Efficacy of Short Duration of Topical Steroids Followed by Adhesiolysis for Management of Preputial Adhesions

ABSTRACT

Aims:

The primary objective was to evaluate the efficacy of a 2-week course of topical corticosteroids and outpatient adhesiolysis in managing preputial adhesions. Secondary objectives included assessing adhesion recurrence rates and monitoring adverse effects related to corticosteroid application and adhesiolysis.

Materials and Methods:

This prospective observational study was conducted at a tertiary care hospital. Boys presenting with symptoms such as inability to retract the prepuce, ballooning, penile swelling/smegma, urinary symptoms, or history of balanitis were enrolled. Preputial retractability was assessed using the KIKIROS scale. Symptomatic boys with lower KIKIROS grades underwent adhesiolysis during the first visit. Others were advised to apply topical steroids twice daily for 2 weeks, followed by adhesiolysis.

Results:

In the 0–<5 years group, the inability to retract prepuce with other symptoms (31%) and ballooning (26%) were common. In the 5–<10 years group, 43.8% had inability to retract the prepuce with associated conditions. In the 10–<17 years group, 64% had inability to retract the prepuce. Post-ointment KIKIROS grading was predominantly 3 in all age groups. After the fifth follow-up, 79.55% of boys who underwent adhesiolysis without ointment achieved KIKIROS 0, compared to 55.39% of those who used ointment.

Conclusion:

Topical steroids are helpful, but adhesiolysis alone shows higher efficacy, especially for those with lower initial KIKIROS grades. Reassurance is appropriate for asymptomatic boys under five, while older boys often benefit from intervention. Post-procedure hygiene education and regular follow-up are crucial to minimize recurrence.

INTRODUCTION

Phimosis is a condition in which the prepuce cannot be retracted over the glans penis.[1,2] Separation of the prepuce from the glans occurs around 24 weeks of gestation. These adhesions persist during the neonatal period resulting in physiological phimosis and gradually break down with age.[3] Physiologic phimosis consists of a pliant, unscarred preputial orifice[1,2] with pink and healthy prepuce.[4] It is common in male patients up to 3 years of age,[1,2] but often extends into older age groups. The foreskin becomes fully retractile, usually by 5 years of age; however, some may develop symptoms.[5] According to Gardeiner, foreskin retractability increases with age: 4–50% of foreskins are retractable by age 1 year, 75% by age 2, and 90% by age 3.[1] Oster documented reduction of phimosis from 8% to 1% from the age of 6 to 17 years and concluded that nonretractability (in the absence of scarring or other abnormality) can be considered normal for males up to and including adolescence.[2] Physiologic phimosis may cause ballooning of the foreskin.[3,6] Additionally preputial pearls-accumulations of smegma consisting of sebaceous secretions and shed skin can collect underneath the prepuce due to adhesions. Asymptomatic physiologic phimosis requires reassurance with proper preputial hygiene.[7]

True pathologic phimosis is failure to retract the prepuce secondary to distal scarring of the prepuce which often appears as a contracted white fibrous ring around the preputial orifice.[1,2] Pathologic phimosis results in pain, local infections, bleeding, and urinary symptoms (dysuria, recurrent urinary infections, urinary retention, and occasional enuresis) with white, fibrotic, and scarred foreskin.[8] In case of balanitis xerotica obliterans (BXO), there is meatal stenosis with involvement of the glans.[8] These require circumcision.[7,9]

While the physiological adhesions typically resolve spontaneously, parental anxiety often prompts outpatient consultation. Intervention, beyond reassurance, is warranted in symptomatic cases (ballooning, dysuria, urinary stream abnormalities, smegma, or urinary tract infections) or those persisting beyond 5 years. Adhesiolysis is appropriate in older children with supple prepuces, reserving circumcision for pathologic phimosis characterized by thickened, scarred foreskin. The primary objective of the study was to evaluate the efficacy of a 2-week course of topical corticosteroids and outpatient adhesiolysis in managing preputial adhesions. Secondary objectives included assessing adhesion recurrence rates and monitoring for local adverse effects related to corticosteroid application and adhesiolysis.

