that urologists maintain a comprehensive understanding of their indications, benefits and limitations to ensure informed, high-quality patient counselling. Objective This narrative review provides a contemporary overview of prepuce-preserving treatment options for phimosis, encompassing non-operative approaches and surgical techniques. Methods A structured literature search was conducted using key search terms capturing both the condition (e.g. “phimosis”, “non-retractile foreskin”) and its management (e.g. “treatment”, “topical corticosteroids”, “preputioplasty”). Identified articles underwent manual review prior to inclusion. Results A wide variety of alternatives to circumcision are available in the treatment of phimosis, encompassing non-operative and operative techniques. A key first-line non-operative strategy employs gentle daily foreskin retraction combined with topical corticosteroid therapy, which has demonstrated high efficacy and minimal adverse effects; however, recurrence rates of up to 18% provide rationale for alterative options in those wishing to avoid surgery. As such, novel therapies such as platelet-rich plasma injections and medical-grade dilatation devices have been proposed. Platelet-rich plasma therapy has demonstrated promise in early studies. Dilatation devices such as Novoglan and Phimostop offer graded dilation of the phimotic ring via an inflatable balloon or silicone tuboid inserted beneath the prepuce, respectively; these devices allow for self-administered, community-based treatment and have shown encouraging outcomes, including high patient satisfaction and ease of use. For patients with phimosis that is refractory or not amenable to conservative therapy, preputioplasty serves as a viable surgical option. Unlike circumcision, preputioplasty encompasses a variety of techniques aimed at preserving the cosmetic and protective functions of the foreskin. Dilatation devices and preputioplasty are contra-indicated in cases associated with balanitis xerotica obliterans due to the risk of iatrogenic trauma and impaired wound healing respectively. Effective phimosis management requires an individualised approach that considers patient preferences, clinical severity and the individual’s ability and/or willingness to comply with treatment. Patient information materials serve as valuable resources capable of supporting individuals in determining their treatment preferences and actively participating in informed, shared decision-making. Conclusions A growing array of prepuce-preserving alternatives to circumcision, including dilatation devices and evolving surgical techniques, are reshaping the management of phimosis. Promoting awareness of these options among clinicians and patients is essential to promoting patient-centred care. Disclosure No