Topical steroid treatment of phimosis in boys

Topical corticosteroids for treating phimosis in boys

BACKGROUND

This is an updated version of a Cochrane Review first published in 2014. Phimosis is a condition in which the prepuce (foreskin) cannot be fully retracted past the head of the penis (glans). Phimosis is often treated surgically by circumcision or prepuce plasty; however, reports of non-invasive treatment using topical corticosteroids applied for four to eight weeks have suggested favorable outcomes.

OBJECTIVES

To assess the effects of topical corticosteroids applied to the stenotic portion of the prepuce for the treatment of phimosis in boys compared with placebo or no treatment.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS, and ClinicalTrial.gov. We checked reference lists of included studies and relevant reviews for additional studies. There were no restrictions on the language of publication. The date of the last search was 4 October 2023.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) that compared the use of any topical corticosteroid with placebo or no treatment for boys with any type or degree of phimosis.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data related to the review's primary and secondary outcomes, and assessed the studies' risk of bias. We used the random-effects model for statistical analyses and expressed dichotomous outcomes as risk ratios (RRs) with 95% confidence intervals (CIs). We contacted the authors of the primary articles to request details of the study design and specific outcome data. We used GRADE to assess the certainty of evidence on a per-outcome basis.

MAIN RESULTS

In this update, we identified two new studies with 111 participants, bringing the total number of included studies to 14 (1459 randomized participants). We found that types of corticosteroids investigated, participant age, degree of phimosis, type of phimosis, and treatment duration varied considerably among studies. Compared with placebo or no treatment, topical corticosteroids may increase the complete resolution of phimosis after four to eight weeks of treatment (RR 2.73, 95% CI 1.79 to 4.16; I² = 72%; 10 trials, 834 participants; low-certainty evidence). Based on 252 complete resolutions per 1000 boys in the control group, this corresponds to 436 more complete resolutions per 1000 boys (95% CI 199 more to 796 more). We downgraded the certainty of the evidence by one level for serious study limitations and by one level for serious inconsistency. Topical corticosteroids may also increase the partial resolution of phimosis at four to eight weeks of treatment compared with placebo or no treatment (RR 1.68, 95% CI 1.17 to 2.40; I² = 44%; 7 trials, 745 participants; low-certainty evidence). Based on 297 partial resolutions per 1000 boys in the control group, this corresponds to 202 more partial resolutions per 1000 boys (95% CI 50 more to 416 more). We downgraded the certainty of the evidence by one level for serious study limitations and by one level for serious inconsistency. We are uncertain of the effect of topical corticosteroids compared to placebo on change in retractability score (standardized mean difference [SMD] -1.48, 95% CI -2.93 to -0.03; I²91%; 2 trials, 177 participants; very low-certainty evidence). We downgraded the certainty of the evidence by one level for serious study limitations, one level for serious heterogeneity, and one level for serious imprecision. Compared with placebo, topical corticosteroids may increase the long-term complete resolution of phimosis six or more months after treatment (RR 4.09, 95% CI 2.80 to 5.97; I² = 0%; 2 trials, 280 participants; low-certainty evidence). Based on 171 long-term complete resolutions per 1000 boys in the control group, this corresponds to 528 more complete resolutions per 1000 boys (95% CI 308 more to 850 more). We downgraded the certainty of the evidence by one level for serious study limitations and by one level for serious imprecision. There may be little or no difference in the risk of adverse effects between topical corticosteroids and placebo or no treatment (RR 0.28, 95% CI 0.03 to 2.62; I² = 22%; 11 trials, 1091 participants; low-certainty evidence). Only two of 11 studies that recorded adverse effects reported any adverse effects; one event occurred in the corticosteroid group and six in the control group. We downgraded the certainty of the evidence by one level for serious study limitations and by one level for serious imprecision.