MATERIALS AND METHODS

This prospective observational study was conducted at a tertiary care hospital between February 2023 and October 2024. Boys presenting with inability to retract the prepuce, ballooning, penile swelling/smegma, urinary symptoms (poor stream, recurrent urinary infections, dysuria, burning, and urinary retention), or a history of balanitis were enrolled. Asymptomatic boys under 5 years were reassured. All participants underwent a detailed physical examination, including assessment of preputial retractability. KIKIROS grading was employed to classify the degree of phimosis. The intervention was offered to symptomatic boys regardless of age.

KIKIROS GRADING [Figure 1a-f]:[10]

Figure 1.

(a-f) KIKIROS grading of preputial adhesions

• Grade 0. Full retraction, not tight behind the glans, or easy retraction limited only by congenital adhesions to the glans

• Grade 1. Full retraction of the foreskin, tight behind the glans

• Grade 2. Partial exposure of the glans, prepuce (not congenital adhesions) limiting factor

• Grade 3. Partial retraction, meatus just visible

• Grade 4. Slight retraction, but some distance between the tip and glans, i.e., neither meatus nor glans can be exposed.

• Grade 5. Absolutely no retraction.

First visit

• Lower grades (KIKIROS 1, 2, 3)

  • Adhesiolysis without ointment.

• Higher grades

• Topical steroid application

  • Demonstration of procedure for application of topical steroid application to the parents/attenders to carry out gentle retraction of the prepuce, application of steroid ointment locally, and forward retraction of the prepuce. This procedure was to be done twice daily for 14 days (2 weeks)

  • If prepuce closed/nonretractable:

Prepuce was opened up with mosquito forceps after the local application of xylocaine jelly.

The parents/attenders were demonstrated the procedure to apply local steroid ointment.

• Revisit after 14 days

  • Gentle Adhesiolysis [Figure 2a-e]

    • Performed in the outpatient setting with gauze after consent

Figure 2.

(a and b) Smegmal Pearl, (c-e): Case of Smegmal Pearl -Post Adhesiolysis

Post-adhesiolysis care:

1. Day 1 onwards

   • Thrice-daily betadine sitz baths for 5 days

   • Oral paracetamol for analgesia (15 mg/kg) for 48 h

2. Day 2 onwards:

   • Start hygienic practices:

     • Local cleaning with mild soap water during bath.

Follow-up evaluations

• 1-week post procedure

• 1-month post procedure

• Between 1 and 3 months

• Between 3 and 6 months

• After 6 months.

Patients with balanitis

• Sitz bath for 5 days

• Local application of Neosporin ointment

• Analgesic

• Once resolved, then the procedure of topical steroid application was demonstrated, and the regimen was followed.

Exclusion criteria

1. Pathologic phimosis:

   • BXO: Whitish, fibrotic, scarred foreskin ± meatal stenosis

   • Secondary phimosis due to trauma/infection.

2. Contraindications to intervention

   • Requiring immediate circumcision:

     • 5–<10 years: 20 excluded

     • 10–<17 years: 20 excluded.

   • Active infection (e.g., severe balanitis requiring prior treatment)

     • Defaulters – Patients who did not visit after the ointment application

     • Lost to follow-up (f/u) – Patients who visited after the ointment application, underwent adhesiolysis but did not come for subsequent visits.

Total patients enrolled – 281, of which, 0–<5 years = 119, 5–<10 years = 137, 10–<17 years = 25.

Complaints at presentation in different age groups [Table 1]

Table 1.

