PEDIATRIC UROLOGY

Phimosis: Stretching Methods With or Without Application of Topical Steroids?
Zampieri N, Corroppolo M, Camoglio FS, Giacomello L, Ottolenghi A.
Department of Surgical Sciences, Pediatric Surgical Unit, University of Verona, Verona, Italy
J Pediatr. 2005; 147: 705-6

• 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).
  
  
• Editorial Comment
  The authors studied the effect of betamethasone and stretching on a population of children referred for circumcision. They found that the treatment (up to 3 monthly cycles) worked in the great majority of patients. Indeed, only 10 of 247 patients ultimately underwent a surgical procedure for the phimosis. Success rate for the first month of treatment was 77% and for the 2nd and 3rd it was 57% and 60% respectively.
  These results are impressive and remind us that for families that chose not to have their son’s circumcised as newborns, there is an effective non-surgical treatment available. On the other hand, the authors leave several questions unanswered. There was a control group that just did stretching and did not apply the betamethasone. Unfortunately, the authors give very little data on this group. However, 76% of these got better! Would the addition of any type of cream augment that success rate?
  Most important, the authors provide no data on whether these patients required any treatment whatsoever. Most everyone recognizes that resolution of phimosis occurs spontaneously in most cases. Only in situations of balanitis or posthitis is treatment really necessary. Hence, without that information, it is hard for the reader to know the value of the therapy. Indeed, it is the patients with inflammation/scarring or a history of pain and infection that might make the stretching difficult. It would be important to know the success rate of treatment in this group in particular. One might guess it would be lower. Nonetheless, the authors do present enough compelling data that a trial of non-operative treatment seems worthwhile in most cases.

Dr. Barry A. Kogan
Chief and Professor of Urology and Pediatrics
Albany Medical College
Albany, New York, USA