PEDIATRICS Vol. 102 No. 4 October 1998, p. e43

ELECTRONIC ARTICLE:
Cost-effective Treatment of Phimosis

Robert S. Van Howe

From the Department of Pediatrics, Marshfield ClinicLakeland Center, Minocqua, Wisconsin.

	ABSTRACT

Top Abstract Methods Results Discussion References

Objective.  To determine the most cost-effective treatment for phimosis.

Design.  The costs of three treatment strategies for treating phimosis were evaluated using a decision-tree analysis. Three therapeutic approaches were considered: circumcision, preputial plasty (the use of plastic surgical techniques to enlarge the preputial opening without removing tissue), and topical therapy with steroids and nonsteroidal antiinflammatories. Published failure and complication rates were used to calculate the cost per case.

Outcome Measures.  Cost in dollars to treat each case of phimosis.

Results.  Topical steroid therapy was the most cost-effective strategy, costing between $758 and $800 per case. Preputial plasty cost between $2515 and $2580 per case. Circumcision cost between $3009 and $3241 per case.

Conclusions.  The most cost-effective management for treating phimosis is to initiate topical therapy. Daily external application from the tip of the foreskin to the glandis corona with betamethasone 0.05% cream for 4 to 6 weeks has been demonstrated to be very effective, resulting in a 75% savings compared with circumcision. Surgical intervention should not be considered until topical therapy has been given an adequate trial. When contemplating surgery, the lower morbidity, lower costs, and tissue preservation of preputial plasty may make it preferable.  Key words:  phimosis, betamethasone, preputial plasty, circumcision.

It has recently been demonstrated that patients with true phimosis can be treated successfully with topical creams in 65% to 95% of cases.^1-10 Also, a number of prepuce-sparing surgical treatments (preputial plasty) for phimosis have been developed.^11-18 Two studies have compared the results of preputial plasty with conventional circumcision,^19-20 finding that the plastic procedure lowered morbidity and recovery time as well as the incidence of meatal stenosis after surgery.

With the advent of these newer, less invasive, less morbid alternatives, it is important to document the most cost-effective manner of treating phimosis.

	METHODS

Top Abstract Methods Results Discussion References

A decision-tree analysis was performed for three initial treatment strategies: circumcision, preputial plasty, and topical steroids. The costs, complication rates, failure rates, and time missed from work (parental or personal) are listed in Table 1.

The failure rate for topical therapy was calculated by combining the results of the 10 studies published to date (Table 2).^1-10 Time lost from work was based on the mean time it took after surgery for underpants to be worn comfortably.¹⁹ Income was assumed to be $35 000 per annum.

Although the British study by Cuckow et al¹⁹ documented a 20% overnight hospitalization rate after circumcision, the rate in the United States is unknown. Most of the overnight hospitalizations were secondary to anesthesia complications. Overnight hospitalization rates of 6% (the rate of reoperation for bleeding) and 20% were used for calculations. Hospitalization rates for preputial plasty were 40% of those for circumcision.¹⁹ The reported rates of meatal stenosis requiring meatotomy after circumcision range from 2.8%²¹ to 11.1%.²² Calculations were made using meatotomy rates of 2.8% and 8%.²⁰

For the preputial plasty group, failures were treated with circumcision. For the topical therapy, failures were treated with circumcision under the assumption that those who failed topical therapy did not respond because the underlying pathology was balanitis xerotica obliterans (BXO) based on the determination that the failure rate of topical therapy was nearly the same as the incidence of BXO in circumcision specimens (Table 3).^23-29

	RESULTS

Top Abstract Methods Results Discussion References

For each case of phimosis it costs between $3009 and $3241 to use circumcision as the primary treatment modality. Preputial plasty costs between $2515 and $2579 per case. Using topical therapy as the initial therapy costs between $758 and $800, a 75% savings compared with circumcision.

Topical therapy would need to exhibit a 93% failure rate to be as costly as initially relying on circumcision. A failure rate of 20% to 24% for preputial plasty would make that option as costly as circumcision. In those treated initially with topical therapy, treatment failure accounted for more of the costs than their initial therapy (Fig 1).

