Modern treatment of phimosis

Non-surgical methods now the standard approach

Much of the pressure for circumcision in the Victorian era and up until the 1960s was fear of phimosis - inability or difficulty in retracting the foreskin to expose the glans. In the nineteenth century this condition was wrongly believed to be the cause of a host of nervous and other diseases, leading many doctors to insist that unless the foreskin was fully mobile within a few weeks of birth, circumcision was essential. It was not until the 1940s that this error was corrected by Douglas Gairdner, though it persists in parts of the United States to this day. Research since the 1940s has established that it is perfectly normal for the foreskin not to become retractable until a boy reaches puberty, and that there is no need for any intervention unless he is experiencing discomfort, since most cases resolve spontaneously as he matures.

For cases of persistent phimosis, where there was discomfort, pain or other problems, it is true that there was probably no alternative to circumcision until the 1990s, when it was realised that the application of steroids caused the foreskin tissue to loosen and expand, thus permitting retraction. A host of articles in medical journals since the early 1990s has now established beyond any doubt that application of one or more of several different steroid creams to the foreskin is nearly always effective in resolving problem cases of phimosis. The notion that circumcision is the appropriate response to phimosis is now outdated and unscientific. The only situation where circumcision may still be necessary is in persistent cases of Balanitis xerotica obliterans (BXO or Lichen sclerosus - a very rare skin disease, possibly of fungal origin, but not yet fully understood) that do not respond to conservative treatment.

Most of these articles are available on CIRP, but an additional selection of articles is provided below. These show how assertions of the need for circumcision have decreased as understanding of normal penile development has improved. It is interesting to observe how allegations of the "need" for circumcision fade away as it is increasingly appreciated that, in most cases, the phimotic condition is normal and harmless, and that the foreskins of many healthy boys  do not become fully retractable until puberty or even later. In the first paper below (early 1990s) doctors are still circumcising quite young boys whose foreskins have not become retractable if they do not respond quickly to the steroid treatment. But as more experience is gained (and as false Victorian/Edwardian understanding dissipates) the anxiety recedes.  It comes to be appreciated that that it is quite normal for foreskins not to become retractable until puberty or after, and that in many cases they will do so naturally, even without treatment. What is particularly interesting about the results of many of the papers below is the number of boys in the control (non-treatment) group whose phimosis resolved quite naturally during the course of the study. The lesson here is to be patient and recall the old proverb: Fools rush in where angels fear to tread.

It is doubtful whether any boy needs treatment unless he is still phimotic after puberty and experiencing discomfort, but is is certainly better to undergo a harmless  course of steroid ointment than to suffer the risks and losses of amputating surgery. There is some evidence that extra testosterone can also held achieve foreskin mobility, suggesting that a low testosterone level may be connected with the phimotic condition in the first place.

A selection of recent papers in medical journals

The response of phimosis to local steroid application

C. S. Kikiros, S. W. Beasley and A. A. Woodward

ABSTRACT:  The effectiveness of topical steroid application in relieving phimosis was studied in 63 boys treated with local application of steroid ointment to the foreskin. Betamethasone valerate 0.05% (42 patients), hydrocortisone 1% (18 patients), or hydrocortisone 2% (3 patients) was applied three times daily for 4 weeks. Thirty-seven of the patients treated with 0.05% betamethasone valerate ointment (half-strength Betnovate) showed an initial improvement and circumcision was performed on 5 non-responders. Six patients showed initial improvement but later redeveloped phimosis: they were given a further course of treatment, resulting in 2 satisfactory responses and 4 failures requiring circumcision. Two patients using 2% hydrocortisone and 16 using 1% hydrocortisone ointment showed improvement, but 2 of the latter group ultimately required circumcision. Overall, a permanent improvement was achieved in 51 of the 63 patients, with the ability to retract the foreskin after one or more treatments. The remaining 12 boys required circumcision. Local application of steroid ointment to the foreskin results in resolution of phimosis in the majority of cases, but if the foreskin has a circumferential white scar, it is slightly less likely to respond. Following cessation of steroids, phimosis redevelops in a proportion of patients.

