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TREATMENT OF PHIMOSIS WITH TOPICAL STEROIDS Vol. 31 (4): 370-374, July - August, 2005 Official Journal of the Brazilian Society of Urology TREATMENT OF PHIMOSIS WITH TOPICAL STEROIDS AND FORESKIN
TATIANA C. MARQUES, FRANCISCO J.B. SAMPAIO, LUCIANO A. FAVORITO Urogenital Research Unit, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil ABSTRACT
Objectives: To correlate topical steroidal treatment of stenosed foreskin with the different degrees of glans exposure and the length of time the ointment is applied.
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 exposureof only the urethral meatus, group C presented exposure of half of the glans, and group D presentedexposure 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 theprepuce 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%) ingroup A did not obtain adequate glans exposure after treatment. In group A (38 patients), fully retract-able 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 fore- skin anatomy. The improvement may require several months of treatment. Patients with impossibilityof urethral meatus exposure present around 10% treatment failure.
Key words: penis; phimosis; anatomy; steroids; circumcision
Int Braz J Urol. 2005; 31: 370-4
INTRODUCTION
ally transmitted diseases and, in adults, carcinoma ofthe penis (2).
Circumcision is frequently performed in the The correction of phimosis in infancy is per- United States and Canada, although in a variety of formed with general anesthesia, a procedure that is locations around the world, such as Europe and South not without risks, with a complication rate that may America, this procedure is not done on a routine ba- reach 34% (3). The main complications following sis. When it is not done routinely, the incidence of circumcision are hemorrhage, stenosis of the urethral pathological phimosis is increased (1). Pathological meatus and the foreskin ring, and even amputation of phimosis results when there are adherences to the fi- the glans (4). In addition, this procedure presents con- brotic foreskin ring that make it impossible to expose the penis glans (1). This situation hinders adequate Recently, clinical treatment of phimosis us- penis hygiene, which favors the occurrence of fore- ing topical corticosteroids has been proposed as an skin infections, repeated urinary tract infections, sexu- alternative to surgery with good results (6-8). Regard- TREATMENT OF PHIMOSIS WITH TOPICAL STEROIDS less of the patient’s age, the results are encouraging, The patients were divided into groups accord- with success rates ranging from 67 to 95% of cases ing to the degree of foreskin retraction (11) (Figure- 1). Group A consisted of patients who presented no There are several classifications for the posi- foreskin retraction, group B presented exposure of tion of the phimotic ring (1,2,9,10), although only the urethral meatus only, group C presented expo- Kayaba et al. (11) demonstrated the form and degree sure of half of the glans, and group D presented in- of retractability of the prepuce. Studies that correlate complete exposure of the glans due to preputial ad- foreskin anatomy with topical treatment using corti- costeroids in patients with phimosis are rare, or even After classification into one of the groups, the patients were submitted to application of 0.05% The objective of this work is to correlate topi- betamethasone ointment on the phimotic ring (distal cal treatment of 0.05% betamethasone in the stenosed aspect of the prepuce). Parents were instructed to foreskin with the different degrees of exposure of the gently apply traction to the foreskin until the ring glans and the length of application needed for the appeared, applying a thin layer of cream twice daily foreskin to become fully retractable.
for a minimum of 30 days and a maximum of 4months, in association with correct hygiene of the MATERIALS AND METHODS
penis. These children were followed every month inour outpatient service.
Between January 2001 and October 2003, we Therapy was considered successful when the evaluated 95 patients with phimosis for possible prepuce was fully retractable with total glans expo- circumcision. The patients ranged in age from 19 sure. Failure was considered when it was impossible months to 14 years (mean age 7.7 years). The Human to achieve glans exposure, when there was no alter- Research Committee at our institution approved the ation in the degree of stenosis after more than 4 investigation. An informed consent form was obtained months, and if there was infection during the treat- from the parents (mother or father) of each patient.
ment. In such cases, circumcision would be indicated.
Figure 1 – Diagram based on the work by Kayaba et al. (11) showing the 4 types of foreskin according to the position of the phimotic
ring and the retraction ability, as well as the incidence found in the present study. Group A - no foreskin retraction, group B - exposure
of the urethral meatus, group C - exposure of half of the glans, and group D - incomplete exposure of the glans due to preputial
adherences to the coronal sulcus.

