Betamethasone dipropionate circumcision.Betamethasone Cream Phimosis

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- The efficacy of topical betamethasone for treating phimosis: a comparison of two treatment regimens

 

A declining circumcision rate means more and more parents need to be educated about care of their son's foreskin and more pediatricians need to be prepared to manage problems associated with an uncircumcised penis.

Although still very common, routine neonatal circumcision has been declining in prevalence in the United States in recent years. In this article, we do not address in depth the pros and cons of neonatal circumcision. Rather, we focus on the development and routine care of the normal, uncircumcised penis, as well as management of common associated problems.

Circumcision has been a controversial topic in both professional and lay circles for a number of years. The procedure has historically been performed for cultural, religious, and medical reasons. Opposition to routine neonatal circumcision has been vocal, and medical indications have been revisited over the past three decades. The American Academy of Pediatrics AAP has issued several policy statements during this period, the most recent in Current AAP recommendations state that while there are potential medical benefits of newborn male circumcision, the data are not sufficient to recommend routine neonatal circumcision.

At eight weeks' gestation, the skin of the body of the penis begins growing forward over the developing glans penis, initially as a ridge of thickened epidermis. The prepuce grows more quickly dorsally than ventrally, where full development depends on final formation of the glanular urethra. This explains why the foreskin is usually deficient ventrally in cases of hypospadias. If all proceeds normally, the prepuce is complete by 16 weeks' gestation.

The squamous epithelial lining of the inner prepuce is contiguous with the glans at this stage, so that preputial adhesions are a normal part of development, not a pathologic state. The rupture of these cysts allows progressive separation of the inner prepuce from the glans. Penile growth, along with intermittent erection, aids in the process that eventually completely separates the prepuce from the glans to form the preputial space.

This process begins late in gestation and proceeds at varying rates during childhood; therefore, the age when the prepuce is completely retractable also varies. In contrast, some boys will not have complete separation of the prepuce circumferentially beyond the corona until accelerated penile growth occurs at puberty. Parents of a newly circumcised boy receive instructions on care of the infant's penis, but parents whose son is not circumcised typically receive no such advice. As a result, many parents have misconceptions.

The most common misconception encountered in our practice is that the foreskin is completely retractable early in life and that complete retraction is necessary to keep the penis clean and prevent infection.

Many consults are prompted by parental concerns about the presence of congenital adhesions or by questions about the need for circumcision to prevent irritation and infection.

Many parents and physicians are unaware that preputial adhesions are normal and that they resolve on their own at an individual pace. Parents should be educated to avoid forcible retraction of the prepuce; the tearing that may result could lead to fibrosis and subsequent true phimosis discussed later or pathologic adhesions, or both.

In the infant, washing the penis with a cloth and water is adequate to keep the penis clean. If a mild soap is used, the penis should be rinsed well to avoid irritation. However, we typically counsel parents to avoid using soap. Once preputial adhesions have separated naturally, typically around the age of toilet training, the foreskin will be retractable and should be retracted with routine bathing. After cleaning, it is helpful to retract the foreskin again to dry the glans and prevent irritation from moisture trapped under the foreskin.

Mild redness of the foreskin or glans is common, particularly in the infant and young child still in diapers, and usually requires only cleaning. Focal erythema may occur sporadically as preputial cysts break through adhesions to allow separation of the prepuce from the glans.

These whitish cysts are sometimes mistaken for pus due to infection, but they merely represent sterile collections of desquamated skin Figure 2. More significant dermatitis may require a barrier cream with zinc oxide.

Some physicians believe that the foreskin should be left alone until the child is old enough to retract it on his own. There is no consensus about the appropriate age to teach penile hygiene, including regular retraction of the foreskin. We recommend teaching the school-age child to retract and clean beneath the foreskin at least once a week as part of routine hygiene, whether complete retraction is possible or not. Others advocate waiting until puberty, when complete retraction is readily achieved.

Assessment at well-infant and well-child exams should address any concerns about the appearance of the genitalia. Retractability of the prepuce should be assessed by history as well as on examination. In the infant it is usually, but not always, possible to visualize the meatus Figure 3. Rarely, in cases of pathologic phimosis, the urinary stream may be blocked, causing ballooning of the prepuce with urination or deflection of the urinary stream.

As the child grows, the foreskin should gradually become more retractable. Trauma or infection of the glans balanitis can cause erythema and edema.

The term balanoposthitis refers to inflammation of the glans and prepuce. Purulent discharge from the thickened and erythematous preputial orifice is the usual sign Figure 4. Patients often complain of dysuria, making the distinction between balanoposthitis and true urinary tract infection difficult. A suprapubic tap can obtain a urine specimen directly from the bladder without the risk of preputial contamination, but is not commonly done.

Distinguishing between balanoposthitis and urinary tract infection is, therefore, often a matter of clinical judgment. Purulent drainage from the preputial orifice and preputial swelling and erythema are not usually seen with a urinary tract infection.