AUTHORS' CONCLUSIONS

Topical corticosteroids, compared to placebo or no treatment, may increase complete and partial resolution of phimosis when assessed after four to eight weeks of treatment, and may increase long-term complete resolution of phimosis assessed six or more months after treatment. Topical corticosteroids may have few or no adverse effects, and we are uncertain about their effect on retractability scores. The body of evidence is limited by poor reporting of methods in the studies, important clinical heterogeneity, and serious imprecision in the results. Future, higher-quality trials with long-term follow-up would likely improve our understanding of the effects of topical corticoids on phimosis in boys.

The efficacy of topical 0.1% mometasone furoate for treating symptomatic severe phimosis: A comparison of two treatment regimens

BACKGROUND

Twice daily 0.1% mometasone furoate is an effective treatment for phimosis in children. However, mometasone furoate has an important therapeutic advantage because it is effective in once-daily applications. This study was to compare the efficacy of two different topical 0.1% mometasone furoate regimens for the treatment of symptomatic severe phimosis in pediatric patients.

METHODS

A total of 1,689 patients with symptomatic severe phimosis classified by the Kikiros system were prospectively enrolled in the study from March 2018 to February 2021. A total of 855 patients received 0.1% mometasone furoate twice-daily (BID group) and 834 patients received 0.1% mometasone furoate once-daily (QD group) for 4 weeks.

RESULTS

A total of 1,595 boys completed the treatment (798 and 797 in the BID and QD groups, respectively). The success rate of the BID group was higher than that of the QD group at the end of week 2 (44.8% vs. 33.3%, P < 0.05), while there was no difference in the success rate at 4 weeks and 3 months between the two groups (70.7% vs. 69.7%, and 66.8% vs. 64.9%, respectively) (P > 0.05). In both treatment groups, the success rate of grade 5 phimosis was lower than that of grade 4 at 2 weeks, 4 weeks, and 3 months. A total of 83 patients experienced recurrence of phimosis. Only fifteen patients had local mild adverse drug reactions.

CONCLUSION

Topical application of 0.1% mometasone furoate once-daily or twice-daily for 4 weeks had comparable efficacy in children with symptomatic severe phimosis. A once a day regimen may be more suitable for children. Topical steroid application is more effective in children with low-grade phimosis than those with high-grade phimosis.

Preputioplasty as a surgical alternative in treatment of phimosis

Preputioplasty denotes various surgical techniques directed at resolving phimosis without the need for radical or partial circumcision. This narrative review summarizes the best-known surgical techniques of preputioplasty. A MEDLINE and EMBASE-based literature search of original manuscripts and case reports published in English has been carried out using the following key words: “circumcision”, “partial circumcision”, “phimosis”, “paraphimosis”, and “preputioplasty”. Six different procedures are explored in more detail and illustrated. The complication rates of all surgical procedures presented here are reported to be low. In cases of medical (rather than cultural and religious) indications, foreskin-preserving procedures present useful alternatives to circumcision in the routine clinical practice of urologists and pediatric surgeons.

Efficacy of topical steroid treatment in children with severe phimosis in China: A long-term single centre prospective study

AIM

To evaluate the efficacy of topical steroid (0.1% mometasone furoate) therapy and factors affecting long-term outcome of paediatric severe phimosis in China.

METHODS

A total of 1550 patients with severe phimosis classified by Kikiros system were prospectively enrolled in the study from January 2016 to February 2020. They were prescribed with 0.1% mometasone furoate twice a day for 4 weeks. Patients were re-evaluated at the end of weeks 2, 4, 8 and 6 months follow-up.

RESULTS

A total of 1499 patients completed the treatment, 71.1% responded at the end of week 4. The long-term success rate was 66.0% over a mean follow-up of 26.9 months. The success rate of grade 4 phimosis was significantly higher than that of grade 5 at 4, 8 weeks and 6 months (P = 0.005, P < 0.001 and P < 0.001, respectively). Patients with balanoposthitis had a poorer outcome compared with patients without symptoms and patients symptoms by prepuce ballooning or urinary tract infections (P < 0.001). Initial grade of 5 phimosis and symptom with balanoposthitis were independent risk factors for recurrence. All patients had no systemic side effects, 23 cases developed local erythema or burning sensation.

