PEDIATRIC UROLOGY

CONSERVATIVE TREATMENT OF PHIMOSIS IN CHILDREN

USING A TOPICAL STEROID
ANNA ORSOLA, JORGE CAFFARATTI, AND JOSE MARIA GARAT

ABSTRACT
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 presen-
tation, 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. UROLOGY 56: 307–310, 2000. © 2000, Elsevier Science Inc.

T he prepuce is a specialized, highly innervated,

junctional mucocutaneous tissue that forms
the anatomic covering of the glans penis.1 At birth,
it is not retractable because the inner epithelial sur-
face is fused to the glans; this normal anatomic
condition in infants is often mistaken as phimosis.
Within 2 to 3 years, the foreskin detaches from the
glans following the formation of keratinized
pearls.2 This, together with intermittent erections,
allows the foreskin to separate, resulting in a phys-
iologic retraction. In 80% to 90% of uncircumcised
boys, the foreskin can be retracted over the glans
by 3 years of age,3 although isolated adherent areas
in the coronal margin may persist.
Circumcision is not only one of the oldest and
more commonly performed surgical procedures,
but it is also a source of dilemma and controversy.4
From the Department of Pediatric Urology, Fundacio Puigvert,
Barcelona, Spain
Reprint requests: Anna Orsola, M.D., Department of Urology,
Children’s Hospital, Harvard Medical School, 300 Longwood Av-
enue (HU-216), Boston, MA 02115
Submitted: December 23, 1999, accepted (with revisions):
March 9, 2000
In countries such as the United States and Canada
and in communities such as the Jewish commu-
nity, it is frequently performed during the neonatal
period for prophylactic or religious reasons.5 In
contrast, about 80% of the world population does
not practice routine neonatal circumcision, and
the aesthetic of an uncircumcised phallus is ac-
cepted culturally.4
In uncircumcised males, adequate care and hy-
giene of the prepuce during childhood are of fun-
damental importance. In the absence of routine
care and hygiene, a pathologic phimosis can result
from a preputial ring becoming fibrotic, preventing
the foreskin from fully retracting.6 In cases of
pathologic phimosis, surgical correction is the
standard treatment. However, in recent years, the
topical application of steroids provides an alterna-
tive to the management of this disease.7 Herein, we
present our results of the treatment of pathologic
phimosis with topical steroids in a large group of
patients, of diverse age, and with long follow-up.
We hypothesize on the mechanism of action of
topical steroids, focusing on the importance of de-

