Cost-effective treatment of phimosis

Topical corticosteroids for treating phimosis in boys

BACKGROUND

This is an updated version of a Cochrane Review first published in 2014. Phimosis is a condition in which the prepuce (foreskin) cannot be fully retracted past the head of the penis (glans). Phimosis is often treated surgically by circumcision or prepuce plasty; however, reports of non-invasive treatment using topical corticosteroids applied for four to eight weeks have suggested favorable outcomes.

OBJECTIVES

To assess the effects of topical corticosteroids applied to the stenotic portion of the prepuce for the treatment of phimosis in boys compared with placebo or no treatment.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS, and ClinicalTrial.gov. We checked reference lists of included studies and relevant reviews for additional studies. There were no restrictions on the language of publication. The date of the last search was 4 October 2023.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) that compared the use of any topical corticosteroid with placebo or no treatment for boys with any type or degree of phimosis.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data related to the review's primary and secondary outcomes, and assessed the studies' risk of bias. We used the random-effects model for statistical analyses and expressed dichotomous outcomes as risk ratios (RRs) with 95% confidence intervals (CIs). We contacted the authors of the primary articles to request details of the study design and specific outcome data. We used GRADE to assess the certainty of evidence on a per-outcome basis.

MAIN RESULTS

In this update, we identified two new studies with 111 participants, bringing the total number of included studies to 14 (1459 randomized participants). We found that types of corticosteroids investigated, participant age, degree of phimosis, type of phimosis, and treatment duration varied considerably among studies. Compared with placebo or no treatment, topical corticosteroids may increase the complete resolution of phimosis after four to eight weeks of treatment (RR 2.73, 95% CI 1.79 to 4.16; I² = 72%; 10 trials, 834 participants; low-certainty evidence). Based on 252 complete resolutions per 1000 boys in the control group, this corresponds to 436 more complete resolutions per 1000 boys (95% CI 199 more to 796 more). We downgraded the certainty of the evidence by one level for serious study limitations and by one level for serious inconsistency. Topical corticosteroids may also increase the partial resolution of phimosis at four to eight weeks of treatment compared with placebo or no treatment (RR 1.68, 95% CI 1.17 to 2.40; I² = 44%; 7 trials, 745 participants; low-certainty evidence). Based on 297 partial resolutions per 1000 boys in the control group, this corresponds to 202 more partial resolutions per 1000 boys (95% CI 50 more to 416 more). We downgraded the certainty of the evidence by one level for serious study limitations and by one level for serious inconsistency. We are uncertain of the effect of topical corticosteroids compared to placebo on change in retractability score (standardized mean difference [SMD] -1.48, 95% CI -2.93 to -0.03; I²91%; 2 trials, 177 participants; very low-certainty evidence). We downgraded the certainty of the evidence by one level for serious study limitations, one level for serious heterogeneity, and one level for serious imprecision. Compared with placebo, topical corticosteroids may increase the long-term complete resolution of phimosis six or more months after treatment (RR 4.09, 95% CI 2.80 to 5.97; I² = 0%; 2 trials, 280 participants; low-certainty evidence). Based on 171 long-term complete resolutions per 1000 boys in the control group, this corresponds to 528 more complete resolutions per 1000 boys (95% CI 308 more to 850 more). We downgraded the certainty of the evidence by one level for serious study limitations and by one level for serious imprecision. There may be little or no difference in the risk of adverse effects between topical corticosteroids and placebo or no treatment (RR 0.28, 95% CI 0.03 to 2.62; I² = 22%; 11 trials, 1091 participants; low-certainty evidence). Only two of 11 studies that recorded adverse effects reported any adverse effects; one event occurred in the corticosteroid group and six in the control group. We downgraded the certainty of the evidence by one level for serious study limitations and by one level for serious imprecision.

AUTHORS' CONCLUSIONS

Topical corticosteroids, compared to placebo or no treatment, may increase complete and partial resolution of phimosis when assessed after four to eight weeks of treatment, and may increase long-term complete resolution of phimosis assessed six or more months after treatment. Topical corticosteroids may have few or no adverse effects, and we are uncertain about their effect on retractability scores. The body of evidence is limited by poor reporting of methods in the studies, important clinical heterogeneity, and serious imprecision in the results. Future, higher-quality trials with long-term follow-up would likely improve our understanding of the effects of topical corticoids on phimosis in boys.

