P U T R I WA H Y U N I N G S I H

JURNAL READING
“EFFECTIVENESS OF DEXAMETHASONE AND HYALURONIDASE +
V A L E R AT E O F B E T H A M E TA S O N E A S S O C I AT E D W I T H P R E P U C I A L
M A S S A G E I N T H E T R E AT M E N T O F C H I L D P H I M O S I S ”
 The External Structure

The external structures of the male reproductive system are

the penis, and the scrotum

Penis —It has three parts: the root, which attaches to the wall
of the abdomen; the body, or shaft; and the glans, which is the
cone-shaped end of the penis. The glans, is covered with a loose
layer of skin called foreskin (prepuce).
THE PENIS

The opening of the urethra is the tube that

transports semen and urine, is at the tip of the glans
penis. Penis consists of 3 sinus cavities of erectile tissue:

A. 2 larger cavities: called corpus cavernosa

B. Corpus spongiosum, surrounds the urethra. If the
cavity is filled with blood, the penis becomes larger,
stiff and erect.
 THE PENIS

 The penis consists of three cylindrical carbohydrate

erectile tissue bodies covered by fibrous capsules, the
tunica albugenia.

 On the outside of the tunica albugenia there is a deep

penis fascia which forms a joint wrapper for the penile
corpus spongiosum and both penile corpus
cavernosum, the Buck’s fascia.
 THE PENIS

The penis is hung by ligaments including:

a. Penile fundiform ligament: a thick layer originating from the superficial fascia

and from the anterior abdominal wall above the pubis.

b. Penile suspensory ligament: in the form of triangular thread.

 THE PENIS

There are also a number of blood vessels in the penis. Penile blood vessels
include:

a. Internal pudendal artery: a branch of the hypogastric artery that supplies

blood to the cavernous chamber.

b. Penile deep arteries: branches of the penile dorsalis arteries, branching open
directly into the cavernous chamber. This capillary branch will supply blood to the
cavernous trabecular space and be returned to the veins in the dorsum to form
the dorsal penis veins through the superior surface of the corpora and then join
with the others.
THE PENIS

Nerves in the penis: Is a branch

of the pudendal nerve
 THE SCROTUM

• The scrotum contains three major (paired) structures:

Testis – the site of sperm production.
Epididymis –It functions as a storage reservoir for sperm.
Spermatic cord – a collection of muscle fibres, vessels, nerves and ducts that run to and from the testes.
• The scrotum has a protective function and acts as a climate control system for the testes.
• Scrotum is, in the form of pouches consisting of skin
without fat, has a little muscle tissue that is in a wrapper
called tunica vaginalis.

• A pair of these scrotums hang at the base of the pelvis.

• On the front of the scrotum there is a penis and behind it

there is the anus.

• The scrotum is dorsokaudal to the penis and caudal to

symphysis pubica.
 Neurovascular Supply
Vessels
The scrotum receives arterial supply from the anterior and posterior scrotal arteries. The anterior scrotal artery
arises from the external pudendal artery, while the posterior is derived from the The scrotal veins follow the major
arteries, draining into the external pudendal veins.
Nerves
1. Genital ramus of the genitofemoral nerve (L1, L2) which
branches into sensory branches on the ventral and lateral
scrotum surfaces.

2. Ilioinguinal nerve branch (L1), also for the ventral scrotum

surface.

3. Perineal ramus of the pudendal nerve (S2-S4) for the dorsal

scrotum surface.

4. Perineal ramus of the posterior cutaneus femoris nerve (S2, S3)

for the surface of the caudal scrotum.
• From the kidneys urine flows down the ureters to the bladder propelled by peristaltic
contraction of smooth muscle.
• The bladder is a balloon-like bag of smooth muscle = detrussor muscle, contraction
of which empties bladder during micturition.
• Bladder can hold 250 - 400ml
PHIMOSIS

DEFINITION
Phimosis is a condition in which the
prepuce cannot be retracted over
the glans penis.
 PHIMOSIS

• Pathologic phimosis would result from inflammatory

or traumatic injury to the prepuce resulting in an
acquired inelastic scar that prevents retraction.

