© IMiD, Wydawnictwo Aluna Developmental Period Medicine, 2018;XXII,1

71

Deepa Makhija, Hemanshi Shah, Charu Tiwari, Pankaj Dwiwedi, Suraj Gandhi

OUTCOME OF TOPICAL STEROID APPLICATION

IN CHILDREN WITH NON!RETRACTILE PREPUCE
Departament of Pediatric Surgery, T.N.M.C., Mumbai, India

Abstract
True phimosis is overdiagnosed due to the failure to distinguish it from physiological phimosis, which
is a normal developmental non retractability of the foreskin. The non-retractile prepuce in children is
a cause of parental anxiety and concern. This leads to the majority of the children undergoing surgical
procedures. Pathological phimosis needs to be differentiated from physiologic phimosis to avoid
unnecessary circumcision. In recent years, topical steroid application use in cases of non-retractile
prepuce has shown a good success rate and is well accepted by the parents. It has low risks, is cost
effective and avoids anaesthetic and surgical complications.
This is an observational study of 100 children with non-retractile foreskin who were managed by local
application of topical steroid cream (0.1% Mometasone) over a period of 6 weeks. The non-retractibility
was classified according to Kikiro’s classification. These patients were analyzed on the basis of age at
presentation, complaints at the first presentation, grade of phimosis at first presentation (as per Kikiro’s
classification), results of the topical steroid application as assessed at 6 weeks after starting application
and after stopping of the steroid administered for 6 weeks. The results were analyzed on the basis of the
resolution of symptoms and the decrease in Kikiro’s grade. Those patients in whom there was no response
to treatment or who developed recurrence after stopping steroid treatment underwent circumcision. A
total of 19 patients required surgical intervention in the form of circumcision. The use of topical steroids
yields satisfactory results in patients with a non-retractile prepuce. It could be a first-line treatment for
management in such cases and is an effective alternative designed to avoid unnecessary circumcision.

Key words: phimosis, physiological, pathological, steroid, topical

DEV PERIOD MED. 2018;XXII,1:7174

INTRODUCTION with a peak in incidence at the age of 11 years, and is rarely

encountered before the age of 5 years [2]. With the advent of
Phimosis is the non-retraction of the prepuce. It is newer effective and safe medical and conservative techniques,
physiological in younger children due to adhesions between circumcision is gradually getting outmoded.
the prepuce and glans penis [1]. Most patients referred due In the 90’s, topical steroids were introduced as a
to phimosis are actually suffering from the physiological nonsurgical alternative for the treatment of phimosis3.
type of non-retractability. Physiological phimosis is widely Their potential advantages are: less trauma, lower cost,
prevalent in male newborns. However, the degree of avoidance of anaesthesia and surgical complications
preputial retractability increases with age and the stage like hemorrhage, pain and infection [3]. The success
of preputial separation varies greatly among individuals2. rates of steroids in phimosis as reported in the literature
It is termed pathologic when associated with local or ranges from 65% to almost 90% [3]. The aim of topical
urinary complaints attributed to the scarred prepuce. corticosteroid treatment is to reduce skin tightening
The difficulty in differentiating between physiological around the tip of the penis. This offers a relatively less
and pathological phimosis leads to undue concern and invasive treatment and may limit the need for surgery
anxiety among parents and unnecessary referrals. among the majority of boys [4].
In the past decades, the first line of treatment of non-
retractile prepuce was circumcision. This operative intervention
is not without adverse effects and has a large economic MATERIALS AND METHODS
impact. The only reasonable indication for circumcision, This is a retrospective observational study. With
i.e. a pathological phimosis, affects about 0.6% of boys, informed consent, we retrospectively analyzed the data
72 Deepa Makhija et al.

of consecutive 100 paediatric patients (age less than 12 of balanoposthesis/a history of recurrent urinary tract
years) who presented with a non-retractile prepuce at our infections were excluded from the study. At the first visit,
Paediatric Surgery Out Patient Department, a tertiary a clinical examination was performed and phimosis was
care centre, from August 2013 to February 2017. Patients evaluated according to the classification of Kikiros and
who had previously taken treatment or who had signs Woodward (Table I) [5]; (Figure 1 to Figure 6).

