OF PHIMOSIS WITH TOPICAL STEROIDS AND FORESKIN ANATOMY
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TATIANA C. MARQUES,
FRANCISCO J.B. SAMPAIO, LUCIANO A. FAVORITO
Research Unit, State University of Rio de Janeiro, Rio de Janeiro, RJ,
To correlate topical steroidal treatment of stenosed foreskin with the
different degrees of glans exposure and the length of time the ointment
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.
words: penis; phimosis; anatomy; steroids; circumcision
Int Braz J Urol. 2005; 31: 370-4
is frequently performed in the United States and Canada, although in a
variety of locations around the world, such as Europe and South America,
this procedure is not done on a routine basis. When it is not done routinely,
the incidence of pathological phimosis is increased (1). Pathological
phimosis results when there are adherences to the fibrotic foreskin ring
that make it impossible to expose the penis glans (1). This situation
hinders adequate penis hygiene, which favors the occurrence of foreskin
infections, repeated urinary tract infections, sexually transmitted diseases
and, in adults, carcinoma of the penis (2).
The correction of phimosis in infancy is
performed with general anesthesia, a procedure that is not without risks,
with a complication rate that may reach 34% (3). The main complications
following circumcision are hemorrhage, stenosis of the urethral meatus
and the foreskin ring, and even amputation of the glans (4). In addition,
this procedure presents considerable costs (5).
Recently, clinical treatment of phimosis
using topical corticosteroids has been proposed as an alternative to surgery
with good results (6-8). Regardless of the patient’s age, the results
are encouraging, with success rates ranging from 67 to 95% of cases (2,8,9).
There are several classifications for the
position of the phimotic ring (1,2,9,10), although only Kayaba et al.
(11) demonstrated the form and degree of retractability of the prepuce.
Studies that correlate foreskin anatomy with topical treatment using corticosteroids
in patients with phimosis are rare, or even inexistent.
The objective of this work is to correlate
topical treatment of 0.05% betamethasone in the stenosed foreskin with
the different degrees of exposure of the glans and the length of application
needed for the foreskin to become fully retractable.
January 2001 and October 2003, we evaluated 95 patients with phimosis
for possible circumcision. The patients ranged in age from 19 months to
14 years (mean age 7.7 years). The Human Research Committee at our institution
approved the investigation. An informed consent form was obtained from
the parents (mother or father) of each patient.
The patients were divided into groups according
to the degree of foreskin retraction (11) (Figure-1). Group A consisted
of patients who presented no foreskin retraction, group B presented exposure
of the urethral meatus only, group C presented exposure of half of the
glans, and group D presented incomplete exposure of the glans due to preputial
adherences to the coronal sulcus.
After classification into one of the groups,
the patients were submitted to application of 0.05% betamethasone ointment
on the phimotic ring (distal aspect of the prepuce). Parents were instructed
to gently apply traction to the foreskin until the ring appeared, applying
a thin layer of cream twice daily for a minimum of 30 days and a maximum
of 4 months, in association with correct hygiene of the penis. These children
were followed every month in our outpatient service.
Therapy was considered successful when the
prepuce was fully retractable with total glans exposure. Failure was considered
when it was impossible to achieve glans exposure, when there was no alteration
in the degree of stenosis after more than 4 months, and if there was infection
during the treatment. In such cases, circumcision would be indicated.
For statistical analysis, we used the chi-squared
test. P < 0.05 indicates statistically significant differences (12).
type of foreskin anatomy found in the 95 children is shown in Table-1.
There was a predominance of group A (43 children - 45.2%) and group B
(34 - 35.7%). Groups C (6 - 6.3%) and D (12 - 12.6%) presented a lower
incidence. Of the 95 patients, 10 (10.52%) abandoned the treatment and
15 patients in groups C and D were excluded from the study because they
were not strictly considered as having phimosis. Among the patients who
abandoned treatment, one presented the foreskin anatomy of group A, 6
of group B and 3 of group D. Among the remaining 70 patients, only 4 patients
(5.7%) in group A did not obtain adequate exposure of the glans after
Of the 66 patients (94.2%) who did obtain
adequate exposure of the glans after treatment (fully retractable prepuce),
38 (57.5%) were in group A and 28 (42.5%) were in group B. The response
to topical treatment for the groups studied in relation to the length
of time the ointment was used is shown in Table-2.
In group A, 8 patients (21%) were ≤
3 years old and 30 patients (79%) were > 3 year old. Of the patients
who responded to treatment in group A (38 of 42 patients - 90.4%), fully
retractable foreskins were obtained in 19 patients (50%) after 1 month
of treatment, in 5 patients (13.1%) after 2 months, in 9 patients (21.6%)
after 3 months, and in 5 patients (13.5%) after 4 months.
In group B (28 patients), 4 patients (14.2%)
were ≤ 3 years old and 24 patients (86%) were > 3 year old. All
patients in group B responded to treatment and fully retractable foreskins
were obtained in 18 patients (64.2%) after 1 month, in 6 patients (21.4%)
after 2 months, in 1 patient (3.5%) after 3 months, and in 3 patients
(10.7%) after 4 months.
Independently of the group they were classified,
37 of the patients (56%) achieved glans exposure within 30 days of treatment.