Pediatric Surgery International
Vol 8, No 4, May 1993

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Treatment of childhood phimosis with a moderately potent topical steroid

Wai-Tat Ng, Ning Fan et al

BACKGROUND:   Recently, topical steroid application has been shown by a small number of studies to be an effective alternative to circumcision for the treatment of phimosis. However, only potent or very potent corticosteroids have been more thoroughly studied in this treatment option. A prospective study was conducted to determine whether comparable results could be achieved using a weaker steroid cream.

METHODS:   Boys, 3–13 years of age, with non-retractable foreskin due to a tight ring at the tip were offered the regimen of twice-daily preputial retraction and topical application of 0.02% triamcinolone acetonide cream. The degree of preputial retractability was assessed at presentation and at 4 and 6 weeks of treatment. Success was defined as full retraction or free retraction up to agglutination of the foreskin to the glans.

RESULTS:   Eighty-three boys completed the treatment. Successful retraction was achieved in 48/83 (58%) patients after 4 weeks and 70/83 (84%) patients after 6 weeks of application. The overall response rate aggregated from six published series using 0.05% betamethasone was 87% at 4 weeks and 90% on completion of treatment. Thus, the results appear inferior when analysed at 4 weeks but compare favourably with those reported for a more potent steroid on completion of the full course of treatment.

CONCLUSIONS:   Even though the triamcinolone cream used in the present study is less potent than the more commonly used 0.05% betamethasone valerate cream, it could effect comparable improvements in foreskin retractability after 6 weeks of treatment.

Australia and New Zealand Journal of Surgery
Vol 71, 2001, 541-543

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Debe realizarse circuncisión en la infancia? [Should circumcision be performed in infancy?]

Julio César Morales Concepción, Emilio Cordiés Jackson et al

OBJECTIVE: To evaluate prepuce development and retractibility in a group of boys. To point out the value of circumcision and preputial forced dilation during childhood.

METHODS: Prepuce development and retractibility were evaluated in 400 boys ages between 0-16 year old.

RESULTS: In boys under 1 year prepuce retractibility (assessed only in children who did not undergo forced dilation previously) was type I (non retractile) in 71.5% whereas type V (completely retractile) was only 5.5%. In adolescent boys type I prepuce was observed in 1 boy only, 1.6%, whereas type V was observed in 82.3%. Furthermore, it was observed that at the time of examination for the study 106 boys who had undergone forced dilation at an earlier age had balano-preputial adhesions again , which demonstrates that prepuce adheres again to glans penis in many boys after a forced dilation is performed.

Only 11 boys were considered in need for circumcision, three of them for preputial orifice stenosis, which prevented normal urination, causing a preputial sac, one case due to a constrictive ring below the preputial edge that would have prevented ulterior retractibility, two cases with repetitive balano-posthitis, and five cases secondary to xerosal balanitis, accounting for 2.7% of all examined boys.

CONCLUSIONS: Incomplete separation between prepuce and glans penis is normal and common among new-borns, progressing until adolescence to spontaneous separation, at which time it is complete in the majority of boys. Accordingly to the criteria we have sustained for years and present study's findings, circumcision has few indications during childhood, as well as forced preputial dilation.

NOTE:  This article makes the important point that premature or forcible separation of the foreskin from the glans before the boy is ready is likely to cause bleeding and subsequent adhesion as the torn surfaces fuse together as they heal. In other words, premature retraction may cause pathological phimosis.

Arch. Esp. Urol., Vol. 55 No. 7, 2002, 807-811

[The use of corticosteroid cream to treat phimosis]

van Basten JP, de Vijlder AM, Mensink HJ.
Academisch Ziekenhuis, afd. Urologie, Postbus 30.001, 9700 RB Groningen, The Netherlands

ABSTRACT: Many of the boys diagnosed with “phimosis”, who are referred for circumcision, do not have a dermatopathology and thus there is no indication for surgery. If an unretractable prepuce causes hygienic problems, and also in the case of dermatopathology, topical corticosteroid application may be an effective alternative to circumcision. In a literature search 13 studies were found on the effectiveness and the safety of topical steroid application for phimosis. Three of the studies were placebo controlled. A total of 1121 boys with an unretractable prepuce were treated with a topical corticosteroid, which was mostly applied twice daily. After a treatment duration of 4 to 8 weeks, about 75% of the patients achieved complete retractability of the prepuce. In the studies evaluated, local or systemic adverse effects were not noted. Different types of corticosteroids gave similar results. Topical corticosteroid application for the treatment of unretractable prepuce complaints seems to be effective and safe, and is therefore recommended before surgical intervention is considered.