CONCLUSION

Topical steroid (0.1% mometasone furoate) is an effective treatment for severe phimosis in children. The recurrence was related to the grade or symptoms of severe phimosis.

Urology Mythbusters: are topical corticosteroids effective for treating postcircumcision penile adhesions?

In this edition of Mythbusters, we evaluate the common claim that topical corticosteroids (TCS) can be used for treatment of postcircumcision penile adhesions (PCPA). Although many textbooks and websites of respected pediatric institutions include topical steroids as one of the options for treatment of PCPA, the scientific basis of this claim is unclear and none of the references we found cited any specific sources. In review of the literature, we could find no peer-reviewed studies that support (or even assess) the utility of TCS for PCPA. It appears that the claims regarding TCS may be extrapolations from the demonstrated effectiveness of TCS for phimosis and related problems, although these are different conditions with different etiologies. We conclude that there is no scientific evidence supporting the use of TCS for PCPA. The verdict for this urolegend: 'Debunked.'

Prepuce sparing: Use of Z-plasty for treatment of phimosis and scarred foreskin

INTRODUCTION AND OBJECTIVES

The desire to preserve the prepuce is often based on cultural norms. Recently, the concept of "genital autonomy" has been invoked to delay circumcision (or any genital altering procedure) until the individual reaches maturity and can make his or her own decision. However, some uncircumcised boys develop one or more episodes of balanitis resulting in scarring of the prepuce and pathologic phimosis which is difficult to treat. Herein we report on the management of severe phimosis and preputial scarring using preputial Z-plasties.

MATERIALS AND METHODS

We reviewed the records of 28 patients, aged 3-12 years who underwent prepuce-sparing surgery within the previous 5 years with a minimum follow-up of 6 months. All patients were uncircumcised, with severe phimosis defined as a tight, pinpoint opening. All patients failed to respond to 6-10 weeks of betamethasone treatment. All parents requested preservation of as much of the foreskin as possible.

RESULTS

All patients healed satisfactorily, without infection, hematoma, or flap necrosis. One child developed mild scarring which responded to local steroid application. At follow-up evaluation, ranging from 6 to 24 months, the prepuce was fully retractable in all patients (Fig.).

CONCLUSIONS

Excision of the scarred preputial ring results in a circular suture line, which is in essence a straight line, curved and connected at each end, and this is likely to contract over time. The principle of Z-plasty can be exploited to elongate and interrupt the straight line, preventing contracture thus widening and sparing the prepuce.

Topical corticosteroids for treating phimosis in boys

BACKGROUND

Until recently, phimosis has been treated surgically by circumcision or prepuceplasty; however, recent reports of non-invasive treatment using topical corticosteroids applied for four to eight weeks have been favourable. The efficacy and safety of topical corticosteroids for treating phimosis in boys has not been previously systematically reviewed.

OBJECTIVES

We aimed to 1) compare the effectiveness of the use of topical corticosteroid ointment applied to the distal stenotic portion of the prepuce in the resolution of phimosis in boys compared with the use of placebo or no treatment, and 2) determine the rate of partial resolution (improvement) of phimosis, rate of re-stenosis after initial resolution or improvement of phimosis, and the rate of adverse events of topical corticosteroid treatment in boys with phimosis.

SEARCH METHODS

We searched the Cochrane Renal Group's Specialised Register through contact with the Trials' Search Co-ordinator using search terms relevant to this review. Date of last search: 16 June 2014.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared use of any topical corticosteroid ointment with placebo ointment or no treatment for boys with phimosis.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed titles, abstracts and the full-text of eligible studies, extracted data relating to the review's primary and secondary outcomes, and assessed studies' risk of bias. Statistical analyses were performed using the random-effects model and results were expressed as risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CI). We contacted authors of primary articles asking for details of study design and specific outcome data.