Chronic pelvic pain syndrome: Highlighting medicinal plants toward biomolecules discovery for upcoming drugs formulation

Chronic pelvic pain syndrome (CPPS) can be triggered by a various types of gynecological, gastrointestinal, urological, and musculoskeletal disorders. Recently, the role of the central nervous system has proven to be an integral part on the development of any chronic pain syndrome, including CPPS. However, owing to the complex and heterogeneous etiology and pathophysiology of CPPS, the establishment of effective therapeutic interventions remains challenging for both physicians and patients. Nonetheless, recent studies have pointed that medicinal plants and their secondary metabolites can be effectively used in CPPS therapy, besides contributing to restore the patients' quality of life and potentiate the conventional CPPS management. In this sense, this review aims to provide a careful overview on the biomedical data for the use of medicinal plants use and their secondary metabolites on CPPS management.

Outpatient surgery is the solution at hand for reducing costs and hospital stays for pediatric surgery too: a hospital trial

BACKGROUND

Outpatient management has proven to be the most useful method of treatment for various minimally complex surgical specialties compared to day-hospital management or ordinary inpatient processes, a fact confirmed by numerous technical documents and works in the literature.

METHODS

We analyzed 27,713 surgical interventions carried out in our hospital between 2005 and 2017. This analysis included all interventions for which the indication of the level of care has moved, over the years, to an outpatient setting. We evaluated the direct costs of these services, comparing them by year and by treatment setting.

RESULTS

From the analysis of costs in general, for the same number of services, a reduction of 56.6% can be seen in the comparison between 2005 and 2017. In addition, the analysis of the length of stay shows an average reduction in the number of days of hospitalization from 2.9 to 1.2 between 2005 and 2017. On the basis of a large quantity of data, our study confirms that outpatient surgery can have a significant impact in reducing costs and days of hospitalization, even in a pediatric setting, demonstrating that it is the best choice in terms of saving resources and, above all, clinical and organizational appropriateness.

CONCLUSIONS

Outpatient surgery is in fact a valuable solution that provides an advantage for both the patient and his/her family, especially in the pediatric field, for the hospital and more generally for the health system as a whole.

Prepuce sparing: Use of Z-plasty for treatment of phimosis and scarred foreskin

INTRODUCTION AND OBJECTIVES

The desire to preserve the prepuce is often based on cultural norms. Recently, the concept of "genital autonomy" has been invoked to delay circumcision (or any genital altering procedure) until the individual reaches maturity and can make his or her own decision. However, some uncircumcised boys develop one or more episodes of balanitis resulting in scarring of the prepuce and pathologic phimosis which is difficult to treat. Herein we report on the management of severe phimosis and preputial scarring using preputial Z-plasties.

MATERIALS AND METHODS

We reviewed the records of 28 patients, aged 3-12 years who underwent prepuce-sparing surgery within the previous 5 years with a minimum follow-up of 6 months. All patients were uncircumcised, with severe phimosis defined as a tight, pinpoint opening. All patients failed to respond to 6-10 weeks of betamethasone treatment. All parents requested preservation of as much of the foreskin as possible.

RESULTS

All patients healed satisfactorily, without infection, hematoma, or flap necrosis. One child developed mild scarring which responded to local steroid application. At follow-up evaluation, ranging from 6 to 24 months, the prepuce was fully retractable in all patients (Fig.).

CONCLUSIONS

Excision of the scarred preputial ring results in a circular suture line, which is in essence a straight line, curved and connected at each end, and this is likely to contract over time. The principle of Z-plasty can be exploited to elongate and interrupt the straight line, preventing contracture thus widening and sparing the prepuce.

Does Circumcision Increase Meatal Stenosis Risk?-A Systematic Review and Meta-analysis

CONTEXT

Meatal stenosis (MS) as a potential complication of male circumcision and controversy regarding the magnitude of risk.

OBJECTIVES

To conduct a systematic review and meta-analyses to assess (1) MS diagnosis after circumcision, (2) the potential association of MS with circumcision, and (3) a potential method of prevention.

DATA SOURCES

PubMed, Google Scholar, Cochrane Library and bibliographies of original studies were searched using the keywords circumcision and stenosis or stricture.

STUDY SELECTION

Studies containing original data on MS following circumcision at any age.

DATA EXTRACTION

Two reviewers independently verified study design and extracted data.