• Physiologic phimosis is common in male patients up

to 3 years of age, but often extends into older age
groups.
CAUSES AND RISK FACTORS

It is most likely to occur in older boys with:

1. Repeated urinary tract infection
2. Foreskin infection
3. Repeated rough handling of the foreskin
4. Foreskin trauma

In adults, risk factors for phimosis include sexually

transmitted infections, uncircumcised males
 PATOPHYSIOLOGY

• Physiological phimosis is the result of

adhesion of the epithelial layers between the
inner prepuce and the glans penis.

• This adhesion will spontaneously disappear

during erection and intermittent retraction of
the prepuce

• So as we age (puberty) physiological phimosis

will disappear.
 PATOPHYSIOLOGY
• Poor hygiene in the area around the penis that leads to scar
formation in the prepuce orificium, can lead to
pathological phimosis.

• Forced retraction of the prepuce can also result in small

injuries to the prepuce orificio which can lead to
scarring and continued phimosis.

• Adults who have not been circumcised have the risk of

secondary phimosis due to loss of skin elasticity.
MANIFESTATION
1. The penis is enlarged and swollen due to a pile of urine ("balloning")

2. Sometimes complaints can be the tip of the pubic bulging when you start urinating which then disappears after urinating.

This is caused by the urine coming out first being held in a room confined by the skin at the tip of the penis before exiting

through the narrow mouth.

3. Usually babies cry and push when urinating because of pain.

MANIFESTATION

4. Penile skin can not be pulled towards the base when it will be cleaned

5. Urine comes out not smoothly. Sometimes it drips and sometimes it radiates in unexpected directions.

6. Can also be accompanied by fever

7. Irritation of the penis.

Classification according to Kikiros et al:
Score 1: full retraction of the prepuce, with a narrow section
behind the glans
Score 2: glans can be seen partially
Score 3: partial retraction: meatus can be seen
Score 4: slight retraction, but no meat or glans can be seen
Score 5: prepuce cannot be retracted at all
THERAPY

• Circumcision
• Manual Retraction Therapy (not
recomended)
• Topical Steroid Therapy
a low potential steroid, hydrocortisone, two
studies showed satisfactory success rates of
86-90%.
 ABSTRACT
Introduction: The phimosis condition is characterized by the inability to retract the foreskin on the
glans, making it impossible to expose them. Surgical treatment, although effective, has been questioned by
the risk to which the patient is exposed.

Goals: To compare the effectiveness of Dexamethasone and Hyaluronidase + Betamethasone Valerate

associated with preputial massage in the treatment of infantile phimosis, the degree of regression of
phimosis, the time needed to achieve complete effi cacy, possible adverse reactions, long-term outcome
and parental adherence to treatment in children attending a specialized service in Blumenau, Santa
Catarina.
 ABSTRACT

• Materials and methods: Controlled clinical trial, quantitative, non-blind, prospective and randomized
sample analysis through the analysis of 523 patients.

• Results: After 1 month of treatment, 435 patients presented some degree of regression and 63 children were
referred to surgery. The success rate in this period was 45.8% in boys who were taking Hyaluronidase +
Betamethasone Valerate and 49.8% in those who used Dexamethasone. In the late evaluation, 398 children reached
grade 0, and 213 used Hyaluronidase + Betamethasone Valerate and 185, Dexamethasone; 39 patients were
referred to the postectomy.Adherence to treatment was similar in both groups.
 ABSTRACT

Conclusion: Both topical corticosteroids were effective in the resolution of phimosis. However, in
the evaluation after the fi rst month and in the regression, Dexamethasone proved to be more
effective. The time to resolution of the condition was similar for both. The surgical procedure was
taken when there was no clinical improvement. No adverse effects were reported in both groups.
INTRODUCTION
The term phimosis has a Greek origin - phimosis - and is defined as the inability to retract the
foreskin on the glans, making it impossible to expose them either by preputial meatus stenosis or by
bucklings-preputial adhesions [1]

The foreskin formation occurs in the third week of life of the embryo, a period in which there is
the development of a skin fold from the base of the glans.