MAIN RESULTS

We included 12 studies that enrolled 1395 boys in this review. We found that both types of corticosteroids investigated and treatment duration varied among studies.Compared with placebo, corticosteroids significantly increased complete or partial clinical resolution of phimosis (12 studies, 1395 participants: RR 2.45, 95% CI 1.84 to 3.26). Our analysis of studies that compared different types of corticosteroids found that these therapies also significantly increased complete clinical resolution of phimosis (8 studies, 858 participants: RR 3.42, 95% CI 2.08 to 5.62). Although nine studies (978 participants) reported that assessment of adverse effects were planned in the study design, these outcomes were not reported.Overall, we found that inadequate reporting made assessing risk of bias challenging in many of the included studies.Selection bias, performance and detection bias was unclear in the majority of the included studies: two studies had adequate sequence generation, none reported allocation concealment; two studies had adequate blinding of participants and personnel and one had high risk of bias; one study blinded outcome assessors. Attrition bias was low in 8/12 studies and reporting bias was unclear in 11 studies and high in one study.

AUTHORS' CONCLUSIONS

Topical corticosteroids offer an effective alternative for treating phimosis in boys. Although sub optimal reporting among the included studies meant that the size of the effect remains uncertain, corticosteroids appear to be a safe, less invasive first-line treatment option before undertaking surgery to correct phimosis in boys.

Phimosis in children

Phimosis is nonretraction of prepuce. It is normally seen in younger children due to adhesions between prepuce and glans penis. It is termed pathologic when nonretractability is associated with local or urinary complaints attributed to the phimotic prepuce. Physicians still have the trouble to distinguish between these two types of phimosis. This ignorance leads to undue parental anxiety and wrong referrals to urologists. Circumcision was the mainstay of treatment for pathologic phimosis. With advent of newer effective and safe medical and conservative surgical techniques, circumcision is gradually getting outmoded. Parents and doctors should a be made aware of the noninvasive options for pathologic phimosis for better outcomes with minimal or no side-effects. Also differentiating features between physiologic and pathologic phimosis should be part of medical curriculum to minimise erroneous referrals for surgery.

Local steroid therapy as the first-line treatment for boys with symptomatic phimosis - a long-term prospective study

AIM

Phimosis is a common paediatric urological disorder and often necessitates circumcision. We prospectively evaluated local steroid therapy (LST) as the first choice therapy for such children.

METHODS

Two hundred and sixty symptomatic boys up to 15 years of age (mean 34 months) with phimosis were started on betamethasone dipropionate (0.05%) application on gently stretched prepuce twice a day. Follow-up visits were arranged at the end of weeks 1, 2 and 4 and 6 months. Grade of phimosis was objectively graded.

RESULTS

Ninety one percent of the boys showed a successful outcome at the end of 4 weeks; 72% responded in first week, further 16% responded in week 2, and only 2.6% achieved alleviation of phimosis on further application of LST beyond 2 weeks. Fourty two (17.8%) boys had a recurrence of phimosis on a long-term follow-up (mean - 25.4 months, range 6-48 months); thus, the long-term success rate was 77%, while 60 (23%) boys underwent surgery.

CONCLUSION

Local steroid therapy is safe and successful in alleviating symptomatic tight foreskin in a large majority of children. The response can be seen as early as 1 week; most of the children respond by week 2 and continuing therapy further may not be very effective.

Long standing balanitis xerotica obliterans resulting in renal impairment in a child

Balanitis xerotica obliterans (BXO) is the most common cause of pathological phimosis in boys. Presented here is the case of a previously well 13-year-old boy who developed obstructive renal impairment (serum creatinine = 190 micromol/l) at least in part from phimosis due to BXO. A circumcision and, 2.5 months later, meatal dilatation were done. Nine months after his initial presentation, his serum creatinine returned to a permanently elevated nadir of 119 mumol/l. Presentation with the complications of phimosis can be delayed in teenage boys because they may feel embarrassed to come forward. Circumcision remains the definitive treatment of BXO induced phimosis though if the penile meatus is involved, more complex surgery is sometimes required. Topical steroids are useful for residual disease. Follow-up is very important due to the frequent involvement of the skin of the glans. In the very long term there is an increased chance of penile malignancy, which can occur even after circumcision.