Ned Tijdschr Geneeskd. 2003 Aug 9;147(32):1544-7 (in Dutch)

PMID: 12942843 [PubMed - indexed for MEDLINE]

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

ABSTRACT: 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 or circumcision).

J Pediatr. 2005 Nov;147(5):705-6.

PMID: 16291369 [PubMed - indexed for MEDLINE]

Preputial retraction in children

Abhinav Agarwal, Anup Mohta, Ritesh K Anand

Department of Surgery, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, Delhi, India?

OBJECTIVE: The aim of the study was to assess preputial retractability in children at various ages.

MATERIALS AND METHODS: Nine hundred and sixty boys attending the hospital were included in the study. Children with hypospadias or history of preputial manipulation were excluded. Preputial anatomy was studied and subjects were classified into five groups as described by Kayaba et al.

RESULTS: The prepuce could not be retracted at all so as to make even the external urethral meatus visible in 61.4% children aged 0-6 months while this decreased to only 0.9% in children aged 10-12 years. At the other end of the spectrum, while prepuce could not be fully retracted in any child below 6 months, it could be done in about 60% in the age group of 10-12 years.

CONCLUSION: Preputial non-separation is the major cause of preputial nonretraction in the pediatric age group. Prepuce spontaneously separates from the glans as age increases and true phimosis is rare in children. Surgical intervention should be avoided for non-separation of prepuce.

J Indian Assoc Pediatr Surg 2005;10:89-91 (Full text)

Topical hydrocortisone and physiotherapy for nonretractile physiologic phimosis in infants

Jung Won Lee, Su Jin Cho, Eun Ae Park and Seung Joo Lee

The following article suggests that steroid treatment to resolve phimosis can cure recurrent Urinary Tract Infections without the need for circumcision.

ABSTRACT:  The effect of hydrocortisone (HC), the steroid of lowest potency, and physiotherapy (PT) on non-retractile physiologic phimosis (PP) and the reduction of subsequent recurrent UTI was evaluated in male infants with UTI. Seventy-eight male infants with febrile UTI and nonretractile PP were prospectively randomized into HC (Plancol, n=39) and control (Vaseline, n=39) groups. Topical application of HC as a thin film around the preputial margin twice a day for four weeks with PT was instructed. The response rate in the HC group was 89.7% (35/39), which was significantly higher than the rate (20.5%; 8/39) in the control group (P<0.05). In the HC group, the response rate was much higher (96.1%) in the subgroup with PT than in the group without PT. Most of the response (88.5%) was observed within two weeks. During the following year, the recurrent rate of UTI was 7.1% (2/28) in the infants with retractile prepuces, which was significantly less than than the rate (29.6%; 8/27) in infants with nonretractile prepuces (P<0.05). In conclusion, topical HC and PT for 2–4 weeks proved to be a simple, safe and effective treatment for nonretractile PP in infants with UTI, and this procedure was beneficial in reducing recurrent UTI.

