P.A. DEWAN, Tieu HC, Chieng BS
Phimosis: is circumcision necessary?
Urology Unit, Women's and Children's Hospital, and the Departments
of Surgery and Paediatrics, University of Adelaide, Adelaide, Australia.
J Paediatr Child Health 1996 Aug;32(4):285-9
Circumcision has been the traditional treatment for phimosis, but now
is not the only management option, the best of which appears to be
topical steroid application. Importantly, the literature suggests that
phimosis probably is over-diagnosed, indicating that a prospective,
randomized controlled study is needed to compare the non-circumcision
options. Such a study would require consensus on the diagnostic criteria
for phimosis; therefore, a more exacting definition would be needed
and is suggested. Despite the non-controlled data on medical treatment
of true phimosis, there seems little doubt that surgical intervention
is not needed for all male infants with adherence of the foreskin to
the glans, a non-retractable foreskin or, indeed, true phimosis.
... circumcision is the oldest and most performed surgical procedure
in the world.
The most common stated medical indication for circumcision is phimosis,
however, the definition of this condition is obscure in most publications.
Øster found that the prepuce is retractable in ... 99% at 17
years of age. (My Note: one of the repeated "misreadings" of Øster:)
Little is known or written about the aetology of true phimosis,
despite the supposed frequency varying from 4 to 10%.
In his text book in 1948 Winsbery-White defined phimosis as the
congenital or acquired narrowing of the preputial opening, characterised
by a non-retractable foreskin without adherence, which can lead to
retention of secretions .. irritation .. balanitis .. interference
with micturition ... pressure on the bladder, ureters and kidneys.
A more precise and practical guide to the difference between a
non-retractable and a phimotic foreskin is as follows, when the normal
but non-retractable infant foreskin is examined, attempted gentle retraction
results in the distal part of the foreskin pouting, and the narrow
portion is proximal to the tip of the prepuce (Fig 1). Forced retraction
of such a foreskin can result in splitting as is well demonstrated
in the figures presented by Stenram et al. In contrast true phimosis
produces a cone-shaped foreskin during the same gentle retraction manoeuvre,
with a fibrotic, circular band that forms the most distal and narrowest
part of the prepuce (Fig 2).
Confusion about the definition of true phimosis is highlighted
by the study of Griffiths and Frank, who found that of 128 boys with
a medical reason for referral to a paediatric urologist for circumcision,
only 30 had true phimosis (although they did not give an exacting definition).
(12) They suggested that ballooning and non-retracability is often
over-interpreted, in some cases, the referring practitioner may have
used the term "phimosis" to facilitate referral, thus further confusing
the debate on the appropriate management of phimosis.
Techniques of Phimosis Management
.... Steroid cream is a painless, less complicated and more economical
alternative to circumcision for the treatment of phimosis. Wright had
a success rate of 80% (89 of 111 boys) using a 0.05% betamethasone.
Kikiros et al. reported an improvement in 33 of 42 boys (78%) with
0.05% betamethasone, and in 18 of 21 boys (86%) with hydrocortisone,
but they considered that the betamethasone worked more quickly. Another
steroid cream, 0.05% clobetasol propionate, has also been used successfully
by Jorgersen and Svensson. ........
..... Observed recurrence of phimosis after topical steroid treatment
... makes it important to commence retraction of the foreskin a number
of times each day, once the phimosis has resolved.
... From the published results thus far 0.05% betamethasone appears
to be more effective than 1% hydrocortisone. It would appear that regular
retraction of the foreskin is necessary after initial success has been
achieved ... However, a double-bind randomized control study of different
steroids and placebo is needed to assess the relative effectiveness
of each of the steroid options. Long-term follow up is needed to assess
the recurrence risk, ...