Complaints of patients at presentation in different age groups

Complaints	0–<5 years, n (%)	5–<10 years, n (%)	10–<17 years, n (%)
Inability to retract prepuce	25 (21)	60 (43.8)	16 (64)
Ballooning	31 (26)	5 (03.65)	0
Urinary symptoms	12 (10)	10 (07.03)	1 (4)
Swelling over the penis	6 (5)	2 (1.46)	0
Balanitis	7 (5.8)	3 (2.19)	0
History of recurrent balanitis	0	0	1 (4)
Discharge from penis	1 (0.8)	0	0
Inability to retract prepuce + ballooning	0	26 (18.98)	4 (16)
Inability to retract prepuce + balanitis	0	00
Inability to retract prepuce + urinary symptoms	37 (31)	18 (13.14)	2 (8)
Inability to retract prepuce + ballooning + urinary symptoms	0	6 (4.03)	1 (4)
Inability to retract prepuce + balanitis + urinary symptoms	0	0	0
Ballooning + urinary symptoms	0	5 (3.06)	0
Inability to retract prepuce + ballooning + urinary symptoms + balanitis	0	2 (1.45)	0
Total patients	119	137	25

Complaints at presentation in different age groups are shown in Table 1

Examination findings in all age groups are shown in Table 2

Table 2.

Examination findings of patients in different age groups

Examination	0–<5 years, n (%)	5–<10 years, n (%)	10–<17 years, n (%)
Physiological phimosis	96 (80)	0	0
Preputial adhesions	0	132 (96.35)	25 (100)
Physiological phimosis + smegma pearl	22 (18. 05)	0	0
Physiological phimosis + balanitis	1 (0.8)	0	0
Preputial adhesions + smegma pearl	0	1 (0.73)	0
Preputial adhesions + balanitis	0	3 (2.19)	0
Retractable prepuce	0	1 (0.73)	0
Total patients	119	137	25

Pre and post ointment KIKIROS grading in all age groups are shown in Table 3.

Table 3.

Pre and post ointment KIKIROS grading in different age groups

KIKIROS grade	Preointment			Postointment
	0–<5 years, n (%)	5–<10 years, n (%)	10-<17 years, n (%)	0–<5 years, n (%)	5–<10 years, n (%)	10–<17 years, n (%)
0	0	3 (2.18)	0	1 (1.59)	0	0
1	0	3 (2.18)	1 (4)	0	6 (6.9)	0
2	4 (3.36)	14 (10)	4 (16)	6 (9.52)	12 (13.8)	2 (15)
3	37 (31)	34 (25)	8 (32)	32 (50.79)	61 (70)	9 (69)
4	32 (26.89)	57 (41.6)	9 (36)	15 (23.81)	7 (8)	1 (7.6)
5	24 (20)	20 (14.5)	3 (12)	9 (14.29)	1 (1)	1 (7.6)
5 (closed prepuce)	22 (18.48)	6 (4.37)	0	0	0	0

Observations in different age groups are shown in Table 4.

Table 4.

Observations in different age groups

Serial number	Observations	0–<5 years	5–<10 years	10–<17 years
1	Total number of patients	119	137	25
2	Reassurance	44	3	0
3	Balanitis	0	3	0
4	Adhesiolysis without ointment	6	28	10
I	Lost to follow up	0	6	1
II	Recurrence	0	2	2
III	KIKIROS 0 after 5th follow-up	6	20	09
5	Ointment advised	69	103	15
I	Defaulter	08	16	02
II	KIKIROS 0 with ointment (without adhesiolysis)	02	06	0
III	Lowered KIKIROS grade with ointment	14	0	0
IV	Adhesiolysis with ointment	45	81	13
	A. Lost to follow-up	13	22	3
	B. Recurrence	3	8	4
	C. Follow-up not possible	13	0	0
	D. KIKIROS 0 after 5th follow-up	16	51	10

In the 0–<5 years age group (n = 119), 44 were reassured as they were asymptomatic. Out of the remaining 75 patients, 6 underwent adhesiolysis without ointment; all of them, i.e., 6/6 (100%) were KIKIROS 0 after 5th follow-up. There were no patients who were lost to follow-up or had recurrence. Sixty-nine patients were advised ointment, of whom 8 were defaulters (did not visit after ointment application), 2 patients responded with ointment application and had fully retractable prepuce.