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ALL RIGHTS RESERVED PII S0090-4295(00)00576-8 307
 TABLE I. Results at final follow-up (6 months) between primary and secondary (history of
previous forcible foreskin retractions) phimosis and grouped by age
Initial Presentation Age (No.
(No. of Cases) of Cases)
Primary (39) ⱕ5 yr (22)
⬎5 yr (17)
Secondary (98) ⱕ5 yr (30)
⬎5 yr (68)
Total (137)
KEY: NS ⫽ not significant.
Successful result was considered as a retractable prepuce without a ring. Unsuccessful result includes both partial result and failure (see text). No statistically significant
difference in outcome was seen when evaluating separately boys older or younger than 5 years.
veloping routine foreskin hygiene for long-term
satisfactory results.
PATIENTS AND METHODS
From 1997 through 1998 all boys referred to our outpatient
clinic for surgical treatment of phimosis and who were con-
sidered to have a phimotic foreskin were offered topical treat-
ment with steroids. Phimosis was defined as the presence of a
constrictive preputial ring that resulted in a cone-shaped fore-
skin.8 None of the patients had previously undergone a cir-
cumcision. Those boys with signs of balanitis or balanitis xe-
rotica obliterans (BXO) were excluded. The types of phimosis
were classified as (1) retractable when a tight and constricting
phimotic ring existed, but it did not completely prevent the
retraction of the foreskin; (2) nonretractable when the ring
prevented the retraction of the foreskin, but the external ure-
thral meatus was exposed; and (3) pinpoint when the foreskin
was so constricted that the meatus could not be visualized.
Preputial hygiene habits and previous history of forcible re-
tractions were assessed; patients with a previous history of
forcible foreskin retractions were considered to have second-
ary phimosis.
Both the parents and the patients (when they were old
enough to understand) were instructed to apply a thin layer of
0.05% betamethasone cream on the prepuce twice a day (in
the morning and evening) for 4 weeks. After the fifth day of
treatment, they were asked to gently retract the foreskin sev-
eral times after applying the cream. They were also encour-
aged to retract the foreskin when they voided and during their
daily bath. The importance of complying with these care mea-
sures was strongly emphasized. Patients were evaluated after 5
weeks and at 6 months. The outcome was defined as (1) a
success if the prepuce was retractable and was without a ring;
(2) a partial response when both the physician and the parents
noted that there was a subjective improvement but not a com-
plete disappearance of the ring; and (3) a failure if a constric-
tive ring persisted. Boys who had a partial response or a failure
underwent a second course of topical treatment after discon-
tinuing its usage for 1 month. Results for primary and second-
ary phimosis and in different age groups or type of phimosis at
presentation were analyzed with the use of the chi-square test.
RESULTS
One hundred fifty-one boys entered the study
and 137 were available for follow-up. During the
same period, 11 circumcisions were performed in
patients that did not enter the study for several
reasons (including rejection of topical treatment,
308
Successful Unsuccessful Statistical
Result (%) Result (%) Significance
21 (95.4) 1 (4.7)
NS (P ⬎0.05)
14 (82.3) 3 (17.6)
26 (86.6) 4 (13)
NS (P ⬎0.05)
63 (92.6) 5 (7.3)
124 (90.5) 13 (9.5)
suspicion of BXO, other associated surgeries, or
inability to perform the treatment). The ages of the
patients ranged between 13 months and 14 years,
with a median age of 5.4 years. At initial presenta-
tion, 61 patients had a retractable but phimotic
prepuce, 37 had a nonretractable prepuce, and 39
had a pinpoint prepuce. None of the patients prac-
ticed daily retraction of their foreskin prior to en-
tering the study, and 71% (98 of 137) were consid-
ered to have secondary phymosis.
Five weeks after enrolment, 82% (112 patients)
had a successful result, 12% (17 patients) had a
partial response, and 6% (8 patients) were consid-
ered failures; the latter 25 patients underwent a
second course of treatment. At 6 months of follow-
up, 90% (124 patients) had a retractable prepuce
without recurrence of phimosis: 110 after one
course of treatment and 14 after two courses. In the
remaining 13 patients (3 of them after an initial
success, 4 after initial partial response, and 6 after
initial failure), phimosis recurred or persisted. On
careful evaluation, all of these patients were found
to be noncompliant with the suggested daily fore-
skin care. They subsequently underwent circumci-
sion. The histopathologic study of the prepuce
showed nonspecific dermal fibrosis.
Success rate was similar for patients with pri-
mary or secondary phimosis and for the different
age groups (Table I). No differences in outcome
were found related to the appearance of the pre-
puce at initial evaluation (retractable, nonre-
tractable, or pinpoint prepuce) (Table II). In all
cases, the procedure was well tolerated without
evidence of atrophic skin changes as well as sys-
temic or local side effects because of steroid ab-
sorption. In general, boys older than 6 years per-
formed the retraction by themselves, and, in
younger boys, the retraction was done by the par-
ent.
COMMENT
Pathologic phimosis is a common problem
throughout the world. In Europe, Asia, South
UROLOGY 56 (2), 2000