Pediatric Nephrology
Vol 21, No 8, August 2006, 1127-1130

Phimosis and topical steroids: new clinical findings

Nicola Zampieri, Michele Corroppolo et al

ABSTRACT:  Phimosis has been defined as unretractable foreskin without adherences and/or a circular band of tight prepuce preventing full retraction. The aim of this study is to evaluate the efficacy (response rate) of topical steroids for the treatment of tight phimosis at different age stages. After using the same medication with different dosage schemes, a retrospective analysis was carried out to assess the efficacy of topical steroids in the treatment of tight phimosis. Patients were divided into three groups: group A (betamethasone scheme A), group B (betamethasone scheme B) and group C (control group). Remission of phimosis, with a complete exposure and without a narrowing behind the glans, was considered a complete response to treatment. The outcomes were then related to dosage scheme and patient’s age. The dosage for group A was more effective than the dosage for groups B and C (control group). Phimosis resolved in 90% (group A), 72% (group B) and 56% (group C) of cases. A successful treatment was closely related to the age of patients at the beginning of steroid application. The results showed that treatment with topical steroids, which in general gives good results, proved to be much more successful in patients aged between 4 and 8 years, suggesting the efficacy of an early beginning of the treatment.

Pediatric Surgery International
Vol 23, No 4, April 2007

Outcome and recurrence in treatment of phimosis using topical betamethasone in children in Hong Kong

Wai-Hung Ku, Becky S-K Chiu and Kwai-Fun Huen

AIM:   To study the efficacy of treating phimosis with topical steroid, and its long-term outcome and side effects. We also looked into the effect of daily retraction and cleansing of prepuce on preventing recurrence of phimsosis.

METHODS:   This prospective study comprised 138 boys who were prescribed 0.05% betamethasone ointment (Diprocel) during 1 August 2001–31 July 2004. Five boys were excluded because of non-compliance. Of the remaining 133 boys, 108 were followed-up and assessed. Age ranged from 0.03 to 12.9 years (mean = 3.38, SD = 2.79). The number of treatment course received, short-term and long-term outcome, side effects and the effect of daily foreskin retraction were studied.

RESULTS:   The success rate of first treatment course was 81.5%, and 60.2% of boys remained free from phimosis upon latest assessment. The follow-up period ranged from 0.4 to 4.4 years (mean = 2.45, SD = 0.90). There were no side effects noted. We found a significant and linear relationship between daily foreskin retraction and sustained resolution of phimosis.

CONCLUSION:   Topical steroid is an effective and safe treatment for phimosis, especially when combined with a good hygiene practice of the foreskin with daily cleansing and retraction. A trial of topical steroid treatment should be offered upon considering circumcision.

Journal of Paediatrics and Child Health
Vol 43, Nos 1-2, January 2007

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Phimotic ring topical corticoid cream (0.1% mometasone furoate) treatment in children

Flavio de Oliveira Pileggi, Yvonne A.M.V.A. Vicente

BACKGROUND:   Phimosis, owing to the presence of a preputial fibrotic ring, is surgically treated in 1% of children. During the last decade, however, topical steroid treatment has been proposed for phimosis.

METHODS:   We present a double-blind study comparing 0.1% mometasone furoate topical cream vs moisturizing cream (placebo) for the treatment of phimosis. Children aged from 2 to 13 years (n = 110) presenting with phimosis (Kikiro's classification grade 5) and scheduled for circumcision were included in this trial. The patients were evaluated after 8 weeks of topical treatment with moisturizing cream (n = 54) or steroid cream (n = 56). Non-responders from both groups received an additional 8 weeks of steroid cream treatment.

RESULTS:   In the steroid group, the ring disappeared and glans exposure was obtained in 49 (88%) of 56 patients vs 28 (52%) of 54 patients in the placebo group (P b.05). After a second treatment, in the steroid group, 5 of the 7 patients were finally cured vs 22 of the 26 in the placebo group (P b.05). Two children with persisting phimosis (Kikiro's retractability grade 5 and appearance grade 3) in the steroid group (4%) vs 4 children in the placebo group (7%) ended up receiving postectomy.

CONCLUSION:   The present investigation adds up and supports the effectiveness of phimosis topical corticoid treatment. Nevertheless, hygiene and preputial traction, when appropriately performed, seem to play an important role in the disappearance of the phimotic ring as well. New studies are necessary to confirm if this is true or not.

Journal of Pediatric Surgery
Vol 42, 2007, 1749-52

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Long-term efficiency of skin stretching and a topical corticoid cream application for unretractable foreskin and phimosis in pre-pubertal boys

Ghysel C, Vander Eeckt K, Bogaert GA.
Department of Urology-Pediatric Urology, University Hospital UZ Gasthuisberg, Leuven, Belgium.