RESULTS

Thirty eligible studies were retrieved. A random effects meta-analysis of 27 studies (350 MS cases amongst 1,498,536 males) found that the risk of MS in circumcised males was 0.656% (95% confidence interval 0.435-0.911). Meta-analysis of 3 observational studies that compared MS prevalence in circumcised and uncircumcised males found non-significantly higher prevalence in circumcised males (odds ratio 3.20; 95% confidence interval 0.73-13.9). Meta-analysis of 3 randomized controlled trials investigating the effect of petroleum jelly application to the glans after circumcision found that this intervention was associated with MS risk reduction (relative risk 0.024; 95% confidence interval 0.0048-0.12).

CONCLUSION

MS risk after circumcision is low (< 1%). Weak evidence suggests that MS risk might be higher in circumcised boys and young adult males. Risk is reduced by petroleum jelly application. Further research on MS arising from lichen sclerosus in older uncircumcised males is needed.

Prepuce health and childhood circumcision: Choices in Canada

INTRODUCTION

Worldwide, almost 100% of boys are born with penises with a "hood" called prepuce or foreskin. In the course of the boy's life, the prepuce can be circumcised, can become affected by diseased (e.g., phimosis), or a can become infected and hurt the neonate (and his sexual partner) in adulthood. The objectives of this report are to: 1) review the state, function, fate, and care of the prepuce in childhood, with focus on the neonate, in Canada; 2) understand the current practice of childhood male circumcision in terms of age, indications, performers, techniques, outcomes, and education; and 3) consider ways to sustain a good healthcare professional-parental dialogue for safe practices that are accessible, acceptable, and culturally sensitive in the care of the prepuce.

METHODS

A literature review was carried out in the English language through the major databases: PubMed (MEDLINE), EMBASE, the Cochrane Library, CINAHL, Web of Science (WOS) Core Collection, LILAC, WHO/UNAIDS, Clinical Trials (www.clinicaltrials.gov), Google Scholar, and grey literature. Search words included: prepuce, diseases of prepuce, prepuce in the neonate, prepuce in the neonate in Canada, male circumcision, childhood male circumcision, neonatal circumcision, neonatal circumcision in Canada, complications of neonatal circumcision in Canada, and circumcision adverse events.

RESULTS

From 1970-1999, three of 10 Canadian newborn males were circumcised for religious, cultural, and medical reasons. The rest of the neonates, if alive, are living with their prepuce; <4% expected to require treatment for afflictions of the prepuce at some point. There are several providers of circumcision with different levels of training and competencies and using a diversity of devices and techniques. Neonatal and childhood circumcision in Canada is carried out to fulfill parental wishes, as well as for medical, religious, and cultural reasons. Appropriate informed consent and education regarding choices of care of the neonatal prepuce and genitals are vital.

CONCLUSIONS

Going by current prevalent rate of circumcision in Canada, most Canadian newborn males are likely to live out their lives with an intact prepuce. Despite the age-old debate, childhood circumcision is likely to remain. There is need for careful and proper discussion of the potential risks and benefits, including alternatives, costs, and personal/psychological factors. Acceptance, access, and judicious choices in a culturally sensitive environment will offer the Canadian neonate desirable care of the prepuce for life.

A Cost-Utility Analysis of Neonatal Circumcision

A cost-utility analysis, based on published data from multiple observational studies, comparing boys circumcised at birth and those not circumcised was undertaken using the Quality of Well-being Scale, a Markov analysis, the standard reference case, and a societal perspective. Neonatal circumcision increased incremental costs by $828.42 per patient and resulted in an incremental 15.30 well-years lost per 1000 males. If neonatal circumcision was cost-free, pain-free, and had no immediate complications, it was still more costly than not circumcising. Using sensitivity analysis, it was impossible to arrange a scenario that made neonatal circumcision cost-effective. Neonatal circumcision is not good health policy, and support for it as a medical procedure cannot be justified financially or medically.

