Comparison of Topical Application of Fluticasone Alone
and with Hyaluronic Acid for Phimosis
Sandeep Hambarde, Pradnya Bendre, Rajeev Redkar
Abstract
Phimosis is being treated by local steroids like beta methasone, clobetasol since a
decade with variable results. This article presents a novel technique of adding
hyaluronic acid with fluticasone in the conservative management of phimosis.
Studis have shown that introduction of fluticasone has increased the success of
conservative management of phimosis. Addition of hyaluronic acid has a great
impact in increasing the success of local steroid therapy.
Introduction
management of phimosis.
P
Method
himosis refers to the inability to
retract the distal foreskin over the
glans penis. About 95% of newborn males
have this condition and 90% of them it
becomes retractable because of
spontaneous biologic process. Physiologic
phimosis occurs naturally in newborn
males. Up to 10% of males will have
physiologic phimosis at 3 years of age, and
a larger percentage of children will have
only partially retractible foreskins. One to
five per cent of males will have
nonretractable foreskins by age 16 years.1
This inability to retract many times is
interpreted as pathologic condition by
parents and paediatricians and
circumcision is advised. Preputial skin at
this stage is supple. Simple manoeuvres
like gentle retraction with steroid
application may suffice. Addition of
enzyme hyaluronidase with fluticasone
enhances its action increasing success
rate of conservation treatment.2
Aim
To compare effectiveness of topical
fluticasone alone and in combination with
hyaluronic acid in conservative
Dept. of Paediatric Surgery,, B J Wadia Children
Hospital, Parel, Mumbai - 400 012.
196
100 patients between 6 month to 10
year excluding phimosis with recurrent
balanoposthitis were studied. We have
treated total 50 patients, in the age group
of 6 month to 10 years with topical
fluticasone 0.005% alone and 50 patients
in same age group with topical fluticasone
0.005% with 1500U hyaluronic acid. All
patients underwent adhesiolysis and were
advised seitz bath and application of
ointment twice daily. Most important thing
in adhesiolysis was complete retraction
was never aimed. Only gentle dilation to
open prepuce without causing bleeding.
Bleeding means injury which heals by
fibrosis converting physiologic into
pathologic phimosis.
All patients were followed after one
week and then after one month. The
therapeutic response was graded as total
success when there was complete
exposure of glans and partial success
when exposure of half of the glans,
impended by balanoprepucial adherence
of fibrosis at the prepuce and therapeutic
failure when there was no exposure of
glans.
Bombay Hospital Journal, Vol. 53 , No. 2 , 2011
Results
Group 1
50 patients were treated by fluticasone
cream alone. The results obtained are
tabulated in Table 1.
Table 1 : Results of group 1
Age group
Total improvement
Partial improvement
Failure
0-2 years
> 2 years
22(78%)
2(7%)
4(15%)
18 (82%)
3 (13.5%)
1(4.5%)
(Fluticasone without Hyaluronic acid)
Group 2
50 patients were treated with
fluticasone and hyaluronic acid. The
results obtained are tabulated in Table 2.
Table 2 : Results of Group 2
Age group
Total improvement
Partial improvement
Failure
0-2 years
30(96.7%)
1(3.3%)
Nil
> 2 years
18(94.7%)
Nil
1(5.3%)
(Fluticasone without Hyaluronic acid)
All patients were categorized into two
groups as 0-2 years and > 2 years. Success
of fluticasone alone and in combination
with hyaluronic acid was statistically
similar in > 2 years age group. But addition
of hyaluronic acid definitely increased
success of adhesiolysis in 0-2 years age
group, in both one week and one month
follow up.
Discussion
Whether to preserve or sacrifice
prepuce has always been debatable issue.