View larger version (26K): [in this window] [in a new window]   Fig. 1.   Costs of treating phimosis.

These calculations demonstrate that topical therapy is the most cost-efficient initial therapy for phimosis.

	DISCUSSION

Top Abstract Methods Results Discussion References

The definition of phimosis has never been precise and has been applied to foreskins which do not retract,³⁰ have adhesions to the glans,³¹ have a "tightness,"³² are elongated,¹⁸ are "redundant,"³³ are thickened,³⁴ are inflamed,³⁵ have a fibrous ring,¹⁵ or have a narrow orifice.³⁶ In the United States physicians are encouraged to list "redundant prepuce and phimosis" as the indication for elective circumcisions on normal foreskins to receive third-party payment.³⁷ Unfortunately, the term phimosis is often incorrectly applied to any foreskin that cannot be retracted,³⁸ which includes 96% of newborns, 85% of 3 month olds, 50% of 1 year olds,³⁹ and 1% of 17 year olds.⁴⁰

The reported incidence of phimosis varies. In a population of military dependents receiving postneonatal circumcisions, the incidence of true phimosis was between 0.2 and 0.3%.⁴¹ Krueger and Osborn⁴² found phimosis in 3 of 28 boys (10.7%) more than the age of 4, Herzog and Alvarez⁴³ saw symptomatic phimosis in 8 of 272 intact boys (2.94%) they studied, and following a cohort of 1265 children in Christchurch, New Zealand, Fergusson et al⁴⁴ found that 16% of noncircumcised boys aged 0 to 8 had phimosis. Whether these authors could distinguish between pathologic and physiologic phimosis through retrospective chart reconstructions is debatable. How many of these boys required intervention is likewise unknown.

Prospective studies have demonstrated phimosis to be a rare finding. Smith et al⁴⁵ found 1 case of phimosis in 1000 boys. In 213 Japanese boys under age 2 years, only 4 (1.88%) had a "pinhole prepuce."⁴⁶ In France the rate is 2.6%,⁴⁷ whereas in England, the incidence of true pathologic phimosis was calculated to be 0.9%.⁴⁸

Øster,⁴⁰ who examined nearly 2000 schoolchildren between the ages of 6 and 17, found that 91% of the 6- to 7-year-old age group had retractile prepuces and the incidence of spontaneously retractile foreskins increased yearly until age 17 years when only 1% of the foreskins remained nonretractile. The incidence of a completely retractile prepuce in a study of 603 Japanese boys showed a gradual increase from 0% at age 6 months to 62.9% by 11 to 15 years, while the incidence of a tight preputial ring decreased with age from 84.3% to 8.6%.⁴⁶ One large study failed to find a case of pathologic phimosis in a boy under 5 years of age.⁴⁹

Without clear diagnostic criteria, confusion exists about what constitutes pathologic phimosis as distinct from a physiologic nonretractile foreskin.³⁸ The majority of referrals to pediatric urologists for circumcision constitute developmentally nonretractile foreskin rather than true phimosis.^49-51

When applying gentle retraction to the normal but nonretractable infant foreskin the distal part of the foreskin puckers and the narrow portion is proximal to the preputial tip. When the same gentle retraction is applied to the foreskin with true phimosis it results in a cone-shaped foreskin with a fibrotic, circular band forming the most distal and narrowest part of the prepuce.⁹

Topical therapy has resulted in consistently favorable results (Table 2), a finding that has prompted the Australasian Association of Paediatric Surgeons⁵² to recommend circumcision only for BXO, recurrent balanoposthitis, and phimosis resistant to topical steroid cream. All three placebo-controlled studies have demonstrated topical therapy's superiority (Table 4).^5,7,8 The antiinflammatory and immunosuppressive effects as well as the skin thinning effects of the topical steroids may explain their effectiveness.⁹ Betamethasone has been the most studied cream, with external application giving similar results to mucosal application.

Although the studies using topical creams have produced dramatic results, the boys studied were often younger than 5 years old. How many of these boys merely had a normal, nonretractile prepuce is unknown. Topical therapy may have only accelerated the normal developmental process in these boys. Still, these boys would have been considered candidates for circumcision if topical therapy had not been offered. Lindhagen⁷ noted that placebo responders were 2.4 years older than placebo nonresponders, "reinforcing the opinion that this is a physiological process with increasing potential for spontaneous resolution with increasing age."