Table I. Grades Of Retractability Of The Foreskin According To Kikiros et al.

Grade Descripon
0 Full retracon, not ght behind glans, or easy retracon limited only by congenital adhesions to the glans
1 Full retracon of foreskin, ght behind the glans
2 Paral exposure of glans, prepuce (no congenital adhesions) liming factor
3 Paral retracon, meatus just visible
4 Slight retracon, but some distance between p and glans, i.e., neither meatus nor glans can be exposed
5 Absolutely no retracon

Fig. 1. Kikiros Grade 0. Fig. 4. Kikiros Grade 3.

Fig. 2. Kikiros Grade 1. Fig. 5. Kikiros Grade 4.

Fig. 3. Kikiros Grade 2. Fig. 6. Kikiros Grade 5.

 Outcome of topical steroid application in children with non-retractile prepuce 73

Technique for applicaon of the topical steroid phimosis exists when there is a failure to retract the
ointment penile foreskin which is secondary to distal scarring of
The use of the topical steroid ointment was explained the prepuce [8]. When applying gentle retraction to the
and taught to parents before the initiation of the treatment normal but non-retractable infant foreskin, the distal
at home. The parents were informed about the possible part of the foreskin puckers and the narrow portion
local side effects of the steroid ointment, such as striae, is proximal to the preputial tip. When the same gentle
pigmentation changes, telangiectasia, and hypertrichosis. retraction is applied to the foreskin with true phimosis, it
The technique involved a warm sitz bath for 20 minutes results in a cone-shaped foreskin with a fibrotic, circular
followed by the application of topical mometasone cream band forming the most distal and narrowest part of the
after the gentle retraction of the prepuce. No attempt prepuce [9]. Pathological phimosis results when there
was made to forcibly retract the prepuce, so as to avoid are adherences to the fibrotic foreskin ring that make it
splitting and bleeding of the foreskin. The application impossible to expose the glans penis [10]. This alteration
was done three times a day for a period of six weeks. hinders adequate penile hygiene that favors foreskin
No occlusive dressing was used. Patients were followed infections, repeated urinary infections, sexually transmitted
up every 15 days. diseases and, at adult age, penile carcinoma [10]. The
natural process of enlargement of the prepuce can suffer
Evaluaon of the retractability of the foreskin alterations when facing episodes of balanoposthitis. The
The patients were evaluated every 15 days for a traction of the preputial ring leads to the formation of
period of 6 weeks after treatment initiation by using a healing fibrosis and the impossibility to expose the
the classification of Kikiros and Woodward by a single glans [11].
pediatric surgeon. The response to topical steroid treatment Parents are often overtly anxious and concerned about
was defined as full retraction of the foreskin, i.e. Kikiros non retractability in their children. Most of these cases
retractability grade 0 or 1 (Table I). Recurrence was end up in surgical interventions in form of circumcision.
defined as the reappearance of non-retractibility on The operation of circumcision is not devoid of adverse
stopping of the steroid. The presence of any possible effects and moreover has a huge economic impact. In
local side effects of the steroid ointment was checked, order to avoid such surgeries, it is important to know
including striae, pigmentation changes, telangiectasia, about newer noninvasive, cheaper and safer treatment
and hypertrichosis. options.
Recently, i.e. in the past two decades, topical
corticosteroids have been proposed as an alternative
RESULTS to surgery for the treatment of phimosis. The clinical
A total of 100 patients were retrospectively analyzed. The treatment of phimosis with topical corticosteroids is a
mean age at presentation was 3.9 years with the range being simple procedure, presents low costs and risks, is well
1.5 years to 12 years. The most common complaints were accepted by the parents, has no major side effects and
inability to retract the prepuce, ballooning of the prepuce a good compliance to the treatment3. In this study, the
(77%) and difficulty in micturition (59%). Nineteen patients parent compliance was good and there were no side
had grade 4 phimosis at first presentation. Resolution effects.
of symptoms and complete response was seen in 84 Compared with placebo, corticosteroids significantly
patients (84%). Sixteen patients did not show response to increase the complete or partial clinical resolution of
treatment. The patients who had a successful resolution phimosis [4].Today circumcision is being reserved for
of phimosis at 6 weeks were followed up after stopping recurrent balanoposthitis, pathological phimosis with a
the steroid for 6 weeks. Recurrence of the symptoms non-retractile, scarred foreskin, persistent physiological
and non retractibility was seen in 3 patients. A total of phimosis that is not resolved by other means and Balanitis
19 patients required surgical intervention. Xerotica Obliterans [3].
Medium − to high-potency topical corticosteroids
are effective for phimosis. A variable number of topical
DISCUSSION steroids have been proposed for topical use in phimosis
It is necessary to differentiate between physiologic and like Triamcinolone, Hydrocortisone, Betamethasone,
pathologic phimosis in children to avoid unnecessary Clobetasone and Mometasone [3]. In this study, mometasone
operative interventions. In children, physiologic phimosis was used for topical application.The mechanism of the
is observed owing to adhesion between the inner foreskin action of topical steroids in resolving phimosis remains
and the glans penis [6]. At birth, approximately 96% of speculative and multifactorial [5]. The first mechanism is
all males are known to have a non-retractile foreskin [1]. related to an anti-inflammatory and immunosuppressive
At the end of the first year, the retraction of the penile effect regulated by glucocorticoid activity; this stimulates
foreskin behind the glanular sulcus is possible in about the transcription of anti-inflammatory genes and decreases
50% of boys; this increases to approximately 89% by the the transcription of inflammatory genes [6]. The humoral
age of 3 years [7]. The incidence of phimosis decreases factors involved in the inflammatory response and leukocyte
to about 8% by the age of 8 years to about 1% in males migration are inhibited. Glucocorticoids also interfere
aged 16-18 years [7]. with the function of endothelial cells, granulocytes, and
Physiologic phimosis consists of a pliant and unscarred fibroblasts [6]. The second mechanism of topical steroids
preputial orifice. On the other hand, true pathologic is related to a skin thinning effect caused by the inhibition
74 Deepa Makhija et al.

