Sanjay Khope

Circumcision is traditionally performed for persistent phimosis in boys. Although there continues to be a considerable debate over the merits of circumcision, it is clear that preservation of the pediatric foreskin even in the presence of phimosis is a viable option. Prepuce spontaneously separates from the glans as the age increases and true phimosis is rare in children(1). Prepuce develops and separates from the glans. As it takes time to do so, normal physiological nonseparation is mistaken as phimosis and referred for circumcision. Surgical intervention should be avoided for nonseparation of prepuce. If an unretractable prepuce causes hygienic problems, topical corticosteroid application may be an effective alternative to circumcision. We conducted a study to evaluate the role of long acting topical steroid, mometasone furoate in the topical treatment of phimosis.

A total of 800 boys, 1 to 3 years of age with an unretractable prepuce were treated in our clinic since 1998 with mometasone furoate 0.1% which was applied to the tip of penis twice daily. After treatment duration of 4 to 8 weeks, 87% of the patients achieved complete or near complete retractability of the prepuce. These children had type IV/ III retractible prepuce(2). Circumcision was carried out in 13% Type II and Type I with incomplete or no separation. No local or systemic adverse effects were noted.

Spontaneous prepuce retraction occurs in 80% of boys up to the age of two, whereas in the remaining, retraction is mostly achieved later in the childhood. Attempts at retraction probably cause secondary phimosis, due to tissue damage and scar formation, which may then require operation. We located 13 studies on the effectiveness and the safety of topical steroid application for phimosis, three of them were placebo controlled. Various steroids have been tried with encouraging results. Success rate is high when patient selection is appropriate and long acting steroid is used.

The topical application of mometasone furoate 0.1% is a highly efficacious, safe, and well-tolerated treatment of phimosis in this large series of boys. Nevertheless, hygiene and preputial traction, when appropriately performed, also seem to play an important role in the disappearance of the phimotic ring (3,4).