OBJECTIVES: To evaluate the long-term efficacy of topical application of a potent corticoid cream and skin stretching in the treatment of unretractable foreskin, pinpoint phimosis, balanopreputial adhesions and lichen sclerosus in prepubertal boys.

METHODS: 462 prepubertal boys (mean age 4.7 years) with unretractable foreskin applied a topical potent corticoid cream together with skin stretching twice daily for 6 weeks. Follow-up interview of all patients was performed to evaluate long-term results (median 22 months). Short- and long-term results were compared and evaluated.

RESULTS: 400/462 boys (86%) had a retractable prepuce after 6 weeks of treatment. 62/462 boys had no or only a partial response. After a median follow-up of 22 months, the treatment continued to be successful in 383/462 boys (83%). In 76/462 boys the foreskin was unretractable, of which 35 preferred surgical treatment. 12/462 boys presented with lichen sclerosus and the non-surgical treatment appeared efficient in 9/12 (67%).

CONCLUSIONS: This study has shown that local application of a potent corticoid cream and skin stretching is a safe, simple and effective long-term treatment for all types of unretractable foreskin in prepubertal boys. The efficiency of the treatment was not related to the age of the patient or the type of unretractable foreskin.

Urol Int. 2009;82(1):81-8. Epub 2009 Jan 20.

PMID: 19172103 [PubMed - indexed for MEDLINE]

Doctors often hazy about distinguishing normal phimosis from a pathological condition

McGregor TB, Pike JG, Leonard MP, Phimosis: A diagnostic dilemma?
Canadian Journal of Urology 2005 Apr; 12(2):2598-602

Abstract

INTRODUCTION: Phimosis is defined as the inability to retract the foreskin. Differentiating between physiological phimosis and pathological phimosis is important, as the former is managed conservatively and the latter requires surgical intervention. Referrals of patients with physiological phimosis to urology clinics may create anxiety regarding the need for surgery amongst patients and parents, while unnecessarily expanding the waiting list for specialty assessment.

OBJECTIVES: To determine the ability of referring physicians to differentiate physiological from pathological phimosis, and to see whether there is any difference in this ability between generalists versus specialists.

MATERIALS AND METHODS: A retrospective chart review of 284 consecutive referrals for phimosis to the Children's Hospital of Eastern Ontario (CHEO) Urology Clinic during November 2000 - April 2003 was conducted. Referral sources included family physicians (FP), pediatricians (PD), emergency physicians (ER), and other subspecialists (SS). Data for this study were obtained from the original referral letters and cross-referenced with the impressions of the pediatric urologist following the initial patient encounter. The accuracy in diagnosing phimosis was evaluated among the various types of referring physicians.

RESULTS: A total of 284 phimosis referrals were reviewed of patients ranging from 2 months to 16 years of age (mean = 6.6 years). The referral sources consisted of 222-GP, 33-PD, 23-ER, and 6-SS. The majority of referred cases were diagnosed by the attending pediatric urologist as physiological phimosis across all referral sources, with the exception of subspecialists (FP = 75.2%, PD = 81.8%, ER = 56.5%, SS = 33.3%). Second to this was the diagnosis of pathological phimosis across all referral sources except SS (FP = 14.9%, PD = 12%, ER = 34.8%, SS = 50%). Overall, the circumcision rate for the 284 phimosis referrals reviewed was 14.4%.

CONCLUSIONS: Our findings reveal that many physicians continue to face difficulties in distinguishing physiological phimosis from the pathological. As a result, many unnecessary referrals are made for phimosis . We suggest the implementation of improved educational measures regarding preputial pathophysiology in the medical curriculum. Such measures would serve two purposes: first, to reduce the number of unnecessary specialty referrals and secondly, to aid primary care physicians in recognizing the presence of physiological phimosis so that patients and families may be reassured of normalcy.