of collagen synthesis [6]. Glucocorticoids inhibit the Art. No.: CD008973. DOI: 10.1002/14651858.CD008973.
synthesis of hyaluronic acid, the main glycosaminoglycan pub2.
produced by fibroblasts; thus the dermal extracellular 5. Kikiros CS, Beasley SW, Woodward AA. The response
matrix is reduced and collagen and elastin fibers become of phimosis to local steroid application. Pediatr Surg
tightly packed and rearranged [6]. Int. 1993;8:329-332.
Varying results with success rates ranging from 67% 6. Lee C, Lee S.Effect of Topical Steroid (0.05% Clobetasol
to 95% have been reported [11]. Though side effects like Propionate) Treatment in Children with Severe Phimosis.
suppression of the hypothalamo-pituitary-adrenal axis Korean journal of urology 2013;54:624-630.
or cutaneous atrophy may occur; the doses used in the 7. Tekgül S, Riedmiller H, Dogan H et al. Guidelines on
topical treatment of phimosis do not lead to this type Paediatric Urology. Paediatric urology - update march
of complications. The success rate in this study was 81% 2013.
and there were no complications. 8. McGregor T, Pike J, Leonard M.Pathologic and physiologic
phimosis Approach to the phimotic foreskin. Can Fam
Physician 2007;53:445-448.
CONCLUSION 9. Howe R. Cost-effective Treatment of Phimosis.
The inability to retract the foreskin in a child may be Paediatrics.1998;102; e43.
physiologic or pathologic. For patients with physiological 10. Marques T, Sampaio F, Favorito L. Treatment of phimosis
phimosis, local hygiene and parental reassurance is with topical steroids and foreskin anatomy. Int Braz J Urol.
paramount. Topical steroid therapy accelerates the normal 2005;31:370-374.
developmental process in these boys who would otherwise 11. Favorito L, Balassiano C, Rosado J, Cardoso L, Costa W,
have been considered candidates for circumcision. Sampaio F. Structural analysis of the phimotic prepuce
in patients with failed topical treatment compared with
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Address for correspondence:

Hemanshi Shah
Department of Paediatric Surgery, T.N.M.C,
Mumbai, India
tel.: 02223027324.
e-mail: [email protected]