The failure rate of topical creams (19%) is nearly identical with the rate of BXO (14%) found on histologic examination of prepuces excised from patients with phimosis.^23-29 Of the boys who failed after a complete course of topical therapy, 14 had a histologic examination performed. BXO was diagnosed in 12 (86%) of them.^1,3,7 Although topical steroids are recommended for early BXO,⁵³ their use may act as a screening tool to identify those with more advanced BXO. With the development of effective topical therapy and preputial plasty, the indication for circumcision in the treatment of phimosis has been reduced to the rare cases of BXO.

Meatal stenosis requiring meatotomy after circumcision is seen in 2.8%²¹ to 11.1%²² of patients. Persad et al²⁰ found that after 88 circumcisions for phimosis, 7 (8%) boys developed meatal stenosis, whereas none of the 91 boys who underwent preputial plasty did (P < .01). Traumatic meatitis of the unprotected postcircumcision urethral meatus and/or meatal ischemia after damage to the frenular artery at circumcision have been cited as possible etiologic factors.

Of two similar groups of 50 boys, one underwent circumcision and the other underwent preputial plasty in a recent British study.¹⁹ Of the boys who underwent circumcision, 20% required an overnight stay, 14% had anesthetic complications, and 6% required reoperation because of bleeding. Only 8% of patients had an overnight stay after preputial plasty. None of these patients required reoperation and no bleeding problems were noted. Parental assessment of both operations showed that morbidity was significantly less and of shorter duration for the preputial plasty group. Two patients in the preputial plasty group (4%) had recurrent narrowing of the foreskin caused by scarring and contraction of the incision. The acceptance of preputial plasty as an alternative to circumcision may not occur immediately, despite reductions in cost, morbidity, and the amount of tissue excised, because most surgeon will need to be convinced of the need for change.⁵⁴

Several noneconomic factors deserve consideration. The ridged band at the tip of the prepuce may be the most neurologically complex portion of the penis.⁵⁵ Topical therapy and preputial plasty both spare this highly erogenous tissue. Likewise, severe emotional problems have been documented after circumcision in young boys.⁵⁶ The vast majority of males with a prepuce are not eager to part with it, and these newly developed therapies provide reasonable alternatives.

Lindhagen⁷ states, "contrary to epidemiological data that showed spontaneous resolution of most cases of phimosis, circumcision has become the first line of treatment for these patients. The argument that circumcision is a minor surgical procedure without complications is not only erroneous, but also irrelevant. It is ethically as well as economically questionable to operate on a child to treat a physiological process."

	FOOTNOTES

Received for publication Sep 9, 1997; accepted May 18, 1998.

Reprint requests to (R.S.V.H.) Marshfield Clinic, Lakeland Center, 9601 Townline Rd, PO Box 1390, Minocqua, WI 54548.

	ACKNOWLEDGMENT

I thank Christopher J. Cold, MD, for his invaluable assistance in explaining the pathology of BXO.

	ABBREVIATIONS

BXO, balanitis xerotica obliterans.

