The use of steroid cream for physiologic phimosis in male infants with a history of UTI and normal renal ultrasound is associated with decreased risk of recurrent UTI

Summary Background An uncircumcised male infant with a history of urinary tract infection (UTI), physiologic phimosis, and a normal renal ultrasound is a common patient referred to pediatric urology clinics. Topical steroid creams have been shown to effectively release physiologic phimosis. Objective The objective of this study was to test the hypothesis that use of steroid cream for physiologic phimosis is associated with a lower UTI recurrence in uncircumcised male infants with normal renal ultrasounds. Study design Uncircumcised males younger than 12 months referred for a UTI with a normal renal ultrasound were included. A longitudinal data set was created, and recurrent UTIs were identified. The proportion with a recurrent UTI was compared between those who received a prescription for a steroid cream for phimosis and those who did not. The morbidity of the initial and recurrent UTIs was also described. The association of recurrent UTI with vesicoureteral reflux (VUR) was also evaluated. Results A total of 192 uncircumcised males with a median age of 5.8 months (interquartile range [IQR]: 3.5–7.9 months) were included. Twenty-seven patients were treated with a course of betamethasone valerate 0.1% cream, and 165 were not ( Summary Table ). There were no significant differences between groups in the frequency of voiding cystourethrogram (VCUG), diagnosis of VUR, or use of continuous prophylactic antibiotics (CAP). During a median follow-up of 8.7 months (IQR: 3.1–17.5 months), none of the patients treated with steroid cream had a recurrent UTI compared with 27 of 165 (16%) patients not treated (P = 0.02). Among the 173 patients whose initial UTI was febrile, recurrent febrile UTIs occurred in no treated patients and 23 of 150 (15%) untreated patients (P = 0.047). Discussion The results of this study are consistent with those of a previous randomized trial of steroid cream for physiologic phimosis which found lower recurrent UTI in those whose foreskins became retractable. In addition, the results are consistent with the declining incidence of UTIs in uncircumcised males mirroring the natural history of physiologic phimosis resolving. This study is limited by its retrospective nature and non-standardized follow-up. Conclusion The use of steroid cream for physiologic phimosis is associated with a decreased risk of recurrent UTIs in uncircumcised male infants with a normal renal ultrasound. In this group, steroid cream for physiologic phimosis is a well-tolerated and simple alternative to circumcision to potentially decrease risk of recurrent UTI. Summary table . Patient characteristics and results Patient characteristic or result All patients (n = 192) Steroid cream group (n = 27) Non-steroid cream group (n = 165) P-value Median age in months at referral (IQR) 5.8 (3.5–7.9) 6.2 (3.6–8.4) 5.7 (3.4–7.8) 0.4 a Documented Febrile UTI 173 (90%) 23 (85%) 150 (91%) 0.3 b Catheterized specimen documented 132 (69%) 20 (74%) 112 (68%) 0.7 b VCUG obtained 118 (61%) 20 (74%) 98 (59%) 0.2 b VUR diagnosed 39 (20%) 5 (19%) 34 (21%) 0.9 b CAP use at any point 27 (14%) 6 (22%) 21 (13%) 0.2 b Median follow-up time in months (IQR) 8.7 (3.1–17.5) 12.1 (6.4–17.5) 7.8 (3.0–17.7) 0.3 a Recurrent UTI 27 (14%) 0 27 (16%) 0.02 b UTI = urinary tract infection; IQR = interquartile range; VCUG = voiding cystourethrogram; VUR = vesicoureteral reflux; CAP = continuous antibiotic prophylaxis. a Wilcoxan rank-sum test. b Fisher exact test.