In neonates and during the first years of life, the glans and foreskin are not completely separated
[3]. This natural adhesion characterizes physiological phimosis, which in most cases does not
require treatment
INTRODUCTION
• Pathological or true phimosis occurs when there is persistence of the buckano-preputial
adhesions and it is possible to observe a βibrous ring around the preputial oriβice - due to a
cicatricial process - that prevents retraction.

• The surgical procedure, besides costing more than double the topical treatment, poses
considerable risks to the patient, since general anesthesia is necessary and complications reach
34%.

• The most frequent complication: hemorrhage, pain, infection, urinary obstruction, bad esthetic
results and other rarer ones: urethral meatitis and preputial ring stenosis, and even amputation of
the glans.
INTRODUCTION
• Clinical treatment, based on the use of topical corticoste-roids for phimosis, poses no risk to
patients and there is no signiβicant side-effect or systemic effec

• After the period of drug therapy, the need to continue the massage and maintain good local
hygiene is stressed, in order to avoid relapses

• Low cost and promising results, with success rates of up to 95%, make the choice by this
plausible therapeutic method before the immediate surgical indication
INTRODUCTION
• In the public service of our county, the ointment with topical corticosteroid supplied free of
charge is Dexamethasone acetate 0.1% cream

• While the cost of the combination of Betamethasone 2.5 mg / g and Hyaluronidase 150 utr / g
for specific use in the treatment of phimosis ranges from R$ 75.65 to R$ 102.90.
GOALS

To compare the effectiveness of Dexamethasone and Hyaluronidase + Betamethasone

Valerate associated with preputial massage in the treatment of infantile phimosis

+ The degree of regression of phimosis, the time needed to achieve complete

efficacy, possible adverse reactions, long-term outcome and parental
adherence.
.
MATERIAL AND METHOD
• Design: Controlled clinical trial, quantitative, non-blind, prospective and
randomized sample analysis

• Sample : A randomized sample of 523 patients, aged 1 to 13 years (mean age of

5.1 years) selected between June and December 2017, with a diagnosis of
phimosis of the pediatric urology

• Place : outpatient clinic in the city of Blumenau , Santa Catarina Brazil.

• Total Sampel: 523

MATERIAL AND METHOD
At the βirst visit, a clinical examination was performed to conβirm the diagnosis of
phimosis by a pediatric urologist, who categorized the phimosis according to the
classiβication of Kikiros and Woodward.

Patients were randomly divided into two groups

The application of the creams and the realization of the preputial massage were
explained and demonstrated to the parents, and both creams were provided free of
charge to all.

Twenty-three patients were excluded from the evaluation, being: 4 for recurrent
urinary tract infection and 19 for bala-noposthitis.

Group 1: use of Betamethasone cream 2.5 mg / g and Hyaluronidase 150 utr / g associated with preputial massage.
Group 2: use of Dexamethasone acetate 0.1% cream associated with preputial massage
Classification according to Kikiros et al:
Score 1: full retraction of the prepuce, with a narrow section behind the glans
Score 2: glans can be seen partially
Score 3: partial retraction: meatus can be seen
Score 4: slight retraction, but no meat or glans can be seen
Score 5: prepuce cannot be retracted at all
MATERIAL AND METHOD
The initial treatment lasted 1 month and the creams were applied 2 times a day, associated with the preputial
massage, being one of the times after the bath and the second time at any time of day

After 1 month reassessed using the Kikiros and Woodward classification by the same pediatric urologist of the first
consultation  The response to treatment was defined by the degree of preputial retratillation

Patients who did not reach grade 0, were submitted to more cycles, ranging from 1 to 2 months, according to
the initial response.

All patients who showed partial or total improvement were instructed to maintain massage and hy-giene, as well as to
return to the clinic for a third visit after the 6-month to 1-year interval from the start of treatment to evaluate the long-
term response term.
MATERIAL AND METHOD
Those who did not obtain any response to the clinical treatment were referred for surgery.

