Treatment of Childhood Phimosis with Topical Steroid

INTRODUCTION

Until recently in Australia, most males were circumised routinely at birth. With reduction in this practice, medical practitioners have had to advise parents on the management of the normal foreskin and to recognize and treat abnormalities. Until ever more recently, the treatment of most of these was circumcision. However topical steroids provide alternative treatment in the management of phimosis.

To assess its effectiveness, a prospective study was performed in a referral paediatric surgical practice in New Castle, New South Wales, Australia. The protocol was based on that of Kikiros, Beasley and Woodward.¹

METHODS

The patients were boys referred for circumcision or for advice concerning penile problems. They were admitted to the trial if they had true phimosis at any age, or a non-retractable foreskin beyond the age of three years. True phimosis was defined as non-retractablity with some degree of obstruction to urine flow evident as ballooning on micturition.

Assessment and classification of the pathology was based on the degree of retractability of the foreskin and the state of the skin itself. Following the same plan as Kikiros, Beasley and Woodward retractability was classified into six groups.¹

1. No retractability.
2. Some retraction leaving a gap between the tip of the prepuceand the glans.
3. Retraction sufficient to see the glanular meatus.
4. Retraction to allow partial exposure of the glans.
5. Full retractablity but tight.
6. Full and free retraction.

The state of the foreskin was considered as (i) normal; (ii) cracking and tendency to bleed on attempted retraction; (iii) scarring, and (iv) balanitis xerotica obliterans or lichen sclerosus et atrophicus.

When considering retractability, adhesions between the glans and the foreskin were discounted, particularly in early age groups. Treatment consisted of the application of topical steroid three times a day, particularly at night before going to bed. The parent was shown how to apply the cream to the pink tip of the foreskin with gentle massage. No attempt was made to insert it internally. By the very nature of the pathology this is impossible, at least initially. The cream used was betamethasone valerate 0.5% (betnovate 1/2; Duncan Flockhart, Division of Glaxo Aust. Pty Ltd., Boronia, Vic., Aust.).

The boys were reviewed after a month of treatment and if there had been progress but not to a satisfactory end point, a furthermonth of treatment was offered.

The treatment was deemed successful if it produced the normal degree of retractability expected for the age of the child, and at all ages a wide, open supple foreskin with no obstruction to micturition. Over 3 years of age, retractability, either full and free or to the limit of persistent glanular adhesions, was considered normal.

RESULTS

The age distribution was as follows: 31 patients under 3 years of age: 41 between 3 and 6 years of age; 26 between 6 and 9 years of age; and 12 between 9 and 14 years of age.

Success of treatment, according to the definition described in Methods (retractablity to the degree expected

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Table 1. Results of treatment
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                                                  No.   %
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Patients completing treatment                     111
Satisfactory result after 1 month                  84
Satisfactory after a further month                  5  80
Unsatisfactory but persisting with
treatment or refusing circumcision                 11  10
Failed treatment, circumcision                     11  10
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Table 2. Boys requiring circumcision
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Balanitis xerotica obliterans                           6
No BXO; failed treatment                                2
No BXO; failed treatment, poor compliance               3
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for the child's age) was achieved in 80 percent of patients (89 of 111). Eighty-one of these achieved full retractability, limited in some patients by persisting adhesions between glans and prepuce deemed normal for their ages. The remainder were boys less than 3 years of age whose foreskins, though not fully retractable, were well open and no longer obstructing urine flow. No patient with recognizable lichen sclerosis et atrophicus responded to treatment. Apparent 'scarring' and cracking of the skin on attempted retraction were not adverse factors.  [ Note: Dr. Wright uses the word adhesions, which is normally used to describe a pathology, to describe a normal developmental condition. This may be confusing to some readers.] 

Eleven boys required circumcision, six for lichen sclerosis and five for failed treatment. Three of these failures were deemed to be due to poor parental compliance.

The study concluded after one or two courses of treatment, so no long-term assessment of recurrence was made.

DISCUSSION

The study has shown that 80% of boys with phimosis can be successfully treated non-operatively. In the current social climate where neonatal circumcision is less frequently performed than previously, this provides another important modality of treatment. Most parents, having made the decision not to have their newborn male baby circumcised, are understandably even more reluctant to agree to it in later years. They not only recognize the discomfort the child suffers from circumcision, but the necessity of the procedure makes the parents feel that the original decision was wrong, thereby disadvantaging their son.

Kikiros, Beasley and Woodward published similiar results of therapy with half strength betnovate.¹ Seventy-nine percent of their patients improved and 12% required circumcision.

It is important at the beginning of treatment to explain the natural history of the foreskin to the parents. If the child is less than three years of age they must be advised that full retraction cannot be expected. They must be told that natural adhesions between glans and foreskin will not be separated by the treatment.

While it is possible that phimosis, especially in younger age groups may resolve with age, this process is slow. The rapid response over the 1 or 2 months of the study can be attributed beyond reasonable doubt to the treatment.

The scarred fibrotic foreskin of balanitis xerotica obliterans must be recognized at the outset for this will not respond to treatment and circumcision is required.^2-5 This should not be delayed by prolonged conservative therapy.

Correspondence: Dr. J. E. Wright, 116 Everton Street Hamilton, NSW 2303, Australia.

Accepted for publication 28 October 1993.

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