14 patients had lowered KIKIROS grading post ointment application with the resolution of symptoms and hence were reassured. 45 patients underwent adhesiolysis with ointment, but only 16/45 (35.5%) were KIKIROS 0 after 5^th follow-up. 13 patients were lost to follow-up, 3 had recurrences, and in 13 patients, follow-up was not possible. In the 5–<10 years age group (n = 137), 3 patients were reassured as they were asymptomatic, 3 patients were managed for balanitis conservatively. Twenty-eight patients (20%) underwent adhesiolysis without ointment. Of these, 20/28 (71.4%%) were KIKIROS 0 after 5^th follow-up. Six patients were lost to follow-up and 2 patients had recurrences. Of the remaining 103 patients who were advised to use ointment, 16 defaulted. Six patients responded with ointment and had retractable prepuce. 81 (78.64%) patients underwent adhesiolysis with ointment, 51/81 (62.96%) were KIKIROS 0 after 5^th follow-up. Twenty-two patients were lost to follow-up and 8 had recurrence. In the 10–<17 years age group of the total 25 patients, 10 underwent adhesiolysis without ointment and 9/10 (90%) were KIKIROS 0 after 5^th follow-up. Fifteen patients were advised ointment, and 2 were defaulters. Hence, 13 underwent adhesiolysis with ointment, 1 was lost to follow-up, 2 had recurrence, and 10/13 (76.9%) were KIKIROS 0 after 5^th follow up.

RESULTS [TABLE 5]

Table 5.

Results

Treatment given	0–<5 years, n (%)	5–<10 years, n (%)	10–<17 years, n (%)	Total, n (%)
Total	119	137	25	281
Reassurance
Total	44 (36.97)	3 (2.19)	0	47 (16.7)
Adhesiolysis
Total	6	28	10	44
Responders	6 (100)	20 (71.4)	9 (90)	35 (79.55)
Nonresponders	0	2 (7.14)	2 (20)	4 (9)
Lost to follow-up	0	6	1	7 (15.9)
Recurrence	0	2	2	4 (9)
Steroid ointment
Total	69	103	15	187
Responders	2 (2.8)	6 (5.8)	0	8 (4.28)
Nonresponders	59 (85.5)	81 (78.6)	13 (86.6)	153 (81.8)
Defaulter	8	16	2	26 (13.9)
Recurrence	59 (85.5)	81 (78.64)	13 (86.6)	153 (81.81)
Ointment + adhesiolysis
Total	45	81	13	139
Responders	16 (35.5)	51 (62.96)	10 (76.9)	77 (55.39)
Non responders	3 (6.66)	8 (9.87)	2 (15.38)	13 (9.3)
Lost to follow-up or follow-up not possible	26	22	1	49 (35.25)
Recurrence	3	8	2	13 (9.3)
Results	Adhesiolysis with ointment (n=139)		Adhesiolysis without ointment (n=44)
KIKIROS 0 (responders)	77 (55.39)		35 (79.55)
Lost to follow-up	49 (35.25)		7 (15.9)
Recurrence	13 (9.35)		4 (9)

Responders – KIKIROS 0 after 5th follow-up, non responders -KIKIROS grade >0 (any grade) after 5^th follow-up

Overall number of responders (KIKIROS 0 after 5^th follow-up) was more with adhesiolysis alone (79.55%) than steroid ointment for 14 days (4.28%) and combination of steroid followed by adhesiolysis (55.39%).