	REFERENCES

Top Abstract Methods Results Discussion References

1. Wright JE The treatment of childhood phimosis with topical steroid. Aust N Z J Surg 1994; 64:327-328 [Medline]
2. Kikiros CS, Beasley SW, Woodward AA The reponse of phimosis to local steroid application. Pediatr Surg Int 1993; 8:329-332
3. Jorgensen ET, Svensson A The treatment of phimosis in boys, with a potent topical steroid (clobetasol propionate 0.05%) cream. Acta Derm Venereol (Stockh) 1993; 73:55-56
4. Lang K Eine konservative Therapie der phimose. Monatsschr Kinderheilkd 1986; 134:824-825 [Medline]
5. Golubovic Z, Milanovic D, Vukadinovic V, Rakic I, Perovic S The conservative treatment of phimois in boys. Br J Urol 1996; 78:786-788 [Medline]
6. Müller I, Müller H Eine neue konservative Therapie der phimose. Monatsschr Kinderheilkd 1993; 141:607-608 [Medline]
7. Lindhagen T Topical clobetasol propionate compared with placebo in the treatment of unretractable foreskin. Eur J Surg 1996; 162:969-972 [Medline]
8. Atílla MK, Dündaröz R, Odabas O, Öztürk H, Akin R, Gökçay E A non-surgical approach to the treatment of phimosis: local nonsteroidal anti-inflammatory ointment application. J Urol. 1997; 158:196-197 [CrossRef][Medline]
9. Dewan PA, Tieu HC, Chieng BS Phimosis: is circumcision necessary? J Paediatr Child Health 1996; 32:285-289 [Medline]
10. Ruud E, Holt J Fimose kan behandles med lokale steroider. Tidsskr Nor Laegeforen 1997; 117:513-514 [Medline]
11. Wahlin N "Triple incision plasty". A convenient procedure for preputial relief. Scand J Urol Nephrol 1992; 26:107-110 [Medline]
12. Hoffman S, Metz P, Ebbehoj J A new operation for phimosis: prepuce-saving technique with multiple Y V-plasties. Br J Urol 1984; 56:319-321 [Medline]
13. Emmett AJ Four V-flap repair of preputial stenosis (phimosis). Plast Reconstr Surg 1975; 55:687-689 [Medline]
14. de Castella H Prepuceplasty: an alternative to circumcision. Ann R Coll Surg Engl 1994; 76:257-258 [Medline]
15. Holmlund DE Dorsal incision of the prepuce and skin closure with Dexon in patients with phimosis. Scand J Urol Nephrol 1973; 7:97-99 [Medline]
16. Diaz A, Kantor HI Dorsal slit. A circumcision alternative. Obstet Gynecol 1971; 37:619-622 [Medline]
17. Parkash S Phimosis and its plastic correction. J Indian Med Assoc 1972; 58:389-390 [Medline]
18. Ohjimi H, Ogata K, Ohjimi T A new method for the relief of adult phimosis. J Urol 1995; 153:1607-1609 [CrossRef][Medline]
19. Cuckow PM, Rix G, Mouriquand PD Preputial plasty: a good alternative to circumcision. J Pediatr Surg 1994; 29:561-563 [CrossRef][Medline]
20. Persad R, Sharma S, McTavish J, Imber C, Mouriquand PD Clinical presentation and pathophysiology of meatal stenosis following circumcision. Br J Urol 1995; 75:91-93 [Medline]
21. Griffiths DM, Atwell JD, Freeman NV A prospective survey of the indications and morbidity of circumcision in children. Eur Urol 1985; 11:184-187 [Medline]
22. Stenram A, Malmfors G, Okmian L Circumcision for phimosisindications and results. Acta Paediatr Scand 1986; 75:321-323 [Medline]
23. Clemmensen OJ, Krogh J, Petri M The histologic spectrum of prepuces from patients with phimosis. Am J Dermatopathol 1988; 10:104-108 [Medline]
24. Meuli M, Briner J, Hanimann B, Sacher P Lichen sclerosus et atrophicus causing phimosis in boys: a prospective study with 5-year followup after complete circumcision. J Urol 1994; 152:987-989 [Medline]
25. Kristiansen VB, Sorensen C, Kryger AI, Nielsen JB, Mejdahl S Genital lichen sclerosus et atrophicus hos drenge. Ugeskr Laeger 1989; 151:1111 [Medline]
26. Bale PM, Lochhead A, Martin HC, Gollow I Balanitis xerotica obliterans in children. Pediatr Pathol 1987; 7:617-627 [Medline]