[Review of clinical experience for a new preputioplasty technique as circumcision alternative]

Surgery is required for phimosis with a contracted fibrous ring or when the medical treatment with steroids has been unsuccessful. Surgical teams often opt for circumcision when a conservative technique can be used. This surgery could have some psychologic consequences, and when the circumcision in not according to religious convictions, it cannot be live well for the patient and his family. Furthermore, some surgery procedures for prepuce conservation seem to give some unaesthesics aspects with cutaneous excess. The objective of this study was to evaluate our new preputioplasty technique according to the initial diagnosis (phimosis with scarred foreskin or long and narrow foreskin), in situation where circumcision is required currently. Outcome evaluated was: easy and painless foreskin retraction, absence of postoperative phimosis as well as cosmetic aspects of the penis. In this study, 90 children benefited from this technique and subsequent follow-up. The mean age was 7.9 years for the 32 children in the sclerotic phimosis group and 6.8 years for the 58 children in the long and narrow foreskin group. We observed complete foreskin retraction without any recurrence in 100% of children with a phimosis resistant to medical treatment which consisted of progressive foreskin retraction and application of topical steroids, with a mean postoperative follow-up of 1.4 years. Results showed an excellent cosmetic aspect of the penis with absence of enlarged foreskin in all our subjects. This study underlines the relevance of this surgical technique.

Circumcision of privately insured males aged 0 to 18 years in the United States

BACKGROUND

Male circumcision confers protection against HIV, sexually transmitted infections, and urinary tract infections. Compared with circumcision of postneonates (>28 days), circumcision of neonates is associated with fewer complications and usually performed with local rather than general anesthesia. We assessed circumcision of commercially insured males during the neonatal or postneonatal period.

METHODS

We analyzed 2010 MarketScan claims data from commercial health plans, using procedural codes to identify circumcisions performed on males aged 0 to 18 years, and diagnostic codes to assess clinical indications for the procedure. Among circumcisions performed in the first year of life, we estimated rates for neonates and postneonates. We estimated the percentage of circumcisions by age among males who had circumcisions in 2010, and the mean payment for neonatal and postneonatal procedures.

RESULTS

We found that 156,247 circumcisions were performed, with 146,213 (93.6%) in neonates and 10,034 (6.4%) in postneonates. The neonatal circumcision rate was 65.7%, and 6.1% of uncircumcised neonates were circumcised by their first birthday. Among postneonatal circumcisions, 46.6% were performed in males younger than 1 year and 25.1% were for nonmedical indications. The mean payment was $285 for a neonatal and $1885 for a postneonatal circumcision.

CONCLUSIONS

The large number of nonmedical postneonatal circumcisions suggests that neonatal circumcision might be a missed opportunity for these boys. Delay of nonmedical circumcision results in greater risk for the child, and a more costly procedure. Discussions with parents early in pregnancy might help them make an informed decision about circumcision of their child.

Topical corticosteroids for treating phimosis in boys

BACKGROUND

Until recently, phimosis has been treated surgically by circumcision or prepuceplasty; however, recent reports of non-invasive treatment using topical corticosteroids applied for four to eight weeks have been favourable. The efficacy and safety of topical corticosteroids for treating phimosis in boys has not been previously systematically reviewed.

OBJECTIVES

We aimed to 1) compare the effectiveness of the use of topical corticosteroid ointment applied to the distal stenotic portion of the prepuce in the resolution of phimosis in boys compared with the use of placebo or no treatment, and 2) determine the rate of partial resolution (improvement) of phimosis, rate of re-stenosis after initial resolution or improvement of phimosis, and the rate of adverse events of topical corticosteroid treatment in boys with phimosis.

SEARCH METHODS

We searched the Cochrane Renal Group's Specialised Register through contact with the Trials' Search Co-ordinator using search terms relevant to this review. Date of last search: 16 June 2014.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared use of any topical corticosteroid ointment with placebo ointment or no treatment for boys with phimosis.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed titles, abstracts and the full-text of eligible studies, extracted data relating to the review's primary and secondary outcomes, and assessed studies' risk of bias. Statistical analyses were performed using the random-effects model and results were expressed as risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CI). We contacted authors of primary articles asking for details of study design and specific outcome data.