DISCUSSION

Deibert’s 1933 study concluded that prepuce separation in humans occurs through keratinization of epithelium. The prepuce begins forming at 8 weeks in the fetus as a thickened epidermis ring and grows forward by 16 weeks, covering the tip of the glans. Separation happens via desquamation, where squamous cells form nests that degenerate, creating the preputial space. At birth, the preputial separation remains incomplete (preputial adhesion/nonseparation), making it nonretractable.[11] Wright emphasized that the foreskin remains nonretractable in infancy and early childhood to shield the developing glans from mechanical damage caused by clothing and chemical irritation from urine. He suggested that the foreskin should only be retracted when the child is mature enough to handle it independently.[12]

Phimosis has been classified into grades by Meuli et al., Kikiros et al., Kayaba et al.[10,13,14] Management depends on the age at presentation, the clinical examination indicating the grade of phimosis and the presence of associated symptoms. Asymptomatic boys with physiologic phimosis require reassurance, with guidance on hygiene practices. Gentle retraction during bathing and urination is encouraged,[15] while forcible retraction should be avoided to prevent pain, bleeding, and future adhesions.[16] In our study, asymptomatic boys with physiological phimosis were reassured and in cases of symptomatic boys managed with adhesiolysis alone or topical steroid followed by adhesiolysis, parents were instructed to clean the area daily using mild soap.

Topical steroids have been a mainstay of treatment for over two decades, showing success rates of 65%–95%.[17] The mechanism involves local anti-inflammatory and immunosuppressive action. Steroids stimulate the production of lipocortin which inhibits phospholipase 2 decreasing arachidonic acid production. They decrease m RNA and interleukin-1 formation causing anti-inflammation and immunosuppression.[18] Steroids cause thinning of the skin by reducing dermal synthesis of glycosaminoglycans by fibroblasts and epidermal proliferation.[19]

Among commonly used steroids, betamethasone (0.05% or 0.1%) applied twice daily for 4 weeks has demonstrated success.[20] Other effective agents include hydrocortisone (1%), clobetasol propionate 0.05%), triamcinolone (0.1%), and mometasone dipropionate.[21,22] Studies indicate higher success rates in children above 3 years, with outcomes ranging from 67% to 95%, depending on the agent and duration.[23] Monsour et al. (1999) reported 67% success rates with 0.05% betamethasone for 1 month.[24] Chu et al. reported 95% success rate with topical steroid and improved hygiene; however, poor response was observed in cases with buried penis.[25] Pless et al. observed 74% success rates with 0.05% betamethasone ointment twice daily for 1 month and foreskin retraction attempt after 14 days.[26] Webster and Leonard reported 82% success rates with Triamcinolone twice daily for 1 month with failure observed in cases of BXO, buried penis, penoscrotal webbing, and older age group.[7] Elmore et al. reported 74% success rates after 1 month of betamethasone increasing to 92% after 2 months.[20] Ashfield et al. observed 87% success rates with 6-week course of topical steroids.[27] Van Basten et al. reported 75% success rates with topical steroids for 4–8 weeks. Steroid topical cream is a painless, less complicated, and more economical alternative to circumcision for treating physiological phimosis.[28] Marques et al. observed 94.2% success rates with topical 0.05% betamethasone ointment for 4 weeks–4 months with failure in those with no exposure of urethral meatus.[29] Sookpotarom et al. reported 85.9% success rates with 0.05% betamethasone applied twice daily for 2 months.[30] A Cochrane systematic review in 2014 reported that topical steroids significantly increased partial or complete clinical resolution of phimosis.[31] Makhija et al. reported 84% success after 6 weeks steroid local application.[32] There were no systemic/local adverse effects reported with topical steroids so far. However, Zhou et al., observed long-term success rate of 66% over a mean follow up 26.9 months with 0.1% mometasone furoate twice daily for 1 month with higher success rates in grade 4 than 5 with poorer outcome in cases of balanoposthitis and reported local erythema and burning sensation as side effects.[33] Studies have reported decline in retractability several months after completion of therapy.[34] In our study, no systemic/local side effects of steroid were observed after local application for 2 weeks.