27. Flentje D, Benz G, Daum R Lichen sclerosus et atrophicus als Ursache der erworbenen PhimoseZirkumzision als Präventivmassnahme gegen das Peniskarzinom? Z Kinderchir 1987; 42:308-311 [Medline]
28. Chalmers RJ, Burton PA, Bennett RF, Goring CC, Smith PJ Lichen sclerosus et atrophicus. A common and distinctive cause of phimosis in boys. Arch Dermatol 1984; 120:1025-1027 [Abstract/Free Full Text]
29. Liatsikos EN, Perimenis P, Dandinis K, Kaladelfou E, Barbalias G Lichen sclerosus et atrophicus. Findings after complete circumcision. Scand J Urol Nephrol 1997; 31:453-456 [Medline]
30. Kaufman JJ. Current Urologic Therapy. Philadelphia, PA: WB Saunders Co; 1980
31. Blandy J. Urology, II. Oxford, England: Blackwell Scientific Publications; 1976
32. Brueschke EE, editor. The World Book Medical Encyclopedia. Chicago, IL: World Book, Inc; 1988
33. Eastman NJ. Williams Obstetrics. New York, NY: Appleton-Century-Crofts, Inc; 1956
34. M'Kaig A A remarkable case of phimosis. Edinburgh Med J 1909; 2:252-253
35. Hunter J. A Treatise on the Venereal Disease. Philadelphia, PA: J Webster; 1818
36. Otis FN Reflex hemiplegia and paralysis of the bladder from congenital phymosis in children. Am J Obstet 1874; 7:478
37. Reimbursement adviser: how to get reimbursed for circumcision. OBG Management 1993(Oct);25
38. Gordon A, Collin J Save the normal foreskin. Br Med J 1993; 306:1-2
39. Gairdner D The fate of the foreskin: a study of circumcision. Br Med J 1949; 2:1433-1437
40. Øster J Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child 1968; 43:200-203
41. Wiswell TE, Tencer HL, Welch CA, Chamberlain JL Circumcision in children beyond the neonatal period. Pediatrics 1993; 92:791-793 [Abstract/Free Full Text]
42. Krueger H, Osborn L Effects of hygiene among the uncircumcised. J Fam Pract 1986; 22:353-355 [Medline]
43. Herzog LW, Alvarez SR The frequency of foreskin problems in uncircumcised children. Am J Dis Child 1986; 140:254-256 [Abstract/Free Full Text]
44. Fergusson DM, Lawton JM, Shannon FT Neonatal circumcision and penile problems: an 8-year longitudinal study. Pediatrics 1988; 81:537-541 [Abstract/Free Full Text]
45. Smith GC, Powell A, Reynolds K, Campbell CA The five year school medicaltime for change. Arch Dis Child 1990; 65:225-227 [Abstract/Free Full Text]
46. Kayaba H, Tamura H, Kitajima S, Fujiwara Y, Kato T, Kato T Analysis of shape and retractability of the prepuce in 603 Japanese boys. J Urol 1996; 156:1813-1815 [CrossRef][Medline]
47. Branger B, Sable A, Picherot G, Examen du prépuce chez 511 enfants en maternelle. Rôle des manoeuvres de décalottage. Ann Pediatr (Paris) 1991; 38:618-622 [Medline]
48. Rickwood AM, Hemalatha V, Batcup G, Spitz L Phimosis in boys. Br J Urol 1980; 52:147-150 [Medline]
49. Rickwood AM, Walker J Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence? Ann R Coll Surg Engl 1989; 71:275-277 [Medline]
50. Griffiths D, Frank JD Inappropriate circumcision referrals by Gps. J R Soc Med 1992; 85:324-325 [Abstract]
51. Matsuoka H, Kajiwara I, Tahara H, Oshima K Phimosis as a pathogenetic factor in urinary tract infection and vesicoureteral reflux. Nippon Hinyokika Gakkai Zasshi 1994; 85:953-957 [Medline]
52. Australasian Association of Paediatric Surgeons. Guidelines for Circumcision. Hersion, Queensland, Australia: Australasian Association of Paediatric Surgeons; April 1996
53. Fortier Beaulieu M, Thomine E, Mitrofanof P, Lauret P, Hemet J Lichen scléro-atrophique préputial de l'enfant. Ann Pediatr (Paris) 1990; 37:673-676 [Medline]
54. Davenport M Problems with the penis and prepuce: author's reply. Br Med J 1996; 312:1230 [Free Full Text]
55. Taylor JR, Lockwood AP, Taylor AJ The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996; 77:291-295 [CrossRef][Medline]
56. Cansever G Psychological effects of circumcision. Br J Med Psychol 1965; 38:321-331 [Medline]