Only 8 patients (12.1%) required 4 months of treatment to obtain a fully
retractable prepuce. No adverse side effects were observed from the topical
betamethasone treatment. There was no statistically significant difference
in satisfactory response to treatment over the course of the months between
groups A and B.
phimosis affects 96% of newborns and its incidence diminishes with age.
At 3 years old, 10% of boys present phimosis and by the age of 14 years,
this incidence decreases to 1% (13).
In Australia at the beginning of the 1990s,
Kikiros et al. (10) attested to the efficacy of topical corticosteroids
in the treatment of preputial stenosis. Since then, several authors have
shown satisfactory results (67% to 95%) with the topical use of betamethasone,
clobetasol, sodium diclofenac, 0.05% mometasone furoate and triamcinolone
Betamethasone is one of the steroids that
present the best improvement rates (13,14), and this was the reason the
drug was used in this study. Corticosteroids act by reducing the arachidonic
and hydroxyeicosatetraenoic acids in proliferative inflammatory disease
of the skin, thereby inhibiting prostaglandin release and increasing the
activity of dismutase superoxide. Additionally, they have the potential
to release antioxidants (13). Collateral effects may occur, such as the
suppression of the hypothalamus-hypophysis-adrenal axis or cutaneous atrophy.
However, the doses utilized in topical treatment of phimosis are not large
enough to lead to these types of complications (1). In our study, we did
not observe any adverse effects in our patients.
We obtained a success rate of 94.2% from
the treatment with 0.05% betamethasone ointment, which is similar to what
has been found in recent studies in the literature (1,2,13,15-18). All
patients were advised to continue retracting the foreskin to maintain
penile hygiene. We observed parent satisfaction when the decision to pursue
conservative treatment was made. Topical treatment using corticosteroids
has been shown to have low risk with an absence of side effects and good
adherence to treatment when those responsible for the child have been
Monthly follow-up for observation of the
evolution of the phimotic ring has been shown to be fundamental in the
assessment of the time at which the therapy utilized is having its effect,
or whether it is ineffective. Therapy can be stopped at any time and surgery
can then be indicated.
All 4 patients (5.7%) who showed no improvement
after using the ointment and required a surgical procedure were in group
A. Among the patients in group A who responded to topical treatment, 35%
obtained the desired result only after 3 or 4 months of treatment. The
patients without any foreskin retraction (group A) presented an approximately
10% chance of not benefiting from clinical treatment, even after a long
period of ointment use, and such patients will require circumcision. In
group B, 70% of the patients showed the desired result within the first
two months of ointment application. These results are very significant
at the time of indicating the treatment, especially for patients unable
to have foreskin retraction (group A), which was the most frequent situation
among our patients (incidence of 45%). Patients with foreskin anatomy
in groups B presented a high chance of obtaining the desired result with
treatment duration of less than 60 days.
In conclusion, topical treatment of phimosis
using 0.05% betamethasone ointment presented a success rate of 94.2%,
regardless of the form and degree of foreskin retraction. Most previous
reports have described one month of treatment; nevertheless, we found
that the desired improvement might take several months of treatment.
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in children using a topical steroid. Urology. 2000; 56: 307-10.
- Elmore JM, Baker LA, Snodgrass WT: Topical steroid therapy as an
alternative to circumcision for phimosis in boys younger than 3 years.
J Urol. 2002; 168: 1746-7; discussion 1747.
- Chu CC, Chen KC, Diau GY: Topical steroid treatment of phimosis in
boys. J Urol. 1999; 162: 861-3.
- Ozkan S, Gurpinar T: A serious circumcision complication: penile
shaft amputation and a new reattachment technique with a successful
outcome. J Urol. 1997; 158: 1946-7.
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approaches and their economic effect. BJU Int. 2001; 87: 239-44.
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conservative treatment of phimosis in boys. Br J Urol. 1996; 78: 786-8.
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a potent topical steroid (clobetasol propionate 0.05%) cream. Acta Derm
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et al.: Treatment of phimosis with betamethasone ointment in children.
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in children: our experience with topical steroids. J Urol. 1995; 162:
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Received: April 17, 2005
Accepted after revision: June 20, 2005
Dr. Luciano Alves Favorito
Urogenital Research Unit - UERJ
Av. 28 de Setembro, No. 87, fundos
Rio de Janeiro, RJ, 20551-030, Brazil
Fax: + 55 21 2587-6121
authors have confirmed successful treatment of phimosis in children with
betamethasone ointment as has been shown in other studies. In addition,
they have demonstrated success with lower dose betamethasone ointment
(0.05% instead of 0.1%) and that only one month treatment is needed in
about half of the cases. However, they do not report on long term follow-up
to determine if recurrence is a problem. Ashfield et al. (Reference 18
in article) also did not report long term follow-up but they examined
patients six weeks following cessation of treatment, which should have
at least detected early recurrences.
more important point on this topic to consider is when this treatment
is indicated. From the results in this study, this would seem the best
treatment for phimosis causing ballooning of the prepuce with voiding
and/or when phimosis is thought to be causing recurrent infections. These
authors do not note that any of these boys had symptoms. While these authors
and others have shown resolution of phimosis with steroid ointment, they
have not demonstrated that treating asymptomatic phimosis in pre-pubertal
boys has any medical benefit.
Children’s Hospital of the King’s Daughters
and Eastern Virginia Medical School
Norfolk, Virginia, USA