Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

pre-pubertal phimosis, congenital or physiological

1st line – reassurance and hygiene

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ACUTE
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pre-pubertal phimosis, congenital or physiological
1st line – 

reassurance and hygiene

In patients with congenital or physiological phimosis, the best treatment is simply observation over time.

Expectant management for congenital (physiological) phimosis is preferred up to the time of puberty (typically around 12 years of age).[11][46]​​​

Reassurance to parents and child about normal penile anatomy and proper hygiene (without the need to forcibly retract the foreskin) will generally suffice. Routine cleaning of the external skin is desirable, but it is not necessary to retract the phimotic foreskin for cleaning until natural separation of the foreskin occurs.[42]

Consider – topical corticosteroids

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ACUTE
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pre-pubertal phimosis, congenital or physiological
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with cicatrix or balanitis xerotica obliterans (BXO)
Consider – 

topical corticosteroids

Additional treatment recommended for SOME patients in selected patient group

Presence of cicatrix or BXO/lichen sclerosis requires treatment regardless of age.

Success rates of 83% have been reported at a median follow-up of 22 months among pre-pubertal boys (n=462; mean age 4.7 years), including 67% of patients with BXO.[49]

Treatment course: 4 to 6 weeks. Course may be repeated once. Care should be taken to educate the patient and family on proper application techniques of topical corticosteroids.

Primary options

betamethasone dipropionate topical: (0.05%) apply sparingly to the preputial outlet twice daily

OR

triamcinolone topical: (0.1%) apply sparingly to the preputial outlet twice daily

Consider – preputial surgery

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ACUTE
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pre-pubertal phimosis, congenital or physiological
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with cicatrix or balanitis xerotica obliterans (BXO)
Consider – 

preputial surgery

Additional treatment recommended for SOME patients in selected patient group

Patients with phimosis who do not respond to or cannot tolerate a course of properly applied topical corticosteroid are managed with circumcision.[11][35]​​​ If the patient or carer wishes to avoid the cosmetic effect of circumcision but needs surgical intervention, they may be offered a preputioplasty.

A preputioplasty consists of limited dorsal slit(s) with transverse closure made along the constricting band of skin. Preputioplasty can be an effective alternative to full circumcision in most children; however, patients with BXO should undergo standard circumcision.[51][52]

post-pubertal phimosis

1st line – topical corticosteroid

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post-pubertal phimosis
1st line – 

topical corticosteroid

Phimosis persisting after puberty and into adulthood is generally treated with topical corticosteroid.[11][47][48][49]​​​​​ Results from one systematic review (that included adolescents up to age 17 years) indicate that topical corticosteroid may resolve phimosis (low-quality evidence).[50]​

Acquired or pathological phimosis (e.g., cicatrix or balanitis xerotica obliterans [BXO]/lichen sclerosis) requires treatment regardless of age.

Treatment course: 4 to 6 weeks. Course may be repeated once. Care should be taken to educate the patient and family about the proper application of topical corticosteroids.

Primary options

betamethasone dipropionate topical: (0.05%) apply sparingly to the preputial outlet twice daily

OR

triamcinolone topical: (0.1%) apply sparingly to the preputial outlet twice daily

2nd line – preputial surgery

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post-pubertal phimosis
2nd line – 

preputial surgery

Patients with phimosis who do not respond to or cannot tolerate a course of properly applied topical corticosteroid are managed with circumcision.[11][35]​​ If the patient or carer wishes to avoid the cosmetic effect of circumcision but needs surgical intervention, they may be offered a preputioplasty.[11]

A preputioplasty consists of limited dorsal slit(s) with transverse closure made along the constricting band of skin. Preputioplasty can be an effective alternative to full circumcision in most children; however, patients with BXO should undergo standard circumcision.[51][52]

paraphimosis

1st line – manual reduction

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paraphimosis
1st line – 

manual reduction

Paraphimosis should be managed with immediate manual reduction.[Figure caption and citation for the preceding image starts]: ParaphimosisFrom the collection of Nicol Corbin Bush, MD [Citation ends].com.bmj.content.model.Caption@7538f6af

The goal of treatment is prompt reduction of the foreskin to its normal anatomical position (distal to the glans penis).