Phimosis and topical steroids: new clinical findings

Phimosis has been defined as unretractable foreskin without adherences and/or a circular band of tight prepuce preventing full retraction. The aim of this study is to evaluate the efficacy (response rate) of topical steroids for the treatment of tight phimosis at different age stages. After using the same medication with different dosage schemes, a retrospective analysis was carried out to assess the efficacy of topical steroids in the treatment of tight phimosis. Patients were divided into three groups: group A (betamethasone scheme A), group B (betamethasone scheme B) and group C (control group). Remission of phimosis, with a complete exposure and without a narrowing behind the glans, was considered a complete response to treatment. The outcomes were then related to dosage scheme and patient's age. The dosage for group A was more effective than the dosage for groups B and C (control group). Phimosis resolved in 90% (group A), 72% (group B) and 56% (group C) of cases. A successful treatment was closely related to the age of patients at the beginning of steroid application. The results showed that treatment with topical steroids, which in general gives good results, proved to be much more successful in patients aged between 4 and 8 years, suggesting the efficacy of an early beginning of the treatment.

Outcome and recurrence in treatment of phimosis using topical betamethasone in children in Hong Kong

AIM

To study the efficacy of treating phimosis with topical steroid, and its long-term outcome and side effects. We also looked into the effect of daily retraction and cleansing of prepuce on preventing recurrence of phimsosis.

METHODS

This prospective study comprised 138 boys who were prescribed 0.05% betamethasone ointment (Diprocel) during 1 August 2001-31 July 2004. Five boys were excluded because of non-compliance. Of the remaining 133 boys, 108 were followed-up and assessed. Age ranged from 0.03 to 12.9 years (mean=3.38, SD=2.79). The number of treatment course received, short-term and long-term outcome, side effects and the effect of daily foreskin retraction were studied.

RESULTS

The success rate of first treatment course was 81.5%, and 60.2% of boys remained free from phimosis upon latest assessment. The follow-up period ranged from 0.4 to 4.4 years (mean=2.45, SD=0.90). There were no side effects noted. We found a significant and linear relationship between daily foreskin retraction and sustained resolution of phimosis.

CONCLUSION

Topical steroid is an effective and safe treatment for phimosis, especially when combined with a good hygiene practice of the foreskin with daily cleansing and retraction. A trial of topical steroid treatment should be offered upon considering circumcision.

Betamethasone cream for the treatment of pre-pubertal labial adhesions

PURPOSE

We evaluated the efficacy of 0.05% betamethasone cream for the treatment of pre-pubertal labial adhesions.

METHODS

We retrospectively reviewed the records of 19 children with labial adhesions who were treated with betamethasone cream from 6/2001 to 3/2003. Children were treated with 1 to 3 courses of twice-daily 0.05% betamethasone cream for 4 to 6 weeks. Successful lysis of adhesions was assessed by clinical exam or parental phone contact and outcomes were defined as: (1) success--complete separation of labia, (2) partial success--greater than 75% separation, (3) progression to surgical lysis, and (4) lost to follow-up.

RESULTS

Nineteen patients with an average age of 58 months (range 12 to 132 months) were treated. Four of the 19 patients had never been treated previously and 1 had been treated previously with surgical lysis of adhesions only. Fourteen of the 19 patients had been previously treated with conjugated estrogen (Premarin) cream. Two of these fourteen patients had also undergone surgical lysis of adhesions. Severity of adhesions ranged from 33% to 99% labial closure. Betamethasone cream was successful in treating 13/19 (68%) pre-pubertal labial adhesions. Eleven (85%) of these 13 patients had complete resolution of labial adhesions with 1 course of treatment, 1 (7.5%) had resolution with 2 courses of treatment and 1 (7.5%) had resolution with 3 courses of treatment. One patient had a partial success with 3 courses of betamethasone cream. Two (11%) patients underwent surgical lysis of adhesion after 1 and 2 courses of betamethasone cream respectively. Three (16%) patients were lost to follow-up. Average follow-up was 7 months (range 1-24 months). No adverse outcomes or untoward effects were noted in any of the patients treated.

