
































Original Article Phimosis in Children

J Nepal Paediatr Soc | VOL 42 | ISSUE 02 |MAY-AUG,  202226

*Sushil Dhungel1, Ajaya Dhakal2, Kamal Koirala3, Rupesh Mukhia3, Narayan Bhusal1, Abhishek Thapa1

1Assistant Professor, Department of Surgery, KIST Medical College and Teaching Hospital, KIST Hospital Road, Mahalaxmi Municipality-1, 
Lalitpur, Nepal
2Associate Professor, Department of Paediatrics, KIST Medical College and Teaching Hospital, KIST Hospital Road, Mahalaxmi 
Municipality-1, Lalitpur, Nepal
3Professor, Department of Surgery, KIST Medical College and Teaching Hospital, KIST Hospital Road, Mahalaxmi Municipality-1, 
Lalitpur, Nepal

Effectiveness of Topical Steroid in Phimosis: A longitudinal Observational 
Study

Introduction: Most non-retractile foreskins have been diagnosed with 
phimosis and referred for circumcision. However, many patients can be 
managed with corticosteroid cream. This study evaluates the effectiveness of the 
topical application of corticosteroid cream and manual prepucial stretching in 
the treatment of phimosis.

Methods: This was a longitudinal observational study carried out among 
children aged six months to 10 years with the diagnosis of phimosis between 
1st September 2019 to 31st August 2020. The patients were advised to apply 
1% Hydrocortisone cream together with manual prepucial stretching twice daily 
for four weeks. Patients were assessed at four weeks and six months at the 
outpatient clinic using Kirkos grading for retractability.

Results: A total of 110 patients were diagnosed with phimosis during the 
study period. Fourteen patients had pathological phimosis out of which four 
had balanitis xerotica obliterans and were excluded from the analysis. Ninety-
six patients with physiological phimosis were treated conservatively with 1% 
hydrocortisone and manual prepucial stretching. Among them, 87 cases 
were successfully treated whereas five patients had a partial response with 
treatment failure in four cases. Those five cases with partial response underwent 
adhesiolysis while circumcision was performed in the remaining four patients 
with treatment failure. Prepucial retraction was possible in four weeks in most 
of the patients with physiological phimosis with successful results in 90.6% of 
cases.

Conclusions: All non-retractile prepuce are not pathological phimosis and 
doesn’t need circumcision. Local application of a potent corticoid cream and 
foreskin stretching is a safe, simple, and effective long-term treatment for 
physiological unretractable foreskin in children. 

Abstract

*Corresponding Author
Sushil Dhungel
Assistant Professor,
Department of Surgery,
KIST Medical College and Teaching 
Hospital,KIST Hospital Road,
Mahalaxmi Municipality-1, Lalitpur, Nepal
Email: sushildhungel@hotmail.com

Article History 
Received On : 22 Apr, 2022
Accepted On : 15 Dec, 2022

Funding sources:  None

Conflicts of interest: None

Keywords: Pathological phimosis, 
phimosis, physiological phimosis, prepucial 
adhesion

Online Access

DOI: 
https://doi.org/10.3126/jnps.v42i2.44533 

Introduction

Phimosis is a condition with a failure to retract the foreskin, which may be due to either 
a narrowness of the opening of the prepuce, congenital adhesions between the glans 
and prepuce, or both.1 Almost all boys (96%) are born with an unretractable foreskin. 

Copyrights & Licensing © 2022 by author(s). This is an Open Access article distribut-
ed under Creative Commons Attribution License (CC BY NC )

Original Article

DOI: 103126/JNPS.V4113



J Nepal Paediatr Soc | VOL 42 | ISSUE 02 |MAY-AUG,  2022 27

Original ArticlePhimosis in Children

Prepuce gradually becomes retractile by three years of age but 
can extend into older age groups (Physiological phimosis).2 There 
is ongoing controversy regarding the use of neonatal circumcision 
for phimosis.3 The American Academy of Pediatrics has adopted 
a neutral or anti-circumcision stance on neonatal circumcision.4 

Physiological phimosis is more appropriately managed by 
conservative measures, such as “tincture of time”, or topical 
steroid therapy.5 Topical steroids have now become an alternative 
to circumcision for the treatment of phimosis with high success 
rates1,6,7 since its introduction in 1993.8 Pathological phimosis is 
defined as failure to retract the foreskin due to distal scarring of 
the prepuce that is seen as a contracted white, indurated, fibrous 
ring around the preputial orifice during physical examination. On 
the contrary, physiological phimosis lacks this scarring process 
and is a normal developmental phase of the prepuce and many 
physicians continue to have difficulty distinguishing one form from 
the other.3,4,9