To perform manual reduction, adequate anaesthesia is administered in the form of dorsal penile nerve block or ring block with local anaesthetic (lidocaine or bupivacaine, without adrenaline [epinephrine]). Children may require conscious sedation and/or general anaesthesia. Circumferential pressure around the oedematous ring of foreskin for several minutes may help to reduce the oedema. Both thumbs are placed on the glans with the fingers wrapped around the shaft of the penis proximal to the foreskin. Gentle pressure is applied to pull the foreskin with the fingers and push the glans with the thumbs until the foreskin is reduced to its anatomical position.[53] Water-based lubrication may facilitate preputial reduction.[54]​ 

Consider – sugar

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ACUTE
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paraphimosis
Consider – 

sugar

Additional treatment recommended for SOME patients in selected patient group

Where manual reduction is difficult applying granulated sugar to the area of oedema, or wrapping a glucose-soaked gauze around the penis for 10 to 20 minutes before attempted manual reduction, may help to extract some of the oedema by osmosis.[56]​ Note that in some cases topical administration of granulated sugar may take 1 to 2 hours to be effective.[53][57]​​​​

2nd line – needle puncture

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ACUTE
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paraphimosis
2nd line – 

needle puncture

Needle puncture may be employed if paraphimosis cannot be treated with more conservative measures.[52]​ Pressure is applied following needle puncture to facilitate reduction of oedema before manual reduction is attempted.[58]

The penis is sterilely prepped and a 26-gauge needle is used to make multiple (about 20) punctures in the oedematous ring of foreskin.

Consider – hyaluronidase

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ACUTE
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paraphimosis
Consider – 

hyaluronidase

Additional treatment recommended for SOME patients in selected patient group

Injection of hyaluronidase into the oedematous tissue may break down hyaluronic acid and its subsequent osmotic gradient.[52][59]​​​ Hyaluronidase may be used to augment the puncture technique.

Induces osmotic diuresis with movement of hyaluronic acid from oedematous tissue.

Primary options

hyaluronidase: consult specialist for guidance on dose

3rd line – compression wrap

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ACUTE
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paraphimosis
3rd line – 

compression wrap

Wrapping the phallus with a tight bandage may help to reduce oedema. One technique utilises a flexible, self-adhering bandage, which is left for 20 minutes before being removed.[60]

Autoreduction of the foreskin has been reported, but manual reduction may be required when the compression wrap is removed.

4th line – preputial surgery

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paraphimosis
4th line – 

preputial surgery

If conservative measures fail, definitive management in terms of either dorsal slit or circumcision may be performed.[33]

hypospadias

1st line – specialist referral

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hypospadias
1st line – 

specialist referral

Although some minor forms of hypospadias do not require surgical intervention, infants with hypospadias should be referred to a specialist for further evaluation to determine the severity of the condition.

If surgical repair is desired, this can be performed in most patients on an outpatient basis as early as 3 months of age.[61]

The patient may need a postoperative urethral stent for up to 2 weeks after surgery depending upon the complexity of the repair. Boys with an incomplete prepuce should not undergo circumcision in the neonatal period and should instead be referred to a specialist. The foreskin can be reconstructed or a circumcision can be performed at the time of urethroplasty with similar outcomes in distal hypospadias.[62]

If megameatus with intact prepuce (a mild variant of distal hypospadias) is discovered during routine neonatal circumcision, the circumcision should be completed and the patient referred electively for urological evaluation thereafter.[63]

Not all patients with hypospadias will benefit from preoperative administration of topical oestrogen or testosterone, and use of topical corticosteroids should be considered for each individual patient.[64][65]

congenital penile curvature and/or torsion

1st line – surgery

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congenital penile curvature and/or torsion
1st line – 

surgery

Surgery to straighten the penis should be offered for congenital penile curvature >30 degrees or torsion >90 degrees. This can be done in conjunction with a circumcision or with foreskin preservation.

