Treatment of phimosis with topical steroids in 194 children

Abstract

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%.

Key Words: phimosis; circumcision; steroids; penis

The Journal of Urology 2003; 169(3):1106-1108.

* Financial interest and/or other relationship with Ortho-McNeil, Janssen-Ortho Canada, GlaxoSmithKline, Farr Laboratories and Merck.

Review:

Although neonatal circumcision has been a standard practice in North America for many years, the incidence has been declining over the past decade. This change has created a new set of problems for primary healthcare givers and urologists who must treat foreskin problems associated with the uncircumcised penis. The traditional approach for managing phimosis and other associated problems has been circumcision under general anesthesia. This procedure has become less acceptable, as the same population that has elected to not circumcise their infants have similar objections to childhood circumcision for minor or transient foreskin problems.

This report examines the success of topical steroid treatment in 194 patients that were referred for circumcision because of persistent phimosis, balanitis, urinary tract infection, or for cosmetic reasons. Betamethasone ointment (0.1%) was applied to the foreskin twice a day for up to 6 weeks. No adverse reactions to the steroid cream were cited. After 3 months follow-up, the degree of phimosis was either insignificant or had resolved completely in 87%, and only 13% of the patients eventually required circumcision. Prior balanitis or urinary tract infection did not affect the outcome of the steroid therapy.

This report is another study that demonstrates the success of topical steroid therapy in an effort to avoid circumcision under anesthesia in older children. This article is an important contribution, as it is a report from a North American institution, where the threshold to proceed to circumcision has historically been lower than other countries, where the parent's desire to avoid late circumcision could potentially overstate the outcome or benefits of the topical steroid therapy. This therapy could also be applied to other foreskin problems such as persistent penile adhesions with similar expected results.

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