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Much confusion about phimosis, but uncircumcised penis requires no special care

Thomas B. McGregor, John G. Pike, Michael P. Leonard, Pathologic and physiologic phimosis: Approach to the phimotic foreskin
Canadian Family Physician 2007(March);53:445-448

Abstract

OBJECTIVE: To review the differences between physiologic and pathologic phimosis, review proper foreskin care, and discuss when it is appropriate to seek consultation regarding a phimotic foreskin.

SOURCES OF INFORMATION: This paper is based on selected findings from a MEDLINE search for literature on phimosis and circumcision referrals and on our experience at the Children’s Hospital of Eastern Ontario Urology Clinic. MeSH headings used in our MEDLINE search included “phimosis,” “referral and consultation,” and “circumcision.” Most of the available articles about phimosis and foreskin referrals were retrospective reviews and cohort studies (levels II and III evidence).

MAIN MESSAGE: Phimosis is defined as the inability to retract the foreskin. Differentiating between physiologic and pathologic phimosis is important, as the former is managed conservatively and the latter requires surgical intervention. Great anxiety exists among patients and parents regarding non-retractile foreskins. Most phimosis referrals seen in pediatric urology clinics are normal physiologically phimotic foreskins. Referrals of patients with physiologic phimosis to urology clinics can create anxiety about the need for surgery among patients and parents, while unnecessarily expanding the waiting list for specialty assessment. Uncircumcised penises require no special care. With normal washing, using soap and water, and gentle retraction during urination and bathing, most foreskins will become retractile over time.

CONCLUSION: Physiologic phimosis is often seen by family physicians. These patients and their parents require reassurance of normalcy and reinforcement of proper preputial hygiene. Consultation should be sought when evidence of pathologic phimosis is present, as this requires surgical management.

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Phimosis does not require circumcision

Peter D Metcalf and Remon Elyas, Foreskin management: Survey of Canadian pediatric urologists
Canadian Family Physician 2010;56:e290-5 (August 2010)

Key points

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Phimosis: Circumcision outmoded treatment

A thoroughly researched article in ISRN Urology by an Indian paediatrician confirms previous research showing that phimosis (inability to retract the foreskin) is normal in children and rarely requires intervention. He further points out that circumcision is an old fashioned and outmoded response to problem cases that has largely been superseded by medical rather than surgical treatments. Unlike papers by Americans and others from circumcising cultures, this survey does not start with the usual litany about circumcision being an ancient surgical procedure, performed by many savage and ignorant cultures blah, blah, blah, but at the proper place: with a discussion of the foreskin as a normal, functional part of male sexual anatomy, followed by a discussion of its development, anatomy and physiology. Only then does the author consider the occasional problems to which a non-retractile foreskin may give rise, and the appropriate responses (i.e. not involving wholesale destruction of the body part in question). The paper points out that there are two types of phimosis - physiological (normal) and pathological - and that only the last of these may warrant surgical intervention. The author is particularly concerned that there is still widespread confusion, among both parents and doctors, between these two types of phimosis, leading to many unnecessary and unwanted circumcision procedures. Better knowledge of foreskin physiology and modern treatment options is needed to minimise mistaken diagnoses of pathological phimosis, reduce the incidence of needless and often harmful surgery.

ABSTRACT: Phimosis is nonretraction of prepuce. It is normally seen in younger children due to adhesions between prepuce and glans penis. It is termed pathologic when nonretractability is associated with local or urinary complaints attributed to the phimotic prepuce. Physicians still have the trouble to distinguish between these two types of phimosis. This ignorance leads to undue parental anxiety and wrong referrals to urologists. Circumcision was the mainstay of treatment for pathologic phimosis. With advent of newer effective and safe medical and conservative surgical techniques, circumcision is gradually getting outmoded. Parents and doctors should a be made aware of the noninvasive options [i.e. not involving cutting or removal of tissue] for pathologic phimosis for better outcomes with minimal or no side-effects. Also differentiating features between physiologic and pathologic phimosis should be part of medical curriculum to minimise erroneous referrals for surgery.

Source: Sukhbir Kaur Shahid, Phimosis in Children. ISRN Urology, 2012.

BXO (Lichen sclerosus)

Information about Balanitis xerotica obliterans (BXO)


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