The standard treatment for pathological phimosis is circumcision6,9 
but dorsal slit and preputioplasty under general anesthesia 
and adhesiolysis under topical anesthetics are other modes of 
treatment. Phimosis creates major concerns for parents and is 
responsible for significant numbers of consultations, referrals to 
paediatric surgeons, and circumcisions.10-12 Recently alternative 
to circumcision and prepuce plasty, conservative treatments 
for phimosis with topical corticosteroids applied to the stenotic 
distal portion of the prepuce for four to eight weeks have been 
published with high rates of resolution. Three large studies have 
recommended the initial treatment of phimosis with topical 
corticosteroids before any surgical intervention.6,13,14  

The study aims to evaluate the effectiveness of the topical corticoid 
cream and manual prepuce stretching for non retractile prepuce. 

Methods

This longitudinal observational study was conducted at KIST 
Medical College and Teaching Hospital from 1st September 
2019 to 31st August 2020 after ethical approval from Institutional 
Review Committee (IRC NO 2076/77/15). Children aged six 
months to 10 years, who were diagnosed with phimosis in the 
outpatient clinic of Surgery and Paediatrics were included in the 
study while children with current active balanoposthitis, recurrent 
urinary tract infections, balanitis xerotica obliterans, buried 
penis, and phimosis secondary to incomplete circumcision were 
excluded from the analysis. Written informed consent was taken 
from the parents of the children after explaining the study.

The treatment options for phimosis using topical steroids or 
surgery were discussed with the parents. Grading of the degree 
of retractability of the foreskin was recorded at presentation 
and during follow-up visits at four weeks and six months after 
the corticosteroid treatment using Kirkos grading.5 The parents 
and / or the patients were instructed to wash prepuce and 
apply 1% hydrocortisone ointment at the tip of the foreskin 
together with manual prepucial stretching twice daily for four 
weeks without stopping even if the foreskin became retractable 
without causing any pain. The patients were then followed up 
at four weeks to analyze the treatment effect. At four weeks of 
treatment, all patients were examined for phimosis using the 

same Kirkos grading. The maximum duration of corticosteroid 
treatment was limited to four weeks. Successful treatment at four 
weeks was defined as a retractile prepuce, patient / or parent 
satisfaction, and clinical examination suggesting circumcision was 
unnecessary. These patients were then followed again six months 
after treatment. Those patients who did not come for follow-up 
were interviewed by telephone. Failure of therapy at four weeks 
was defined as persistent phimosis with the inability to retract the 
outer foreskin and advised for circumcision. Side effects such as 
striae, pigmentation, hypertrichosis, and telangiectasia as well as 
weight gain, and behavioral changes were recorded. During the 
treatment course, the patients or their parents were asked if the 
daily regime of retraction and cleansing of the retractable foreskin 
was diligently followed and whether there was an episode of 
balanitis during treatment. Demographic data, age, and clinical 
data of patients were recorded in predesigned proforma and 
the same proforma was used to record the treatment outcomes 
during the follow-up. The data were entered and analyzed 
using the Statistical Package for Social Sciences (SPSS) Version 
27. Frequencies and percentage values were calculated for the 
various variable using descriptive analysis.

Results

A total of 110 patients ranging from six months to 10 years 
(Mean = 4.28 years) were diagnosed as having phimosis during 
the study period. Out of 110 patients, 14 (12.7%) patients 
had pathological phimosis of which four had balanitis xerotica 
obliterans. These 14 patients were excluded from the study 
and underwent circumcision. Among 96 patients eligible for 
corticosteroid ointment therapy, 39.58% of patients had a grade 
2 phimosis, 5.21% patients had grade 3 phimosis, 34.37% 
patients had grade 4 phimosis, and 20.83% patients had grade 
5 phimosis at initial presentation as shown in Table 1. During the 
study period, no patient had grade 0 and grade 1 phimosis.

Table 1. Grades of phimosis of the study population

 Grade Number of patients Percentage

Grade 0 0 0

Grade 1 0 0

 Grade 2 38 39.58%

Grade 3 5 5.21%

 Grade 4 33 34.37%

Grade 5 20 20.83%

None of the patients were practicing daily retraction of their foreskin 
before entering the study. Ninety-six patients were treated with 1% 
hydrocortisone cream and manual prepucial stretching according 
to protocol. Four weeks after enrollment, 90.6% (87 patients) had 
a successful treatment while 5.21% (Five patients) had a partial 
response, and 4.17% (Four patients) were considered failures 
(Table 2). The five patients with partial response to treatment were 
found to have symptomatic physiological preputial adhesion and 
were managed by simple adhesiolysis in the outdoor clinic under 
xylocaine spray.  Circumcision was performed for four treatment 
failure patients. At six months of follow-up, two patients were lost 



Original Article Phimosis in Children

J Nepal Paediatr Soc | VOL 42 | ISSUE 02 |MAY-AUG,  202228

to follow-up while 88.5 % (85 / 96 patients) had a retractable 
prepuce without recurrence of phimosis.
In all the cases, the treatment was well tolerated without evidence 
of adverse effects. In general, boys older than six years performed 
the retraction by themselves while parents performed the retraction 
procedure in younger boys.