Nonsurgical adhesiolysis/gentle preputial retractions carried out on outpatient basis is cheap, safe, and effective treatment.[35] Local anesthetics (e.g., EMLA) may be used before the procedure.[36] In a study by Aworanti et al., adhesiolysis was performed in 534 cases with circumcision subsequently required in 45 (8.4%) children most being older than 5 years.[37] Combining topical steroids with stretching has yielded high success rates.[38] Preputial adhesiolysis is a safe and effective treatment for symptomatic preputial adhesions in boys younger than 5 years old. 10.2% (7/65) required circumcision due to persistence of symptoms.[39] In our study, following adhesiolysis complications such as recurrence (mostly in lost to follow-up patients), paraphimosis (2 patients), urinary retention (1 patient) in 0-<5 years group) and post adhesiolysis balanitis (2 patients in 0-<5 years, 4 patients in 5-<10 years group) [Figure 3a,b] were observed. However, these complications were managed conservatively. Improved outcomes were noted when combined with short courses of topical steroids.

Figure 3.

Complications following adhesiolysis, (a) Paraphimosis, (b) Post adhesiolysis Balanitis

It was observed that there is lack of compliance and motivation among older patients and caregivers. In our study, combining the application of local steroid followed by adhesiolysis resulted in KIKIROS 0 (after 5^th f/u) in 55.39% of patients, with defaulters 9%, lost to follow-up 27%, and recurrence rates (10%). Among those who underwent adhesiolysis without ointment, 79.55% achieved KIKIROS grade 0 by 5^th follow-up, with 16% lost to follow-up and 9% recurrence rates. Maintenance of local hygienic practices resulted in excellent success rates after 6-month follow-up with completely retractable prepuce.

Following ointment application, the KIKIROS grading improved partially from grade 5 to grades 3 or 4, remaining adhesions released by adhesiolysis. Those with KIKIROS 4 improved to KIKIROS 3 after ointment, further requiring adhesiolysis; those with KIKIROS 3 at presentation had no significant improvement in the grading. Post short course of ointment application, most of the boys had KIKIROS 3 (50%, 70%, 60%), emphasizing the need for adhesiolysis and that the process of manual adhesiolysis is eased with the prior local application of ointment.

Patients lost to follow-up or non-compliant often returned with worsened adhesions, requiring additional interventions. Ballooning of the prepuce and urinary retention in infants with physiologic phimosis (KIKIROS 5) were managed with gentle opening of prepuce and subsequent steroid application. Following 14 days of steroid local application, prepuce opened up in majority of patient who came on follow up with KIKIROS grade 3. Their symptoms had resolved, and hence were reassured. The studies reported in the literature have shown 67%–95% success rates with local application of steroid ointment for a variable period ranging from 4 weeks–4 months. However, in our study, 2-week topical steroid improved symptoms in 11.76% of cases. Success rates are improved in cases of adhesiolysis without ointment (79.5%) and with ointment (55.39 %), with overall success rates of adhesiolysis as 61.2%.

CONCLUSION

It can be concluded that short-course of topical corticosteroids, gentle adhesiolysis, proper hygienic practices, and follow-up is a safe and effective treatment strategy for managing preputial adhesions in children, achieving high rates of foreskin retractability and minimizing the need for circumcision.

Key messages

1. Patients less than 5 years group can be managed by reassurance unless they are symptomatic.

2. Intervention is usually required in the older age groups.

3. Pre ointment KIKIROS grading higher in the younger age groups, with the older children presenting with lower grades as there is spontaneous release of adhesions with increasing age.

4. Topical steroids can be helpful, but adhesiolysis alone demonstrates higher efficacy, especially in those with lower initial KIKIROS grades.

5. Post-procedure hygiene education and regular follow up is crucial to minimize recurrence.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.