Page 3 - Canadian Urological Association guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants (Full Version)

dave et al

Fig 1. Pathological phimosis.

Treatment of physiological phimosis

Several observational studies and randomized trials have
investigated the role of topical steroids and preputial stretch- Fig 2. Balano-posthitis.
ing in resolving physiological phimosis. The key to success
with these protocols lies in differentiating physiological are rare and there was no suppression of the hypothalamic-
and true phimosis, active counselling and patient selec- pituitary-adrenal axis provided treatment is not prolonged
tion. Topical steroid aids by thinning the preputial skin and beyond eight weeks for each course. 17
obliterating the stratum corneum, which then allows gentle
retraction over time. Level 2–4 evidence

Level 1 evidence Zavras et al conducted a prospective study using a mildly
potent steroid, fluticasone propionate (0.05%), to achieve a
Letendre conducted a randomized, double-blind study com- 91% success rate in 1185 boys referred with a diagnosis of
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paring a two-month treatment course of emollient cream phimosis. Long-term success is maintained in over 75% of
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vs. 0.1% triamcinolone in boys 3‒12 years of age. At four the boys following initial success with steroid therapy. 19,20 Ku
months, 76% of those on triamcinolone cream responded et al noted that success rates were higher in boys <3 years
as compared to 39% in the placebo group (p=0.008), with of age (92%) compared to those ≥3 years (70%), which may
no complications. At one year followup, the success rate
in the steroid group had come down to 47%. In another
randomized controlled trial (RCT) comparing a moderate-
ly potent steroid mometasone to moisturizing cream, the
authors found a significantly better response rate of 88%
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at eight weeks compared to 52% in the placebo group.
In a randomized, double-blinded, placebo-controlled study
using betamethasone, Lund et al showed an initial 74% cure
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rate at four weeks’ followup. At 18 months, 14% showed
a relapse, but none required a circumcision. A lower suc-
cess rate of 52% was noted by Nobre et al in a RCT from
Brazil using 0.2% betamethasone-hyaluronidase cream in
boys 3‒10 years of age. 15
Success rates did not vary by steroid potency, as shown by
similar foreskin retraction rates using clobetasone (moderate-
ly potent steroid, success rate 77%) compared to betametha-
sone (highly potent steroid, success rate 81%). Side effects Fig 3. Lichen sclerosus of the foreskin.
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E78 CUAJ • February 2018 • Volume 12, Issue 2