MAIN RESULTS

We included 12 studies that enrolled 1395 boys in this review. We found that both types of corticosteroids investigated and treatment duration varied among studies.Compared with placebo, corticosteroids significantly increased complete or partial clinical resolution of phimosis (12 studies, 1395 participants: RR 2.45, 95% CI 1.84 to 3.26). Our analysis of studies that compared different types of corticosteroids found that these therapies also significantly increased complete clinical resolution of phimosis (8 studies, 858 participants: RR 3.42, 95% CI 2.08 to 5.62). Although nine studies (978 participants) reported that assessment of adverse effects were planned in the study design, these outcomes were not reported.Overall, we found that inadequate reporting made assessing risk of bias challenging in many of the included studies.Selection bias, performance and detection bias was unclear in the majority of the included studies: two studies had adequate sequence generation, none reported allocation concealment; two studies had adequate blinding of participants and personnel and one had high risk of bias; one study blinded outcome assessors. Attrition bias was low in 8/12 studies and reporting bias was unclear in 11 studies and high in one study.

AUTHORS' CONCLUSIONS

Topical corticosteroids offer an effective alternative for treating phimosis in boys. Although sub optimal reporting among the included studies meant that the size of the effect remains uncertain, corticosteroids appear to be a safe, less invasive first-line treatment option before undertaking surgery to correct phimosis in boys.

Is half strength of 0.05 % betamethasone valerate cream still effective in the treatment of phimosis in young children?

INTRODUCTION

0.05 % betamethasone valerate cream is generally used as an alternative to circumcision for the treatment of phimosis in boys. The aim of this study is to determine whether the half-strength formula (0.025 %) of betamethasone is as effective as 0.05 % betamethasone.

METHOD

All boys with phimosis seen at our institution between 2010 and 2012, whose parents complained that their children had problems of micturition, i.e., crying and ballooning, and sought for some instructions or treatments, were instructed to apply betamethasone valerate cream. Two strengths, 0.05 and 0.025 %, were randomly applied to each patient twice a day for 2 months. The patients whose parents were not willing to the conservative treatment underwent circumcision.

RESULTS

Of the 47 patients, 23 boys with an average age of 16.65 ± 4.052 months (range 11-24 months) were given 0.025 % betamethasone cream, whereas the remaining 24 boys in control group with an average age of 18.42 ± 5.030 months (range 10-24 months) were instructed to apply with 0.05 % betamethasone valerate cream. Using unpaired t test, the age in both groups were comparable (p = 0.1932). There was a decrease in phimosis grade by the end of the therapeutic course in both groups. Further analysis using Mann-Whitney test revealed that the phimosis grade in the half-strength group (0.025 % strength) was significantly lower to the phimosis grade in the control (0.05 % betamethasone) group (p = 0.0003). There was no diversion from steroid application to circumcision or any side effects in the both groups.

CONCLUSIONS

0.025 % betamethasone valerate cream produced a clinical improvement. However, the half-strength formula was not effective as the conventional formula of 0.05 % betamethasone valerate cream.

Phimosis in children

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 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.

Local steroid therapy as the first-line treatment for boys with symptomatic phimosis - a long-term prospective study

AIM

Phimosis is a common paediatric urological disorder and often necessitates circumcision. We prospectively evaluated local steroid therapy (LST) as the first choice therapy for such children.

METHODS

Two hundred and sixty symptomatic boys up to 15 years of age (mean 34 months) with phimosis were started on betamethasone dipropionate (0.05%) application on gently stretched prepuce twice a day. Follow-up visits were arranged at the end of weeks 1, 2 and 4 and 6 months. Grade of phimosis was objectively graded.

RESULTS

Ninety one percent of the boys showed a successful outcome at the end of 4 weeks; 72% responded in first week, further 16% responded in week 2, and only 2.6% achieved alleviation of phimosis on further application of LST beyond 2 weeks. Fourty two (17.8%) boys had a recurrence of phimosis on a long-term follow-up (mean - 25.4 months, range 6-48 months); thus, the long-term success rate was 77%, while 60 (23%) boys underwent surgery.

CONCLUSION

Local steroid therapy is safe and successful in alleviating symptomatic tight foreskin in a large majority of children. The response can be seen as early as 1 week; most of the children respond by week 2 and continuing therapy further may not be very effective.

Preputial adhesions--a misunderstood entity

OBJECTIVE

To assess the trends and outcomes in referrals of 'phimosis for circumcision' to a tertiary care pediatric surgical department.

METHODS

This is a prospective study of 100 consecutive children of presumed phimosis referred for circumcision. They were assessed and classified by the senior author as having either preputial adhesions or phimosis. The patients in the former group underwent outpatient preputial adhesiolysis while those in the latter group were offered circumcision primarily. All were followed up till resolution.

