Topical steroid therapy for phimosis

Circumcision has been the traditional treatment for phimosis. Recent reports of medical management of phimosis with topical steroids quote success rates of 67%-95%. We present our results with topical steroid therapy for treatment of phimosis.

Retrospective review of 69 boys between the age of 3 and 13 years (average 7.4) who were referred to Urology clinic over a one year period (August 1999-2000) with phimosis. Boys without a distal preputial ring were excluded. A course of triamcinolone cream was prescribed and parents/patients were instructed to apply it to the preputial outlet twice daily for one month. Six weeks after treatment initiation patients were reassessed. Results were classified as follows: Full retraction (FR)-entire glans and coronal margin seen, Moderate retraction (MR)-proximal glans seen, residual preputial adhesions, Partial retraction (PR)-distal glans and meatus seen, and Failure (F)-no change. FR, MR, and PR were considered successful outcomes. Statistical analysis was performed with Splus software using the prop.test and ordinal logistic regression procedures.

Follow-up ranged from 1-12 months, and 8 patients were lost to follow-up. Of the remaining 61 boys, 82% (12 FR, 26 MR, 12 PR) were successfully managed with topical steroid (95% confidence interval: 69%-90%). Scarring on examination was observed to negatively impact outcome (92% versus 67%) and was statistically significant using ordinal logistic regression (Chi square test=4.48, p-value=0.034). Two boys with severe balanitis xerotica obliterans (BXO) and two boys with buried penis and penoscrotal webbing failed treatment and required surgery. There was an association noted between older age and poorer outcome but this was not statistically significant. There were no local or systemic side effects noted.

Local application of steroid cream to the phimotic foreskin may allow some degree of retraction and avert the need for circumcision. Although the length of follow-up is insufficient to decree ultimate success, topical steroid appears to be a safe and effective treatment for boys over three years of age with evidence of a tight preputial ring. Boys with severe BXO or buried penis and penoscrotal webbing should be considered primarily for surgery.