Surgery for curvature can be deferred until after puberty.[68]

concealed penis <3 years old (before toilet training)

1st line – observation

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ACUTE
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concealed penis <3 years old (before toilet training)
1st line – 

observation

Need for, and timing of, management of concealed penis remains controversial. Although some advocate early intervention, most paediatric urologists feel that observation may be warranted up until the age of toilet training (2-3 years of age).[1][69]​​ In this age group, re-distribution of body fat often leads to spontaneous resolution of the buried penis.

Consider – phalloplasty

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ACUTE
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concealed penis <3 years old (before toilet training)
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with foreskin disproportion, disfiguring trauma, or scarring
Consider – 

phalloplasty

Additional treatment recommended for SOME patients in selected patient group

Urological surgical options are available where weight loss fails to improve concealed penis. In cases of congenital concealed penis (congenital megaprepuce) that are associated with an excess of inner preputial skin with a relative paucity of shaft skin, surgical intervention is warranted at an earlier date. In cases of concealed penis related to trauma or postoperative scarring, surgery is also indicated.[Figure caption and citation for the preceding image starts]: Congenital buried penisFrom the collection of Nicol Corbin Bush, MD [Citation ends].com.bmj.content.model.Caption@25bbc0a6[Figure caption and citation for the preceding image starts]: Congenital buried penis: abundant inner preputial skin with paucity of shaft skinFrom the collection of Nicol Corbin Bush, MD [Citation ends].com.bmj.content.model.Caption@45943dd2[Figure caption and citation for the preceding image starts]: Congenital buried penisFrom the collection of Warren T. Snodgrass, MD [Citation ends].com.bmj.content.model.Caption@72805433[Figure caption and citation for the preceding image starts]: Repaired congenital buried penis (with bilateral hernia repair and scrotoplasty)From the collection of Warren T. Snodgrass, MD [Citation ends].com.bmj.content.model.Caption@410399b2

concealed penis ≥3 years old (after toilet training)

1st line – weight loss

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ACUTE
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concealed penis ≥3 years old (after toilet training)
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without foreskin disproportion, disfiguring trauma, or scarring
1st line – 

weight loss

Boys will have difficulty with a concealed penis as toilet training begins. Weight loss is the primary treatment for concealed penis.

Older boys and adults with concealed penis are unlikely to have spontaneous resolution. Weight loss is recommended primarily, with urological surgical options also available. Although weight loss may help in adolescents and adults, the psychological impact of the condition and the low rate of improvement may warrant surgical referral.

2nd line – phalloplasty

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ACUTE
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concealed penis ≥3 years old (after toilet training)
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without foreskin disproportion, disfiguring trauma, or scarring
2nd line – 

phalloplasty

Urological surgical options are available where weight loss fails to improve concealed penis.

Although weight loss may help in adolescents and adults, the psychological impact of the condition and the low rate of improvement may warrant surgical referral. Several operative techniques have been described, although treatment preferences vary among patient populations and surgeons.[1][4][25][26][32][33][41][59]

1st line – phalloplasty

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ACUTE
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concealed penis ≥3 years old (after toilet training)
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with foreskin disproportion, disfiguring trauma, or scarring
1st line – 

phalloplasty

Surgical techniques vary widely among different patient populations and surgeons.[59]

In patients who have undergone prior circumcision and have a paucity of penile shaft skin, skin grafting may be necessary for complete penile coverage.

micropenis

1st line – endocrine evaluation

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ACUTE
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micropenis
1st line – 

endocrine evaluation

In true cases of micropenis (stretched penile length that is 2.5 or more standard deviations less than the mean for age), endocrine evaluation by a specialist is recommended.[45]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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