CONCLUSIONS

Betamethasone 0.05% cream appears to be a safe and effective treatment of pre-pubertal labial adhesions as primary therapy or in patients that have failed previous therapies and it may avoid the undesirable side effects of breast budding and hyperpigmentation that can be associated with Estrogen creams.

Topical hydrocortisone and physiotherapy for nonretractile physiologic phimosis in infants

The effect of hydrocortisone (HC), the steroid of lowest potency, and physiotherapy (PT) on non-retractile physiologic phimosis (PP) and the reduction of subsequent recurrent UTI was evaluated in male infants with UTI. Seventy-eight male infants with febrile UTI and nonretractile PP were prospectively randomized into HC (Plancol, n=39) and control (Vaseline, n=39) groups. Topical application of HC as a thin film around the preputial margin twice a day for four weeks with PT was instructed. The response rate in the HC group was 89.7% (35/39), which was significantly higher than the rate (20.5%; 8/39) in the control group (P<0.05). In the HC group, the response rate was much higher (96.1%) in the subgroup with PT than in the group without PT. Most of the response (88.5%) was observed within two weeks. During the following year, the recurrent rate of UTI was 7.1% (2/28) in the infants with retractile prepuces, which was significantly less than than the rate (29.6%; 8/27) in infants with nonretractile prepuces (P<0.05). In conclusion, topical HC and PT for 2-4 weeks proved to be a simple, safe and effective treatment for nonretractile PP in infants with UTI, and this procedure was beneficial in reducing recurrent UTI.

Treatment of phimosis with topical steroids and foreskin anatomy

OBJECTIVES

To correlate topical steroidal treatment of stenosed foreskin with the different degrees of glans exposure and the length of time the ointment is applied.

MATERIALS AND METHODS

We studied 95 patients with phimosis, divided according to the degree of foreskin retraction. Group A presented no foreskin retraction, group B presented exposure of only the urethral meatus, group C presented exposure of half of the glans, and group D presented exposure of the glans, which was incomplete because of preputial adherences to the coronal sulcus. Patients were submitted to application of 0.05% betamethasone ointment on the distal aspect of the prepuce twice daily for a minimum of 30 days and a maximum of 4 months.

RESULTS

Of 95 patients, 10 (10.52%) abandoned the treatment and 15 patients in groups C and D were excluded from the study. Among the remaining 70 patients, only 4 patients (5.7%) in group A did not obtain adequate glans exposure after treatment. In group A (38 patients), fully retractable foreskins were obtained in 19 patients (50%) after 1 month of treatment. In group B (28 patients), fully retractable foreskins were obtained in 18 patients (64.2%) after 1 month.

CONCLUSIONS

Treatment was successful in 94.2% of patients, irrespective of the type of foreskin anatomy. The improvement may require several months of treatment. Patients with impossibility of urethral meatus exposure present around 10% treatment failure.

Phimosis: stretching methods with or without application of topical steroids?

Phimosis has been defined as unretractable foreskin without adherences or a circular band of tight prepuce preventing full retraction. We suggested a new treatment protocol combining betamethasone with stretching exercises to reduce the number of patients requiring surgery for phimosis. Between January 2003 and September 2004, 247 boys aged 4 to 14 years (mean 7.6) were included in this consecutive, prospective, open study. Patients were treated with 0.05% betamethasone cream applied to the distal aspect of the prepuce twice daily for the first 15 days, then once daily for 15 more days. Preputial gymnastics started 1 week after topical application of betamethasone. Ninety-six percent of patients receiving 1 or more cycles of betamethasone showed complete resolution of phimosis. There was a significant difference (P < .001) in response rate between the study and control groups. Only 10 boys in the study group had no response to steroid and stretching. Treatment with topical steroids, combined with stretching exercises, is a suitable alternative to surgical correction (preputial plasty/circumcision).

