What is the treatment for a 6-year-old uncircumcised male with dysuria, hematuria, and proteinuria, who is unable to retract his foreskin due to phimosis?

From the Guidelines

The treatment for this 6-year-old boy with phimosis and urinary symptoms should begin with topical steroid therapy, as it is the most effective and least invasive approach, with a success rate of 80% in improving retractability of the foreskin after 1 month of treatment 1. I recommend applying 0.05% betamethasone cream to the tight foreskin twice daily for 4-6 weeks. This steroid helps thin the skin and reduce inflammation, allowing for easier retraction. During this time, gentle retraction attempts during bathing can help stretch the tissue. Some key points to consider in the treatment plan include:

• Antibiotics are also necessary to treat the likely urinary tract infection causing his dysuria, hematuria, and proteinuria - amoxicillin-clavulanate at 45 mg/kg/day divided twice daily for 7-10 days would be appropriate.
• If topical steroids fail after 6 weeks, surgical options should be considered, including circumcision or preputioplasty.
• It's essential to obtain a urine culture before starting antibiotics and to ensure proper hygiene education for both the child and parents.
• This combined approach addresses both the immediate infection and the underlying phimosis, which if left untreated could lead to recurrent infections or balanoposthitis.
• Physiologic phimosis is normal at this age, but when accompanied by symptoms, treatment is necessary to prevent complications, as supported by the British Association of Dermatologists' guidelines for the management of lichen sclerosus 2010 1.

From the Research

Treatment for Uncircumcised Male with Dysuria, Hematuria, and Proteinuria

The treatment for a 6-year-old uncircumcised male with dysuria, hematuria, and proteinuria, who is unable to retract his foreskin due to phimosis, involves addressing the underlying cause of these symptoms.

• The patient's symptoms, such as dysuria, hematuria, and proteinuria, may be related to a urinary tract infection (UTI) or other conditions that require medical attention.
• Phimosis, or the inability to retract the foreskin, can be either physiologic or pathologic 2.
• Physiologic phimosis is a common condition in young boys and can be managed conservatively with proper foreskin care and hygiene 2, 3.
• However, pathologic phimosis requires surgical intervention.

Management of Phimosis

• Topical steroid creams have been shown to be effective in treating physiologic phimosis and reducing the risk of recurrent UTIs 4, 5.
• A study published in the Journal of Pediatric Urology found that the use of steroid cream for physiologic phimosis was associated with a decreased risk of recurrent UTIs in uncircumcised male infants with a normal renal ultrasound 4.
• Another study found that retractable foreskin reduces UTI risk in uncircumcised boys less than one year of age with vesicoureteral reflux 5.

Circumcision as a Preventive Measure

• Circumcision has been shown to reduce the lifetime risk of UTIs in males 6.
• A systematic review and meta-analysis found that 32.1% of uncircumcised males experience a UTI in their lifetime, compared to 8.8% of circumcised males 6.
• However, the decision to circumcise should be made on a case-by-case basis, taking into account the individual's medical history and risk factors.

Recommendations

• The patient should be evaluated by a pediatric urologist to determine the underlying cause of his symptoms and to develop an appropriate treatment plan.
• Proper foreskin care and hygiene should be reinforced to help prevent UTIs and promote the resolution of physiologic phimosis 2, 3.
• Topical steroid creams may be considered as a treatment option for physiologic phimosis, and circumcision may be recommended as a preventive measure for UTIs in some cases 4, 5, 6.