RESULTS

All 100 were referred with a non-retractile prepuce and an additional reason - preputial ballooning at voiding, dysuria or suspect UTI. Eight (mean age -58 months, referred for preputial ballooning at voiding -6/8 and dysuria -2/8) had phimosis and were primarily offered circumcision. The remaining 92 (mean age - 22 months, referred for preputial ballooning at voiding -52/92, dysuria -28/92 and suspect UTI -12/92) had preputial adhesions. In the latter group, none has a documented urinary infection on specific investigations. These 92 underwent outpatient preputial adhesiolysis. Seventy three (79 %) required a single sitting, 11 (12%) required 2 -4 sittings and 4(4.5%) required 5-8 sittings over a follow up period of 1 -24 months (median -3 weeks). 4/92(4.5%) were deemed non-responders to adhesiolysis and were circumcised later.

CONCLUSION

The majority of children referred with 'phimosis for circumcision' to this tertiary pediatric surgical centre were actually physiologic preputial adhesions that were managed with outpatient preputial adhesiolysis. This study underscores a lack of awareness amongst referring primary care physicians regarding preputial adhesions and the potential for an erroneous diagnosis of phimosis translating into unnecessary circumcisions in many young boys.

An 18-month follow-up study after randomized treatment of phimosis in boys with topical steroid versus placebo

OBJECTIVE

To evaluate the treatment of phimosis using topical steroid.

MATERIAL AND METHODS

This was a follow-up study after a prospective, randomized, double-blind study. A total of 137 boys with phimosis were randomly assigned to either betamethasone treatment or placebo for 4 weeks, with application of the cream twice daily. Non-responders to treatment were offered steroid treatment for a further 4 weeks. All patients were invited to a follow-up examination after 18 months.

RESULTS

The mean pre-treatment phimosis grades in the steroid and control groups were 5.08+/-0.66 and 4.97+/-0.70, respectively. At the 4-week follow-up, 49 boys (74%) in the steroid group were cured, compared to only 31 (44%) in the control group. Fourteen boys were circumcised after another 4 weeks of treatment; 43 of the remaining 57 boys (17 in the steroid group; 40 in the control group) had been cured. After a total of 92 boys took part in the 18-month follow-up study: 79 had been cured and 13 had suffered a relapse. Twenty-six patients did not took part in the follow-up investigation. No side-effects were noted.

CONCLUSIONS

When treatment is necessary for phimosis, we recommend application of topical steroid as first-line treatment because surgery can then be avoided in 85% of cases. This first randomized, double-blind, follow-up study shows that the treatment effect persists for at least 18 months.

Y-V plasty of the foreskin as an alternative to circumcision for surgical treatment of phimosis during childhood

PURPOSE

To evaluate the result of Y-V preputioplasty and to compare this with an earlier technique of prepuce-sparing phimosis treatment.

MATERIALS AND METHODS

A total of 65 boys were treated surgically for phimosis without removing the foreskin. Indications were the failure of conservative ointment treatment, congenital uropathies (to prevent infections and to make proper cleaning of the glans and the inner preputium possible to ensure clean urine sampling), recurrent balanitis or painful ballooning of the prepuce, and/or the need for urethral instrumentation. Forty-seven patients were treated with one or two Y-V plasties to widen the narrow preputial ring; 18 were treated using transverse closure of longitudinal incisions of the narrow preputial ring.

RESULTS

Of the 47 Y-V plasties, two patients had recurring complaints and needed further treatment (4.3%), and of the 18 patients treated by transversely closed longitudinal incisions, two patients had recurring complaints (11%). Recurrences occurred regardless of age and premedication with topical therapy. Cosmesis was considered to be excellent in all cases of Y-V plasty. Few patients complained about skin tags after longitudinal incisions.

CONCLUSION

Y-V plasty of the preputial skin as an alternative to circumcision in the treatment of phimosis has good functional and cosmetic results. It is a minor operation with less impact on the penis than partial or total circumcision. The cosmetic results are superior to those after transversely closed longitudinal incisions.

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

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.

Topical hydrocortisone and physiotherapy for nonretractile physiologic phimosis in infants

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.

Décalottage ou circoncision : quelle indication dans le phimosis ?