Few believed that it represents monument
of love with maximum numbers of
meissener’s corpuscle, is a very sensitive
structure, few believes that it protects
neonatal meatus and glans from friction
and exposure injuries, some believe that it
is vestigial and can be chopped without
any harm while others feel that cutting it
protects child from several problems like
recurrent urinary infections, penile
cancers etc.3 There is common layer of
Bombay Hospital Journal, Vol. 53 , No. 2 , 2011
sqamous epithelium between glans and
inner surface of prepuce and this keratin
pearl dissect space between them and
prevent readherence, 96% boys have
physiological phimosis stated by Oster in
1968.4
ln 1948, Winshery-White defined
phimosis as congenital or acquired
narrowing of prepucial opening due to
non-retractile foreskin without adherence,
which lead to accumulation of secretions
under foreskin resulting in irritation and
balanitis.
Stenram in 1986, suggested that true
phimosis produces a coneshaped foreskin
during gental traction with fibrotic,
circular band that form distal and
narrowest part of prepuce and minor
narrowing dose not require intervention.
For the people who believe that
prepuce is important structure and every
effort should be taken to preserve it, only
recurrent balanitis, paraphimosis and
balanitis xerotica obliterance, are the only
indications for circumcision.
Wright in 1994 used betamethasone
and got 80% success.9 Kikiros in 1993
used Hydrocortiscone and got 86%
success.5 Joregersone in 1993 used
Clobetasole propionate got 78% success.5
According to Kragballe in 1989 wrote
that corticosteroids releases arachidonic
acid from phospholipid and inhibit Mrna
responsible for interleukin. 1 formation
that lead to produce anti-inflammatory
and immunosuppressive effect.
Corticosteroids inhibit oedema, fibrin
deposition, capillary dilatation,
proliferation of fibroblasts, depletion of
fibroblasts, depletion of collagen and
cicatrization.6
Secondly, steroids have skin thinning
effect due to inhibition of dermal synthesis
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of glycosaminoglycans by fibroblast
resulting in loss of ground substance.
They cause rearrangement of collagen and
elastin fibres. Prolonged steroid
application reduces horny layer and
rehydration of tissue causes epidermal
thickening. This rebound effect can be
prevented by retraction of foreskin at least
twice daily once phimosis has resolved.7
steroids and addition of hyaluronic acid
especially below 2 yrs of age increases its
success with no significant complications
and can be performed under local
anaesthesia.
References
1.
Favonito L.A. et al Journal of European urology
supplement 2008; 7(3):24.
2.
Hyaluronic acid addition creates tissue
planes and increases tissue permeability
of steroids with reduced rebound
phenomenon.8
J.B.M.Nzayiseng, L. Munkonge et al East and
Central African Journal of surgery, 2005; vol 10
no. 2 dec.
3.
Kikiros CS, SW, Woodward AA. The response of
phimosis to local steriod application. Pediatric
Surg Int 1993; 8:329-32.
Conclusion
4.
P. A. Dewan et al Journal of Paediatrics Aug
1996; vol 32 no. 4:285-289.
5.
Lane Palmer and Jeffrey Palmer, Urology Int,
2008; 72(1).
6.
Øter J. Further fate of the foreskin. Incidence of
preputial adhesions, phimosis and smegma
among Danish schoolboys. Arch. Dis. Child 1968;
43:200-203.
7.
Stebram A, Malfors G, Okmian L. Circumcision
for phimosis : a follow-up study. Scand. J. Urol
Nephrol. 1986; 20:89-92.
8.
Winsbery-White HP. The penis. In : WinsberyWhite HP, ed Textbook of Genito-Urinary
Surgery. Livingstone, Edinburgh, 1948; 600-4.
9.
Wright JE. The treatment of childhood phimosis
with topical steroid. Aust. N. Z. J. Surg. 1994;
64:327-8.
Addition of Hyaluronic acid in
Fluticasone cream has impact in
increasing success after adhesiolysis in
both 0-2 years and 2-10 years age group.
Key Message
Conservative treatment of phimosis is
getting increasing acceptance. Topical
steroid combined with gentle adhesiolysis
are successful provided selection of cases
is done properly and procedure of
adhesiolysis is performed gently. From
this study it was observed that fluticasone
0.005% is as effective as effective as other
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LARS EDVINSSON, MATTIAS LINDE, THE LANCET 2010; 376 : 645
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Bombay Hospital Journal, Vol. 53 , No. 2 , 2011