Troubles with the Foreskin: One Hundred Consecutive Referrals to Paediatric Surgeons

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.

Referrals from primary care with foreskin symptoms: Room for improvement

AIMS

Referrals to secondary care for boys with foreskin symptoms require face-to-face review, resulting in time out of school / work and costs to the family. This study aimed to review outcomes of referrals to ascertain if there was scope to reduce referrals.

METHODS

New patients referred to a UK regional paediatric surgery clinic during 2019 were identified and screened retrospectively. Medical records for boys over one year of age referred due to foreskin symptoms were reviewed.

RESULTS

Of 2598 referrals, 1939 (75%) were boys & 1094 were > 1 yr; 398 (21%) were referred with foreskin symptoms at median age 7.2 yrs (IQR 4-10). 307 (77%) were diagnosed with physiological phimosis, 67 (18%) with pathological phimosis, 9 (2%) with balanitis (the remainder had 'smegma' retention cysts, preputial adhesions, tight frenulum or anatomical abnormalities). 211 (53%) were discharged at the initial appointment, this was significantly more likely for younger boys, and those with physiological phimosis (p<0.001). 62 (16%) were prescribed topical steroids (more likely in older boys, p<0.001). 70 (18%) were offered surgery: circumcisions (n = 51), preputioplasties (n = 13), other (n = 4). The circumcision rate was therefore 12%. Age at referral was positively correlated with GP trial of steroid (older more likely), diagnosis (physiological phimosis more likely if younger) and outcome (topical steroids or surgery more likely if older): Spearman's rank correlation p<0.001.

CONCLUSIONS

Over 75% of boys referred had a normal foreskin, over half were discharged at their first review. Improved knowledge amongst parents and primary care providers could reduce referrals and save money and resources.

LEVEL OF EVIDENCE

Level IV - Case series with no comparison group.

Frequency of lichen sclerosus in children presenting with phimosis: A systematic histological study

BACKGROUND

The incidence of preputial lichen sclerosus (PLS) among children presenting with phimosis varies from 10 to 95%, depending on the age, the protocol for the treatment of pediatric phimosis, the method of diagnosis (clinical versus histological), and case mix (congenital versus acquired phimosis).

OBJECTIVE

PLS may not be clinically obvious. Our aim is to show that a systematic histological examination of the prepuce may diagnose PLS in clinically unsuspected cases.

METHODS

Prospective observational study of the histology of all prepuces resected from boys undergoing circumcision for phimosis but not clinically suspected to have PLS.

RESULTS

PLS was diagnosed histologically in 22 boys (32%). Boys with PLS were significantly older (mean 8.4 versus 4.7 years old). Diagnosis of PLS was not related to the degree of phimosis (summary figure). In three patients (grade 4 phimosis) glans discoloration was observed during surgery, and all had PLS. Follow up for boys found to have PLS ranged from 1 to 10 years. One patient developed recurrent phimosis, attributed to inappropriate conservative resection, and required further surgery. There were no cases of meatal stenosis.

DISCUSSION

Subtle cases of PLS may be difficult to detect clinically. Children are frequently asymptomatic, except for being unable to retract the prepuce. Physical examination has a low negative predictive value for the diagnosis of PLS. Complete removal of the prepuce with permanent glans exposure is regarded as essential to cure PLS and to avoid recurrent phimosis, but our patients were treated with partial circumcisions for cultural reasons. Only one needed reoperation for recurrent phimosis.

CONCLUSION

Histological PLS was present in approximately 1/3 of boys with phimosis, frequently without typical manifestations. Those patients may be cured with partial circumcisions.

Are mechanical and chemical trauma the reason of meatal stenosis after newborn circumcision?