Phimosis remains a major question for mothers and induces a high number of consultations. However, large epidemiologic series have shown that congenital phimosis may disappear spontaneously in around 80% of cases with development and should'nt need any treatment before the age of five or six years old. Theses elements go against sociocultural habits which induce many circumcisions before the age of six. Corticoid treatment of phimosis seems to be very efficient to facilitate the disparition of phimosis. The aim of this literature review is to evaluate medical, socioeconomical and therapeutics aspects of phimosis. Based on these data, we recommend never to treat phimosis before the age of one year old, to wait as long as possible for spontaneous evolution of phimosis until the age of five years old, and, in case of non evolution of congenital phimosis or pathologic phimosis to use as first step treatment corticoid topics rather than surgical treatment.

Phimosis. Preputial plasty using transversal widening on the dorsal side with EMLA local anesthetic cream

BACKGROUND/PURPOSE

In the United States, the treatment of choice for the correction of phimosis is circumcision, whereas in European countries, the condition is usually treated by preputial plasty using Duhamel's method or modified versions. We report our experience in correcting phimosis by preputial plasty using transversal widening on the dorsal side with EMLA local anesthetic cream.

METHODS

Twenty-six patients with phimosis were operated on by preputial plasty, under local anesthesia with EMLA cream. A transversal incision is made on the dorsal side of the ring of prepuce, like 3 contiguous Ts, the middle one inverted with the long arm on the preputial mucosa side. The 2 small mucocutaneous flaps of the prepuce are separated and then sutured with interrupted stitches, thus transforming the incisions from T to V.

RESULTS

No postoperative complications were observed. At 1-year follow-up, the cosmetic and functional results were satisfactory.

CONCLUSIONS

The technique of preputial plasty that the authors present enlarges the stenotic ring of prepuce by a transversal widening on the dorsal side. The ring of prepuce obtained is wide and symmetrical on its dorsal and ventral sides and therefore cosmetically and functionally satisfactory. It is a good alternative to the more radical circumcision technique.

Neonatal Circumcision: A Review of the World’s Oldest and Most Controversial Operation

Untimely old, circumcision has elicited more controversy and war of words than any surgical procedure in history. Although previous claims of benefits like curing masturbation, gout, epilepsy, and even insanity were no doubt absurd, important research has shed light on real medical benefits of circumcision. In particular, the procedure has consistently shown to result in the decreased risk of debilitating and costly diseases such as HIV, cervical cancer, and infantile urinary tract infection. Because of advances in the understanding of the anatomy of the foreskin and pain conditioning in infants, prevailing attitudes have changed about anesthesia and analgesia during the procedure. This article objectively summarizes the bulk of significant medical literature over the last century to provide an accurate statement about what we know and what we do not know about neonatal circumcision, including its history, epidemiology, medical benefits, complications, contraindications, techniques, management for pain, and current controversies.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to describe the evolution of circumcision, to list the potential benefits of circumcision, to outline the various neonatal circumcision techniques, and to summarize the data on the use of analgesia for circumcision.

Urologic emergencies

Genitourinary emergencies are commonly seen in the emergency room, and the primary care physician plays a vital role in the initial evaluation and treatment of each. Although genitourinary trauma is rarely life threatening, it may be the cause of significant long-term morbidity. Key clinical indicators outlined in this article (eg, inability to urinate, gross hematuria) combined with judicious use of imaging help stage the injury and allow a safe and rational approach to treatment. The acute scrotum frequently presents a challenging problem to both the emergentologist and urologist. Although epididymitis may be managed nonoperatively, there should be no delay in exploring suspected testis torsion. The conditions of the penis outlined require urgent treatment to preserve potency (priapism) and restore normal function (eg, penile amputation). Acute urinary retention has a myriad of underlying etiologies, and treatment must be individualized. Urgent bladder decompression by urethral or suprapubic catheterization provides initial relief until urologic consultation is available.

Treatment of phimosis with topical steroids in 194 children

PURPOSE

Topical steroids have been advocated as an effective economical alternative to circumcision in boys with phimosis. We evaluated the effectiveness of topical steroid therapy as primary treatment in 194 patients with phimosis.

METHODS

Between January 1996 and November 2000, 228 boys 16 years old or younger were referred for consideration of circumcision. When intervention was determined to be necessary, a 6-week course of topical steroids was used as primary treatment. Efficacy of treatment was evaluated at 3 months from initiation of therapy.