TABLE II. Results at final follow-up (6
months) according to the appearance of
prepuce at initial evaluation
Type of Phimosis Good Result
(No. of Cases) (%)
Retractable (61) 55 (90.1)
Nonretractable (37) 33 (89)
Pinpoint (39) 36 (92.3)
Total (137) 124
We could not show significant differences in the results depending on the type of
phimosis at the beginning of the study (P ⬎0.05).
America, and Central America neonatal circumci-
sion is not routinely performed, thus childhood
phimosis is not rare. In addition, in the United
States and Canada the rates of neonatal circumci-
sion, estimated to be 60% to 90%,5 are declining.9
Thus, even in the United States and Canada, phi-
mosis is a commonly faced problem. Obviously,
one of the difficulties that arises when studying
phimosis is the lack of a clear definition and differ-
entiation between a pathologic phimosis and a
physiologic nonretractile foreskin.10 In our study,
nonretractable and pinpoint prepuces correspond
to type II and type I of the classification by Kayaba
et al.11 The cases classified as “retractable” phimo-
sis might not be considered pathologic by others
because of a potential for spontaneous resolution
with increasing age. However, all patients included
in our study were originally referred for circumci-
sion, they all had a constrictive ring for which they
had sought medical attention, and they would have
been considered candidates for circumcision if top-
ical therapy had not been offered.
In the treatment of childhood phimosis, surgical
correction has been for many years the standard. In
this age group, circumcision requires general anes-
thesia. Although circumcision is associated with a
low complication rate, potential problems, such as
bleeding, unaesthetic scar, or meatitis with meatal
stenosis, do occur.6 Surgical alternatives to circum-
cision, such as preputial plasty, also require anes-
thesia and have up to 4% recurrence rate.12 In re-
cent years, topical application of steroids has
provided an effective nonsurgical treatment for
phimosis,7 and this treatment is, at present, the
recommended management of phimosis by the
Australasian Association of Paediatric Surgeons.13
When evaluating costs, steroid creams are also the
most cost-effective treatment; $758 to $800 per
treatment compared with $2512 to $3241 for sur-
gery (either conventional circumcision or prepu-
tial plasty).14
Previous series using topical steroids for phimo-
sis have demonstrated a high success rate, ranging
UROLOGY 56 (2), 2000
from 67% to 95%.7,15–18 Our result of 90% success
rate is similar; however, to our knowledge, our re-
port has longer follow-up, allowing for assessment
of long-term outcome. Of importance, we did not
Unsuccessful find statistically significant differences in the re-
Result (%)
sponse rate when stratifying the patients on the
6 (9.8) basis of age or type of phimosis at presentation.
4 (10.8)
Moreover, we showed for the first time that the
3 (7.7)
treatment is equally beneficial when a previous his-
13
tory of forcible foreskin retractions (secondary
phimosis) is present. Of interest, we observed that
in most cases the response to topical steroid treat-
ment was durable at the 6-month follow-up. We
believe that both failure and recurrence rate are
clearly related to the discontinuation of regular
foreskin retraction and hygiene. This belief was
evident in cases in which the child had a successful
initial response but phimosis recurred when daily
retraction of the foreskin was discontinued. Fur-
thermore, in a study in which the parents were
instructed not to make any specific attempt at fore-
skin retraction, the success rate was lower, and,
because there was no follow-up after the first
month, the possible recurrence of phimosis was
not evaluated.19 These observations suggest that
topical steroids act temporarily in treating phimo-
sis, and it is the change of habits in the local han-
dling of the foreskin that is key to long-term suc-
cess.
In our study, the use of topical steroids in chil-
dren was safe, and signs of skin atrophy or systemic
absorption were not seen. None of the cases of
poor compliance were related to pain or irritation
secondary to the application of the steroid cream.
Although, theoretically, there might be a risk of
systemic effects, such as suppression of the hypo-
thalamic-pituitary-adrenal axis, this risk is low be-
cause the quantity of cream applied and the skin
surface to which it is applied are very small. To
avoid increased absorption, it was emphasized in
all cases to use small amounts of cream only in the
constrictive ring and not to use occlusive dress-
ings. Golubovic et al.18 demonstrated that topical
steroid treatment for phimosis did not significantly
change morning cortisol levels. In our series, 4
boys younger than 2 years of age were treated with
betamethasone cream without any local or sys-
temic side effects. For these patients, the families
were strongly advised of the potential risks and to
carefully monitor for signs of toxicity (eg, head-
aches, vomiting). Other studies similarly showed
no side effects in treating children younger than 4
years of age with topical steroids.18,19 The number
of children in this age group treated in these stud-
ies, however, is limited.
The main effect of betamethasone cream is likely
to be in its local anti-inflammatory activity. Al-
though not proven, we speculate that the mecha-
309
nism of action of topical steroids on the phimotic
ring is similar to that in the treatment of BXO (also
known as lichen sclerous et atrophicus or
LSA).20 –22 Even though the pathogenesis of BXO/
LSA and phimosis are probably different, they both
have mucocutaneous thinning and dermal fibrosis
on histology. With the use of clobetasol dipropi-
onate for treating LSA, Dahlman-Ghozlan et al.22
recently showed that its effect is most likely ex-
erted through restoring the balance of collagen
synthesis by the fibroblasts and thus improving the
preexisting epidermal atrophy. We suggest that in
phimosis, topical steroid treatment similarly im-
proves the elasticity of the foreskin. This improved
elasticity together with the moisturizing effect of
the cream allows the child to easily retract the pre-
puce and perform daily hygiene. These routine
care measures will help to prevent the recurrence
of phimosis.
Parents’ preference should play a role and when,
for whatever reason, they decide not to circumcise
a child in the newborn period, it remains the phy-
sician’s duty to educate them and provide them
with guidelines for foreskin care. In a child
younger than 1 year of age, it is adequate just to see
the meatus. Between the ages of 2 and 5 years, local
care should consist of careful retraction and clean-
ing during bathing with progressive exposure of
the glans.3 Forcible retraction should be avoided
because it causes pain and bleeding, contributing
to future adhesions and cicatrix formation that
might lead to phimosis.6 In our experience, non-
compliance to these measures is due to lack of
knowledge regarding the proper care of the fore-
skin.23 By complying with these care measures, it is
estimated that less than 1% of the infants will have
a foreskin problem later in life6 (with an incidence
of phimosis as low as 0.4 cases/1000 boys per year
and, cumulatively, 0.6% of boys affected by their
15th birthday24). We encourage fathers, whether
or not they are circumcised, to play a role in the
daily care of their child’s foreskin. We suggest that
the success of the nonsurgical management of phi-
mosis be initially due to the effect of the steroids on
the narrowed prepuce. Its success, however, will
eventually depend on acquiring the habit of gently
retracting the foreskin when voiding and during
bathing.
CONCLUSIONS
In summary, topical treatment of phimosis with
corticosteroids is a simple, safe, and economical
procedure. It obtains excellent results in diverse
age groups and is well accepted by parents despite
the fact that they have to play a more active role in
the care of the foreskin.
310
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UROLOGY 56 (2), 2000