Mechanical and chemical trauma are a widely accepted theories to explain the pathogenesis of meatalstenosis after newborn circumcision. The aim of the present study was to explore the theory that an exposed glans is prone to meatal stenosis. This was done by a novel investigation of boys who were born with "hooded prepuce", a condition in which the glans is completely exposed. Physical examination, lower urinary tract symptoms, urethral meatus configuration, and surgical procedures of 18 children admitted for routine circumcision, who had congenital hooded prepuce with normally located urethral meatus, were analyzed. The study period was 2013 and 2018. All the cases have been seen because of neonatal circumcision request, but was postponed due to hooded prepuce. The only presenting complaint in children was a cosmetically unattractive appearance. There were no symptoms associated with meatal stenosis, they circumcised in an average of 6 years and non of them required any additional procedure.Conclusion: Meatal stenosis did not occur in cases whose glans penis are naked with hooded prepuce. These findings do not support the default chemical and mechanical trauma theories. Hooded prepuce without any penile anomalies is only a cosmetically unattractive appearance and circumcision can correct this. What is known: • The common theory of meatal stenosis etiology is that the meatus undergoes irritation with chemical/mechanical trauma in the absence of a prepuce after newborn circumcision. • Circumcision is usually postponed in newborns with hooded prepuce. What is new: • We did not notice meatal stenosis in cases whose urethral meatus were not covered with a prepuce congenitally. Ammoniacal dermatitis or mechanical trauma theories may not explain the cause of meatal stenosis. • Hooded prepuce is not a handicap to newborn circumcision. It is just a cosmetic problem and circumcision can solve it.

Balanitis xerotica obliterans: has its diagnostic accuracy improved with time?

Objectives

We observed whether general practitioners are referring more appropriately for balanitis xerotica obliterans in regards to circumcision, especially at a time of clinical concern, and whether their discriminative abilities were affected by age. We also aimed to explore if balanitis xerotica obliterans was over-diagnosed by surgeons potentially leading to unnecessary circumcisions of healthy foreskins.

Design

Cross-sectional descriptive study.

Setting

Leicester Royal Infirmary.

Participants

All children less than 16 years of age were included and were subsequently split into two categories: those less than or equal to five years and those above five years. Circumcision was justified if surgeon found pathology under foreskin commissioning guidelines set by the Royal College of Surgeons of England. After clinical diagnosis of balanitis xerotica obliterans, the pathological database was searched for histological confirmation.

Main outcome measures

Has diagnostic accuracy improved amongst general practitioners for balanitis xerotica obliterans and is there a high clinical to histological confirmation.

Results

Of the total patients, 14.5% were diagnosed clinically with balanitis xerotica obliterans. Only 66.7% of cases were histologically confirmed with chronic inflammation found in the rest; 5.5% of all boys referred had balanitis xerotica obliterans on histology; and 8.2% of children <5 had clinical balanitis xerotica obliterans with 1.7% confirmed histologically. This was in contrast with 18.1% and 9.2% found in the older cohort.

Conclusion

There remains a high diagnostic inaccuracy amongst general practitioners when referring for balanitis xerotica obliterans. This is greatest in those under five years. Although balanitis xerotica obliterans was over-diagnosed, no healthy foreskin underwent unnecessary circumcision.

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.

Preputial adhesions--a misunderstood entity

OBJECTIVE

To assess the trends and outcomes in referrals of 'phimosis for circumcision' to a tertiary care pediatric surgical department.

METHODS

This is a prospective study of 100 consecutive children of presumed phimosis referred for circumcision. They were assessed and classified by the senior author as having either preputial adhesions or phimosis. The patients in the former group underwent outpatient preputial adhesiolysis while those in the latter group were offered circumcision primarily. All were followed up till resolution.

RESULTS

All 100 were referred with a non-retractile prepuce and an additional reason - preputial ballooning at voiding, dysuria or suspect UTI. Eight (mean age -58 months, referred for preputial ballooning at voiding -6/8 and dysuria -2/8) had phimosis and were primarily offered circumcision. The remaining 92 (mean age - 22 months, referred for preputial ballooning at voiding -52/92, dysuria -28/92 and suspect UTI -12/92) had preputial adhesions. In the latter group, none has a documented urinary infection on specific investigations. These 92 underwent outpatient preputial adhesiolysis. Seventy three (79 %) required a single sitting, 11 (12%) required 2 -4 sittings and 4(4.5%) required 5-8 sittings over a follow up period of 1 -24 months (median -3 weeks). 4/92(4.5%) were deemed non-responders to adhesiolysis and were circumcised later.

CONCLUSION

The majority of children referred with 'phimosis for circumcision' to this tertiary pediatric surgical centre were actually physiologic preputial adhesions that were managed with outpatient preputial adhesiolysis. This study underscores a lack of awareness amongst referring primary care physicians regarding preputial adhesions and the potential for an erroneous diagnosis of phimosis translating into unnecessary circumcisions in many young boys.