Those who remained at grade 0 were instructed to maintain hygiene and massage. Those who relapsed, were
referred to surgery - postectomy

In the third evaluation, it was veriβied if the patients maintained the preputial aperture. Those who remained
at grade 0 were instructed to maintain hygiene and massage. Those who relapsed, were referred to surgery

Adherence to treatment by the parents was analyzed through the report of the discontinuity of the massage,
in the βirst month and in the third medical evaluation
 STATISTIC ANALYSIS
1. The data were organized into descriptive tables containing absolute, relative frequencies
and proportion estimates in the form of 95% confidence intervals.
2. The association between qualitative variables was performed through the Qui-square test of
independence.
3. In the comparison between the means of the time the Student’s Test was used for
independent samples.
4. In the comparison of independent proportions, the Independent Proportions Test was used.
5. In all cases, the statistical significance was considered if the P value <0.05
DISCUSSION
 RESULT
• A total of 500 children, of whom 275
were on Hyaluronidase + Betamethasone
Valerate and 225 on Dexamethasone
(Table 1), were evaluated.

• Regarding the phimosis classiβication,

before the start of treatment: 93 boys had
grade 1; 123, grade 2; 94, grade 3;
142,grade 4 and 48, grade 5.
 RESULT AFTER 1 MONTH THERAPY

1. After 1 month of treatment, there was some degree of regression in 435 patients. On average, half of the patients ineach group reached grade
0. The regression to grade 0 after 1 month of initiation of treatment was better when the type of ointment was Dexamethasone, since it
presented higher frequencies close to grade 0 (Table 3).

2. Sixty-three patients were referred to surgery, mainly due the discontinuity of the preputial massage (Table 4).
RESULT

1. At the third medical evaluation, after 6 months to 1

year of initiation of treatment, a total of 398
children with grade 0 (Table 5) were obtained.

2. There was recurrence of phimosis in 39 cases and

as a cause the discontinuity of opening the prepuce
daily in the bath as directed was observed.
Therefore, the surgery for these patients was
surgery (Table 6).
RESULT
1. Regarding adherence to treatment, it was concluded that

in 62 cases there was no expected collaboration in the

βirst month of treatment. On the other hand, in the long

term, 39 patients did not perform the treatment in the

proposed way (Table 7).

2. It was found that the mean time to efβicacy of both

creams was very similar, approximately 6 weeks (Table 8)

No adverse reactions were reported by any patient and / or responsible

due to the use of any of the creams during the study period
DISCUSSION
DISCUSSION
1. As a consequence of its simplicity, of not having signiβicant side effects and having a high
success rate, it has become the βirst choice for the treatment of this pathology.

2. The postectomy surgery triggers stress and anxiety in patients, and these experiences are
threat to their physical integrity [10,11]

3. Although it is very effective, it poses considerable risks, since general anesthesia is

necessary and complications reach 34%, being the most recurrent ones: hemorrhage,
urethral meatitis and preputial ring stenosis, and even amputation of the glans [5].
DISCUSSION
1. Some authors propose that circumcision, without therapeutic purposes, is an unethical act,
since the procedure constitutes mutilation of part of the body without the consent of the
child [12].

2. It is suggested that the patient should be considered the most appropriate person to decide
whether or not to undergo surgery, analyzing whether the risks of remaining with the foreskin
are greater than the risks of operative complications [13].
RESEARCH WITH SIMILAR RESULTS
• In a systematic review of the efβicacy of clinical steroid treatment by Liu et al. [14], 1669
participants were evaluated,of whom 1093 were on steroid therapy and 576 were control
subjects
– It was observed that 84.26% of the cases under analysis reached the degree 0 or 1 of phimosis, which
supports the fact that the drug is an effective and safe method to treatinfantile phimosis.
– The study also showed that topical steroid use is advantageous when compared to placebo because of
its anti-inβlammatory and immunosuppressive action [14]
– The medication interacts with speciβic receptors and produces anti-inβlammatory substances, in
addition to inhibiting pro-inβlammatory drugs, such as collagen I and III synthesis.
RESEARCH WITH SIMILAR RESULTS
• Chu (1999) and Munsour (1999) found that steroids can cause thinning of the skin and improve preputial
elasticity, reducing the production of hyaluronic acid, which had an anti-proliferative effect on the epidermis

• n China [17] and Italy [18], it was found that 74% and 72%, respectively, ofchildren receiving betamethasone
had a complete response at the end of the first month of treatment.