HIGHLY POTENT AND MODERATELY POTENT TOPICAL STEROIDS ARE EFFECTIVE IN TREATING PHIMOSIS: A PROSPECTIVE RANDOMIZED STUDY

PURPOSE

We report a prospective randomized study comparing the effects of highly potent and moderately potent topical steroids in treating pediatric phimosis.

MATERIALS AND METHODS

A total of 70 boys 1 to 12 years old with phimosis were randomly assigned to receive topical application of either betamethasone valerate 0.06% (a highly potent steroid) or clobetasone butyrate 0.05% (a moderately potent steroid). Parents of the boys were instructed to retract the foreskin gently without causing pain, and to apply the topical steroids over the stenotic opening of the prepuce twice daily for 4 weeks, then for another 4 weeks if no improvement was achieved. Retractibility of the prepuce was graded from 0 to 5. Response to treatment was arbitrarily defined as improvement in the retractibility score of more than 2 points.

RESULTS

Mean treatment and followup periods were 4.3 and 19.1 weeks, respectively. The response rates in boys treated with betamethasone valerate and clobetasone butyrate were 81.3% and 77.4%, respectively (p = 0.63). Mean retractibility score decreased from 3.9 +/- 1.0 to 1.7 +/- 1.1, and 4.2 +/- 1.0 to 1.9 +/- 1.0 in the betamethasone and clobetasone groups, respectively. Both steroids were effective in all age groups. Pretreatment retractibility score did not affect treatment outcomes. No adverse effect was encountered.

CONCLUSIONS

Highly potent and moderately potent topical steroids are of comparable effectiveness in treating phimosis. A less potent steroid may be considered first to decrease the risk of the potential adverse effects.

Penile and testicular disorders

Circumcision, priapism, phimosis, Peyronie's disease, orchitis, epididymitis, and testicular torsion are conditions of the male penis and testicles that warrant increased attention by health care providers in practice. Healthy outcomes for penile and testicular disorders can be achieved through education, enhanced screening, and adequate comprehensive treatment. Penile and testicle disorders provide researchers and clinicians with many opportunities for research and practice that can improve the condition of men's health.

Psychological trauma of circumcision in the phallic period could be avoided by using topical steroids

OBJECTIVE

The objective of our study was to assess the efficacy of topical steroids in the treatment of phimosis and evaluate patients using the Diagnostic and Statistical Manual-III-Revised (DSM-III-R) test with the aim of eliminating castration anxiety of circumcision in the phallic period.

METHODS

One hundred and forty-nine children with phimosis who required circumcision were included the study. The average age of the children was 4.47 years. All children underwent the DSM-III-R test and their parents were questioned. Patients were separated randomly into three groups. Group I comprised 51 children who would undergo circumcision; group II comprised 50 children who would be treated with a topical corticosteroid (0.05% bethamethasone cream) twice daily for 1 month; and group III comprised 48 children who would be treated with a topical placebo cream. On the 5th day of treatment, parents were told to retract the prepuce and were given hygiene routine instructions. Patients were seen immediately after treatment and again 2 months later.

RESULTS

In group II, 16 of the 50 children had non-retractable prepuce. Forty-two cases of phimosis were corrected after treatment. Eight patients received further monthly treatment and five benefited from the second course of treatment. In group III, 17 of the 48 patients had non-retractable prepuce and four had satisfactory results. Forty-four patients received placebo treatment for another month and eventually, 40 children underwent circumcision in this group. DSM-III-R test results showed a significant shift to anxiety in the circumcision group. The were no significant differences in the other groups.

CONCLUSION

Topical steroids for the treatment of phimosis is a highly effective treatment alternative to surgery. It avoids or delays circumcision and can be practised during the phallic period to decrease castration anxiety. The treatment is suitable for patients from any religious or cultural background.