TREATMENT OF PHIMOSIS WITH TOPICAL STEROIDS For statistical analysis, we used the chi- In group A, 8 patients (21%) were ≤ 3 years squared test. P < 0.05 indicates statistically signifi- old and 30 patients (79%) were > 3 year old. Of the patients who responded to treatment in group A (38of 42 patients - 90.4%), fully retractable foreskins were obtained in 19 patients (50%) after 1 month oftreatment, in 5 patients (13.1%) after 2 months, in 9 The type of foreskin anatomy found in the patients (21.6%) after 3 months, and in 5 patients 95 children is shown in Table-1. There was a pre- dominance of group A (43 children - 45.2%) and group In group B (28 patients), 4 patients (14.2%) B (34 - 35.7%). Groups C (6 - 6.3%) and D (12 - were ≤ 3 years old and 24 patients (86%) were > 3 12.6%) presented a lower incidence. Of the 95 pa- year old. All patients in group B responded to treat- tients, 10 (10.52%) abandoned the treatment and 15 ment and fully retractable foreskins were obtained in patients in groups C and D were excluded from the 18 patients (64.2%) after 1 month, in 6 patients study because they were not strictly considered as (21.4%) after 2 months, in 1 patient (3.5%) after 3 having phimosis. Among the patients who abandoned months, and in 3 patients (10.7%) after 4 months.
treatment, one presented the foreskin anatomy of Independently of the group they were classi- group A, 6 of group B and 3 of group D. Among the fied, 37 of the patients (56%) achieved glans expo- remaining 70 patients, only 4 patients (5.7%) in group sure within 30 days of treatment. Only 8 patients A did not obtain adequate exposure of the glans after (12.1%) required 4 months of treatment to obtain a fully retractable prepuce. No adverse side effects were Of the 66 patients (94.2%) who did obtain observed from the topical betamethasone treatment.
adequate exposure of the glans after treatment (fully There was no statistically significant difference in retractable prepuce), 38 (57.5%) were in group A and satisfactory response to treatment over the course of 28 (42.5%) were in group B. The response to topical treatment for the groups studied in relation to thelength of time the ointment was used is shown in COMMENTS
Physiological phimosis affects 96% of new- borns and its incidence diminishes with age. At 3 years Table 1 – Incidence of the different types of foreskin
old, 10% of boys present phimosis and by the age of anatomy found in the present study. 14 years, this incidence decreases to 1% (13).
Foreskin Anatomy Patients %
In Australia at the beginning of the 1990s, Kikiros et al. (10) attested to the efficacy of topical corti- costeroids 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 acetonide (8-10).
Table 2 – Therapeutic success rate for groups A and B in relation to the length of time the ointment was applied.
TREATMENT OF PHIMOSIS WITH TOPICAL STEROIDS Betamethasone is one of the steroids that to have foreskin retraction (group A), which was the present the best improvement rates (13,14), and this most frequent situation among our patients (incidence was the reason the drug was used in this study. Corti- of 45%). Patients with foreskin anatomy in groups B costeroids act by reducing the arachidonic and presented a high chance of obtaining the desired result hydroxyeicosatetraenoic acids in proliferative inflam- with treatment duration of less than 60 days.
matory disease of the skin, thereby inhibiting pros- In conclusion, topical treatment of phimosis taglandin release and increasing the activity of using 0.05% betamethasone ointment presented a dismutase superoxide. Additionally, they have the success rate of 94.2%, regardless of the form and potential to release antioxidants (13). Collateral ef- degree of foreskin retraction. Most previous reports fects may occur, such as the suppression of the hypo- have described one month of treatment; nevertheless, thalamus-hypophysis-adrenal axis or cutaneous atro- we found that the desired improvement might take phy. However, the doses utilized in topical treatment of phimosis are not large enough to lead to these typesof complications (1). In our study, we did not observe REFERENCES
any adverse effects in our patients.