• A similar analysis was performed by Lund et al (2005). After 18 months, it was found that 86% of the boys
who used topical corticosteroids were cured.
 CRITICAL
APPRAISAL
PICO ANALYSIS
ITEM ANSWER

Patien/ Child with phimosis

Problem

Intervention Dexametason associated with prepucial massage

Comparasion Hyaluronidase + valerate of betamethasone associated with prepucial

massage
Outcome Effectiveness of the treatment

Conclusion: How is the effectiveness of dexamethasone compared with hyaluronidase +

valerate given with a prepucial massage against phimosis in children?
1. DID THE TRIAL ADDRESS A CLEARLY
FOCUSED ISSUE?
Yes. The purpose of this study is explained in the abstract. Namely to compare the effectiveness
of Dexamethasone and Hyaluronidasei + Betamethasone valerate associated with preputial
massage against phimosis in children.
2. WAS THE ASSIGNMENT OF PATIENTS
TREATMENTS RANDOMIZED?
Yes. 523 participants were randomized and placed into two groups.
Group 1: use of Betamethasone cream 2.5 mg / g and Hyaluronidase 150 utr / g associated with preputial massage.

Group 2: use of Dexamethasone acetate 0.1% cream associated with preputial massage
3. WERE PATIENTS, HEALTH WORKERS
DAN STUDY PERSONNEL BLINDED?
No. In this research, participants, health workers and researchers
were not blinded.
4. WERE THE GROUP SIMILIAR AT THE
START TRIAL?
Yes. In this study, no significant differences
were obtained from the phimosis grade or
therapy given between the two groups. So
at the start trial, the two groups are
similiar.
5. ASIDE FROM THE EXPERIMENTAL
INTERVENTION, WERE THE GROUPS TREATED
EQUALLY?
Yes. Participants were divided into 2 groups with different exposures but they
remained the same ie assessing the level of regression, degree of recurrence, and side
effects that occurred in each patient.
6. WERE ALL PATIENTS WHO ENTERED THE
TRIAL PROPERLY ACCOUNTED FOR AT ITS
CONCLUSION?

No. At the beginning of the study, there were 523 participants. However, the final
calculation became 500 participants. Twenty-three patients were excluded from
evaluation, becoming: 4 for recurrent urinary tract infections and 19 for
balanoposthitis.
7. HOW LARGE WAS THE TREATMENT
EFFECT?
1. After 1 month of treatment, regression occurred
in 435 patients. On average, half of the patients in
each group reached grade 0 (Table 3).

2. Regression to level 0 after 1 month of treatment

was higher in the Dexamethasone ointment type,
because it showed a higher frequency approaching
level 0.
8. HOW PRECISE WAS THE ESTIMATE
OF TREATMENT EFFECT?
Unclear. In this study, no clear estimation
of the effects of dexamethasone or
betamethasone with hyaluronate was given.
However, within 6 months to 1 year there is a
regression to 0 degrees from both
dexamethasone and betamethasone groups
9. CAN THE RESULT APPLIED IN YOUR
CONTEXT (OR THE LOCAL POPULATION)?

Yes. The results of this study can be applied

to the Indonesian population for patients who
are not ready for surgery. However, further
research needs to be done on the value of
Odds Ratio and Risk Ratio on research on the
use of topical steroids in phimosis patients.
10. ARE THE BENEFITS WORTH THE
HARMS AND COSTS?
Yes. Dexamethasone and betamethasone ointments are quite easy to get in Indonesia.
Both prices are also quite affordable. In this study there were no side effects from the
use of topical steroids in phimosis patients.
 KESIMPULAN

1. Apakah penelitian ini Valid? Yes

2. Apakah penelitian ini penting/ important? Yes
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