RESULTS

Of the 228 patients 15 had such a mild degree of phimosis that no intervention was believed to be necessary, 19 were scheduled directly for circumcision due to cosmetic reasons, parent wishes, or severe phimosis with associated voiding problems and the remaining 194 received topical steroids as primary treatment. Of these 194 patients 25 had coexisting balanitis and 4 had a history of urinary tract infection. Conservative treatment was successful in 87%, 88% and 75% of patients with phimosis alone, coexisting balanitis and history of urinary tract infection, respectively. Overall, circumcision was avoided in 87% of patients treated with topical steroids.

CONCLUSION

Topical steroids are becoming the standard conservative measure for treating phimosis. Our study supports this trend, with an overall efficacy of 87%.

Diseases of the foreskin, penis, and urethra

Diseases of the foreskin, penis, and urethra are uncommon conditions that constitute a small percentage of emergency department visits. However, it is important that the emergency physician recognize and treat these conditions and understand which conditions require urologic consultation. Rapid and proper treatment in the emergency department can alleviate patient discomfort, increase patient satisfaction, and prevent future morbidity.

Conservative treatment of phimosis in children using a topical steroid

OBJECTIVES

From 1997 through 1998, we conducted a prospective study to evaluate the long-term outcome of using topical steroids in the treatment of childhood phimosis.

METHODS

Both the parents and their children were instructed to apply 0.05% betamethasone cream topically twice a day for 1 month and to retract the prepuce after the fifth day of treatment. Results were evaluated at the end of the treatment and 6 months later.

RESULTS

One hundred thirty-seven boys were evaluated. The median age was 5.4 years. At initial presentation, 61 boys had a phimotic but retractable prepuce, 37 had a nonretractable phimotic ring, and 39 had a pinpoint opening. Patients with a history of previous forcible foreskin retractions were considered to have secondary phimosis. By 6 months following treatment, 90% (124 children) had an easily retractable prepuce without a phimotic ring. No differences were seen in the response rate between those with primary and secondary phimosis. In all cases, the treatment was well tolerated without local or systemic side effects. All the patients with persistent or recurrent phimosis were found to be noncompliant with the suggested daily foreskin care.

CONCLUSIONS

Topical steroid for the treatment of phimosis is a safe, simple, and inexpensive procedure that avoids surgery and its associated risks. It is effective both in primary and in secondary phimosis. We emphasize the importance of proper and regular foreskin care and hypothesize on the mechanism of action of the steroids.

Medical management of phimosis in children: our experience with topical steroids

PURPOSE

Circumcision has traditionally been regarded as primary therapy for persistent phimosis in boys. Recently groups in Europe and Australia have advocated the use of topical steroids as conservative treatment in children. We report our experience with this approach.

MATERIALS AND METHODS

Between July 1997 and February 1998, 25 boys with a mean age of 8.3 years who presented to our clinic with phimosis were started on a topical steroid. After counseling the family regarding treatment options we prescribed a 1-month course of 0.05% betamethasone cream applied twice daily.

RESULTS

Of the 25 patients 24 completed the treatment and were evaluated. A total of 16 boys (67%) had a normal appearing foreskin that was easily retracted, while in the remaining 8 the outcome was unsuccessful and circumcision was scheduled.

CONCLUSIONS

Our study demonstrates that the application of topical steroids is a viable alternative for treating phimosis in children. Appropriate candidates for this therapy include boys older than 3 years who have persistent phimosis and no evidence of infection.

Medical management of phimosis in children: our experience with topical steroids

PURPOSE

Circumcision has traditionally been regarded as primary therapy for persistent phimosis in boys. Recently groups in Europe and Australia have advocated the use of topical steroids as conservative treatment in children. We report our experience with this approach.

MATERIALS AND METHODS

Between July 1997 and February 1998, 25 boys with a mean age of 8.3 years who presented to our clinic with phimosis were started on a topical steroid. After counseling the family regarding treatment options we prescribed a 1-month course of 0.05% betamethasone cream applied twice daily.

RESULTS

Of the 25 patients 24 completed the treatment and were evaluated. A total of 16 boys (67%) had a normal appearing foreskin that was easily retracted, while in the remaining 8 the outcome was unsuccessful and circumcision was scheduled.

CONCLUSIONS

Our study demonstrates that the application of topical steroids is a viable alternative for treating phimosis in children. Appropriate candidates for this therapy include boys older than 3 years who have persistent phimosis and no evidence of infection.