Orsola A, Caffaratti J, Garat JM: Conservative treat- ment of phimosis in children using a topical steroid.
the treatment with 0.05% betamethasone ointment, which is similar to what has been found in recent stud- Elmore JM, Baker LA, Snodgrass WT: Topical ste- ies in the literature (1,2,13,15-18). All patients were roid therapy as an alternative to circumcision for phi- advised to continue retracting the foreskin to main- mosis in boys younger than 3 years. J Urol. 2002; 168: tain penile hygiene. We observed parent satisfaction when the decision to pursue conservative treatment Chu CC, Chen KC, Diau GY: Topical steroid treat- was made. Topical treatment using corticosteroids has ment of phimosis in boys. J Urol. 1999; 162: 861-3.
been shown to have low risk with an absence of side Ozkan S, Gurpinar T: A serious circumcision compli- effects and good adherence to treatment when those cation: penile shaft amputation and a new reattachment responsible for the child have been well briefed.
technique with a successful outcome. J Urol. 1997; Berdeu D, Sauze L, Ha-Vinh P, Blum-Boisgard C: evolution of the phimotic ring has been shown to be Cost-effectiveness analysis of treatments for phimo- fundamental in the assessment of the time at which sis: a comparison of surgical and medicinal approaches the therapy utilized is having its effect, or whether it and their economic effect. BJU Int. 2001; 87: 239-44.
is ineffective. Therapy can be stopped at any time Gulobovic Z, Milanovic D, Vukadinovic V, Rakie I, Perovic S: The conservative treatment of phimosis in improvement after using the ointment and required a Wright JE: The treatment of childhood phimosis with surgical procedure were in group A. Among the topical steroid. Aust N Z J Surg. 1994; 64: 327-8. Er- patients in group A who responded to topical ratum in: Aust N Z J Surg. 1995; 65: 698.
treatment, 35% obtained the desired result only after Jorgensen ET, Svensson A: The treatment of phimosis 3 or 4 months of treatment. The patients without any in boys, with a potent topical steroid (clobetasol pro- foreskin retraction (group A) presented an pionate 0.05%) cream. Acta Derm Venereol. 1993; 73:55-6.
approximately 10% chance of not benefiting from Atilla MK, Dundaroz R, Odabas O, Ozturk H, Akin R, clinical treatment, even after a long period of ointment Gokcay E: A non-surgical approach to the treatment use, and such patients will require circumcision. In of phimosis: local non-steroidal anti-inflammatory group B, 70% of the patients showed the desired result ointment application. J Urol. 1997; 158: 196-7.
within the first two months of ointment application.
10. Kikiros CS, Beasley SW, Woodward AA. The response These results are very significant at the time of of phimosis to local steroid application. Pediatr Surg.
indicating the treatment, especially for patients unable TREATMENT OF PHIMOSIS WITH TOPICAL STEROIDS 11. Kayaba H, Tamura H, Kitajima S, Fujiwara Y, Kato T, prospective, randomized, double-blind study. Scand J Kato T: Analysis of shape and retractability of the pre- puce in 603 Japanese boys. J Urol. 1996; 156: 1813-5.
16. Lee KS, Koizumi T, Nakatsuji H, Kojima K, Yamamoto 12. Sokol RR, Rohlf FJ: Biometry, 3rd (ed.), New York, A, Kavanishi Y, et al.: Treatment of phimosis with betamethasone ointment in children. Nippon Hinyokika 13. Shankar KR, Rickwood AM: The incidence of phimo- sis in boys. BJU Int. 1999; 84: 101-2.
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Accepted after revision: June 20, 2005 Correspondence address:
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
E-mail: favorito@uerj.br
EDITORIAL COMMENT
the results in this study, this would seem the best treatment of phimosis in children with betamethasone treatment for phimosis causing ballooning of the ointment as has been shown in other studies. In prepuce with voiding and/or when phimosis is thought addition, they have demonstrated success with lower to be causing recurrent infections. These authors do dose betamethasone ointment (0.05% instead of 0.1%) not note that any of these boys had symptoms. While and that only one month treatment is needed in about these authors and others have shown resolution of half of the cases. However, they do not report on long phimosis with steroid ointment, they have not term follow-up to determine if recurrence is a demonstrated that treating asymptomatic phimosis in problem. Ashfield et al. (Reference 18 in article) also pre-pubertal boys has any medical benefit.
did not report long term follow-up but they examinedpatients six weeks following cessation of treatment, Dr. Jean G Hollowell
which should have at least detected early recurrences.
Children’s Hospital of the King’s Daughters The more important point on this topic to and Eastern Virginia Medical School consider is when this treatment is indicated. From

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