Table 2. Putcome of phimosis in Kirko’s grades after steroid 
therapy

Grade Number of patients Percentage

Grade 0 87 90.62%

Grade 1 0 0

Grade 2 4 4.17%

Grade 3 5 5.21%

Grade 4 0 0

Grade 5 0 0

Discussion

This study found that local application of 1% Hydrocortisone 
cream with manual prepucial stretching is an effective, safe 
treatment in patients with physiological phimosis. This finding 
was similar to several articles published recently on the treatment 
of phimosis using topical steroids with success rates from 70% to 
90%.6,13,14 In a study, 233 patients received eight-week treatment 
with 0.02% clobetasol propionate cream, among which 181 
(77.68%) showed full retraction of the foreskin, 28 (12.01%) 
experienced improvement (Disappearance of the phimotic ring), 
and 24 (10.30%) failed to respond, with a total effectiveness rate 
of 89.70%.15 Our result of 90.6 % success rate is similar to the 
above studies. Moreover, this study followed patients and found 
that there was no recurrence in a six months follow-up. 

This study highlights that four weeks of conservative treatment 
could be tried before circumcision reducing the risk of anesthesia16 
as well as complications associated with surgery.16,17 A tight 
foreskin may manifest with symptoms such as itching, smegma 
deposits, straining, ballooning, balanoposthitis, dysuria, or 
urinary infection termed as symptomatic or pathological phimosis. 
Recently the general trend emerging all over the world is to perform 
circumcisions only in symptomatic cases and in possible cases to 
perform a prepuce conserving surgery like Prepucioplasty, V-Y 
plasty, etc.18 The dorsal slit has been known to cause scarring 
of the dorsal prepuce leaving an inadequate amount of ventral 
foreskin in 55% of the boys four years after the operation.19 
Surgical alternatives to circumcision, such as preputial plasty, also 
require anesthesia which has up to a 4% recurrence rate.18  

The exact mechanism of action of topical steroids in phimosis 
is unknown. However proposed mechanisms are inhibition of 
prostaglandin release, downregulation of collagen synthesis, 
and moisturizing effect of steroids improving the elasticity of 
prepuce acid.1,5,7 Steroids applied only to the foreskin (less than 
0.1% of the total body surface area) have very minimal systemic 
side effects even in young boys less than four years of age5,7 
and also topical steroid treatment for phimosis did not change 
morning cortisol levels.7 No local or systemic side effects with 

corticosteroid cream and foreskin stretching were noticed in our 
study. The risk of side effects is unlikely since the quantity of cream 
applied and the treated surface of the prepuce is very small. 
Nevertheless, the parents and patients were informed accordingly 
and possible signs of toxicity such as headaches and vomiting 
were mentioned. The overall cost of topical steroid treatment is 
25 to 35% of circumcision and preputial plasty, therefore cost-
effective.6,13

Sometimes prepucial adhesion may be misdiagnosed as 
pathological phimosis and subjected to circumcision when it 
could have easily been managed by adhesiolysis as an outdoor 
procedure.10-12 Gentle retraction of the prepuce, known as 
physiotherapy, was suggested as an important factor in the 
spontaneous resolution of physiologic phimosis.17 Although 
forcible retraction of the prepuce should be avoided because of 
pain, bleeding, adhesion, and cicatrix formation, which might 
lead to secondary phimosis, careful and gentle retraction has been 
encouraged for the more rapid resolution of severe physiologic 
phimosis.6,17 A previous study found that gentle retraction of the 
foreskin with topical application, reported a 50% success rate 
even with placebo cream and physiotherapy and suggested that 
physiotherapy per se would be effective to resolve physiologic 
phimosis.6 In concurrence to these researches, we also found that 
steroid therapy would be an effective therapy for physiological 
phimosis. The limitation of this study is that it is a single-site study 
with a small number of children from the local region. Hence the 
study should be further carried out in a large population from 
various centers to confirm the finding of this study to extrapolate 
to the general population.

Conclusions

This study has shown that not all non-retractile prepuces are 
pathological phimosis and require circumcision. Local application 
of 1% hydrocortisone cream along with foreskin stretching is a 
safe, simple, and effective long-term treatment for physiological 
unretractable foreskin in children. 

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