Treatment of phimosis with topical steroids in 194 children

PURPOSE

Topical steroids have been advocated as an effective economical alternative to circumcision in boys with phimosis. We evaluated the effectiveness of topical steroid therapy as primary treatment in 194 patients with phimosis.

METHODS

Between January 1996 and November 2000, 228 boys 16 years old or younger were referred for consideration of circumcision. When intervention was determined to be necessary, a 6-week course of topical steroids was used as primary treatment. Efficacy of treatment was evaluated at 3 months from initiation of therapy.

RESULTS

Of the 228 patients 15 had such a mild degree of phimosis that no intervention was believed to be necessary, 19 were scheduled directly for circumcision due to cosmetic reasons, parent wishes, or severe phimosis with associated voiding problems and the remaining 194 received topical steroids as primary treatment. Of these 194 patients 25 had coexisting balanitis and 4 had a history of urinary tract infection. Conservative treatment was successful in 87%, 88% and 75% of patients with phimosis alone, coexisting balanitis and history of urinary tract infection, respectively. Overall, circumcision was avoided in 87% of patients treated with topical steroids.

CONCLUSION

Topical steroids are becoming the standard conservative measure for treating phimosis. Our study supports this trend, with an overall efficacy of 87%.

Treatment of childhood phimosis with a moderately potent topical steroid

BACKGROUND

Recently, topical steroid application has been shown by a small number of studies to be an effective alternative to circumcision for the treatment of phimosis. However, only potent or very potent corticosteroids have been more thoroughly studied in this treatment option. A prospective study was conducted to determine whether comparable results could be achieved using a weaker steroid cream.

METHODS

Boys, 3-13 years of age, with non-retractable foreskin due to a tight ring at the tip were offered the regimen of twice-daily preputial retraction and topical application of 0.02% triamcinolone acetonide cream. The degree of preputial retractability was assessed at presentation and at 4 and 6 weeks of treatment. Success was defined as full retraction or free retraction up to agglutination of the foreskin to the glans.

RESULTS

Eighty-three boys completed the treatment. Successful retraction was achieved in 48/83 (58%) patients after 4 weeks and 70/83 (84%) patients after 6 weeks of application. The overall response rate aggregated from six published series using 0.05% betamethasone was 87% at 4 weeks and 90% on completion of treatment. Thus, the results appear inferior when analysed at 4 weeks but compare favourably with those reported for a more potent steroid on completion of the full course of treatment.

CONCLUSIONS

Even though the triamcinolone cream used in the present study is less potent than the more commonly used 0.05% betamethasone valerate cream, it could effect comparable improvements in foreskin retractability after 6 weeks of treatment.

Cost-effectiveness analysis of treatments for phimosis: a comparison of surgical and medicinal approaches and their economic effect

OBJECTIVE

To compare the cost-effectiveness of surgery and topical steroids as treatments for phimosis (defined as a clinically verifiable, pathological, cicatricial stenosis of the prepuce) and to evaluate the financial basis of these treatments.

METHODS

Data on treatment using topical steroids was obtained from published reports and those for circumcision from claims by private hospitals for children < 13 years old registered at the health insurance department of our facility. The estimate of the French national financial cost of the treatments for 1998 was calculated from public and private institutional information.

RESULTS

Treatment with topical steroids for 4-8 weeks was successful in approximately 85% of patients (mean age 5 years) and had no side-effects; the remaining 15% were treated by circumcision. Topical steroid therapy costs (in French francs) F 360 per patient. For those primarily treated by circumcision (81 boys, mean age 4.3 years) and diagnosed as having phimosis, the cost was F 3330 per patient in the private sector. The total number of circumcisions performed in France, regardless of sector (public or private) for 1998 was estimated to be 51 080, which represents an annual cost of F 195.7 million.

CONCLUSION

As topical pharmacological treatment avoids the disadvantages, trauma and potential complications of penile surgery, including anaesthesia-related risks, the use of topical steroids as a primary treatment appears to be justified in boys with clinically verifiable phimosis. This treatment could reduce costs by 75%, which represents a potential annual saving of approximately F 150 million.