The common causative organisms of balanoposthitis are coliform, such as Escherichia coli or Proteus vulgaris, 3 so empiric antibacterial therapy would likely cover a diagnosis of either balanoposthitis or urinary tract infection. In caring for the uncircumcised male, it is necessary to differentiate between physiologic phimosis and pathologic phimosis.

Phimosis refers to a prepuce that is nonretractable, as is usually the case in the newborn. Physiologic phimosis is present in nearly all newborn males because of congenital adhesions of the prepuce to the glans proximal to the urethral meatus. As noted, in most infants retraction allows visualization of the urethral meatus but not of the remainder of the glans.

True, or pathologic, phimosis is defined as the presence of an abnormal ring of tissue, which prevents sufficient retraction of foreskin to allow visualization of the meatus. The fibrotic preputial ring, or cicatrix , of tissue is distal to the glans and prevents retraction and routine hygiene.

A cicatrix may form following scarring from forcible retraction or following episodes of balanoposthitis. Ballooning after infancy is less common and may represent pathologic phimosis. Pathologic phimosis has been traditionally treated surgically with circumcision.

Although circumcision is effective, it is not without complications, particularly in older infants and boys who must undergo general anesthesia. The risks include anesthetic complications, bleeding, infection, meatal stenosis, penile or urethral injury, discomfort, and possible psychological consequences.

These risks, as well as financial considerations, are all reasons to pursue nonsurgical alternatives to therapy. Parents often made a conscious decision not to circumcise their son and are reluctant to give consent for circumcision at a later age.

A retrospective review of boys with pathologic phimosis seen in our pediatric urology clinic in revealed 20 patients, age 8 months to 14 years mean, 5. A successful outcome was defined as resolution of the phimotic band allowing foreskin retraction proximal to the meatus. Eleven patients had a completely retractable foreskin, whereas six became partially retractable.

Often, a response was seen in less than two weeks. For this reason, we now recommend a four-week, rather than eight-week, course of therapy. Patients who were successfully treated have not had recurrence of phimosis. Two patients developed temporary paraphimosis in which the retracted prepuce becomes trapped proximal to the corona when their foreskins were left retracted, but these were easily reduced by the parents and no medical attention was needed.

No patient has had any apparent side effect from the topical steroid treatment. Three patients did not respond to therapy. The mean age of patients with fully retractable foreskins following therapy was 6. These findings correlate with the finding of a higher prevalence of glanular adhesions in younger patients. The efficacy results of our study correspond to those reported previously. The major variable accounting for differences in the efficacy rate between studies is the definition of successful outcome.

Some groups considered any result short of complete foreskin retractability a treatment failure. Our study chose to include partial retractions as success because adhesions of the foreskin to the glans are common in young boys, and resolve spontaneously. These proximal adhesions should not be considered a contributing factor to phimosis. The cost-effectiveness of therapy for phimosis has been reviewed, comparing medical and surgical interventions. Systemic absorption is enhanced by inflammation, use over a large surface area, prolonged use, and use of an occlusive dressing.

We, therefore, believe that betamethasone dipropionate can be used safely in small amounts for one or two months, despite lack of approval by the Food and Drug Administration for use in persons younger than 16 years.

Instructions for parents on treating phimosis with betamethasone dipropionate are provided in the "Guidelines for treating phimosis with steroid cream" box. The mechanism of effect of betamethasone dipropionate cream on the phimotic ring is thought to be local anti-inflammatory action. Betamethasone cream may improve the elasticity of the foreskin and, together with the moisturizing effect of the cream, allow for easier retractability for hygiene measures, thought to help prevent recurrence of acquired phimosis.

Whether moisturizing creams without an anti-inflammatory agent would have a similar efficacy is unknown. The acute condition paraphimosis develops when the prepuce is retracted and then trapped proximal to the corona, with subsequent edema, pain, and venous congestion. A tight band is created around the penile shaft and the prepuce cannot be returned to its normal position.

Immediate intervention is needed, beginning with manual reduction with gentle pressure. Four fingers from each hand are placed on each side of the trapped prepuce, and upward tension is applied while the two thumbs push the glans downward through the preputial opening. Paraphimosis may progress to the point where urgent urologic consultation is needed, and surgical intervention may be indicated.

Reduction under general anesthesia is almost always possible without need for a dorsal slit, and circumcision should be considered only for the unusual case of recurrent episodes. Urinary tract infection and acute balanoposthitis. Difficulty obtaining a urine specimen in the uncircumcised male makes it challenging to diagnose a urinary tract infection with certainty.

Uncircumcised boys have a higher incidence of urinary tract infection compared with circumcised boys younger than 5 years. Balanitis and balanoposthitis are infrequent problems in children and rarely lead to bacterial ascent in the urethra to initiate a true urinary tract infection.

Only in the most severe cases of infection accompanied by urinary retention is acute surgical intervention a dorsal slit required. An unrelated condition, balanitis xerotica obliterans BXO , also known as lichen sclerosus et atrophicus , is a chronic atrophic mucocutaneous disorder with no known cause.

Fortunately, it is rare in children.

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