The Use of Steroid Cream for Physiologic Phimosis in Male Infants with History of UTI and Normal Renal Ultrasound is Associated with Decreased Risk of Recurrent UTI

Extended 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 our clinic. Topical steroid creams have been shown to effectively release physiologic phimosis. Objective 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 less than 12 months of age referred for a UTI with a normal renal ultrasound were included. A longitudinal dataset was created and recurrent UTIs 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 were also described. The association of recurrent UTI with VUR was also evaluated. Results 192 uncircumcised males with a median age of 5.8 months (interquartile range (IQR) 3.5-7.9 months) were included. 27 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 vesicoureteral reflux (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 to 27/165 (16%) patients not treated (p=0.02). Among the 173 patients whose initial UTI was febrile, recurrent febrile UTIs occurred in 0/23 treated patients and 23/150 (15%) untreated patients (p=0.047). Discussion The results of this study are consistent with a previous randomized trial of steroid cream for physiologic phimosis that 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.