International Journal of Urology, Volume 10, Issue 12: Page 651-656, December 2003.
ERDAL YILMAZ, ERTAN BATISLAM, MEHMET MURAD BASAR AND HALIL BASAR
Department of Urology, Faculty of Medicine, University of Kirikkale, Kirikkale, Turkey
Objective: The objective of our study was to assess the efficacy of topical steroids in the treatment of phimosis and evaluate patients using the Diagnostic and Statistical Manual-III-Revised (DSM-III- R) test with the aim of eliminating castration anxiety of circumcision in the phallic period.
Methods: One hundred and forty-nine children with phimosis who required circumcision were included the study. The average age of the children was 4.47 years. All children underwent the DSM-III-R test and their parents were questioned. Patients were separated randomly into three groups. Group I comprised 51 children who would undergo circumcision; group II comprised 50 children who would be treated with a topical corticosteroid (0.05% bethamethasone cream) twice daily for 1 month; and group III comprised 48 children who would be treated with a topical placebo cream. On the 5th day of treatment, parents were told to retract the prepuce and were given hygiene routine instructions. Patients were seen immediately after treatment and again 2 months later.
Results: In group II, 16 of the 50 children had non-retractable prepuce. Forty-two cases of phimosis were corrected after treatment. Eight patients received further monthly treatment and five benefited from the second course of treatment. In group III, 17 of the 48 patients had non-retractable prepuce and four had satisfactory results. Forty-four patients received placebo treatment for another month and eventually, 40 children underwent circumcision in this group. DSM-III-R test results showed a significant shift to anxiety in the circumcision group. There were no significant differences in the other groups.
Conclusion: Topical steroids for the treatment of phimosis is a highly effective treatment alternative to surgery. It avoids or delays circumcision and can be practised during the phallic period to decrease castration anxiety. The treatment is suitable for patients from any religious or cultural background.
castration anxiety, phallic period, phimosis, topical steroid.
Circumcision is the most frequently practiced surgery in Turkey for religious and traditional purposes. Most of the operations are performed in neonates and primary school children. It has been pointed out that between the ages of 3 and 6 years - the ‘phallic period’ of childhood development - circumcision may affect the psychological status of the child and eventually cause psychological and behavioral disturbances. Awareness of the phallic structure and gender identity develops during the phallic period. The male child’s perspective on genitalia diverts to the female sex during this period and differences in sex are noted by the child. Therefore, circumcision may sometimes be imagined as the total loss of genitalia.1 Castration anxiety, despite its controversial nature, may develop during the phallic period; therefore, elective circumcision is generally avoided during this period.
Cansever assessed 12 boys before and after they were circumcised and reported severe functional disturbances after circumcision as measured by psychological testing.2 Kennedy reported the case of an adolescent boy who was traumatized by circumcision.3 Yorke reported the need for additional studies of psychological trauma. He cited the trauma of circumcision as an example.4
Phimosis is defined as the narrowing of the opening of foreskin, which makes it difficult to retract the foreskin to the coronal sulcus. During the neonatal period and up to 3 years of age, physiologic phimosis is common and the prepuce cannot be retracted. At around 3 years of age, 90% of foreskins become retractable.5 Pathologic phimosis occurs after 3 years of age. When inflammatory processes and voiding difficulties are predominant, phimosis is the reason for performing circumcision before the planned time.
The authors of this study used outmoded diagnostic criteria to determine the existence of phimosis in very young boys. It is probable that most of these boys would have achieved retractable foreskins without treatment in the course of time. For more information on the normal development of the foreskin see Normal.
Topical steroids have proved to be effective in most phimotic patients.6-13 Excluding infectious processes, steroids can be used safely and easily for the treatment of phimosis. Our study was based on the idea that circumcision in patients with phimosis between the ages of 3 and 6 years can be delayed with the use of topical steroids to avoid castration anxiety phenomenon. We also evaluated children using the Diagnostic and Statistical Manual-III-Revised (DSM-III-R) test to assess their psychological status before circumcision.
Between December 1999 and June 2002, 149 children with phimosis between the ages 3 and 6 years were included in the study group. Children were randomly separated into three groups. Group I comprised 51 children who would undergo circumcision, group II comprised 50 children who would be treated with a topical corticosteroid (bethametasone 0.05% cream, twice daily for 1 month), and group III comprised 48 children who would receive a topical placebo neutral cream (Vaseline, twice daily for 1 month). After 5 days of treatment, prepuces were retracted by parents each day throughout the treatment. Hygiene instructions were given to parents and children.
All patients were assessed for the type of phimosis and classified as either: (i) retractable when a tight and constricting phimotic ring existed, but did not completely prevent the retraction of the foreskin; (ii) non-retractable when the ring prevented retraction of the foreskin, and the external urethral meatus was exposed; or (iii) pinpoint when the foreskin was so constricted that the meatus could not be visualized.
Control examinations were held immediately after treatment and again after 1 and 2 months. The outcome was defined as: (i) a success if the prepuce was retractable and was without a ring; or (ii) a failure if a constrictive ring persisted.
The parents provided informed consent for entering their children into the study. Children and parents were evaluated and given information about the treatment by a urologist and a child and adolescent psychiatrist 1 month before treatment. Parents were told to observe the child for 1 month and their observations were recorded at the end of this period. DSM-III-R assessment was performed twice for each patient: the first time 1 month before the main treatment, before treatment information was given to the child and his parents; and the second time just before treatment, after treatment information had been provided. The aim of the observation and DSM-III-R evaluation was to assess the possibility of castration anxiety, particularly in the circumcision group compared to the other two groups. Circumcision was performed accordingly in 51 children by the guillotine technique under ketamine anesthesia. There were no postoperative complications in any of the cases.
Statistical analysis was performed using the Pearson χ2 test.
All patients were re-evaluated after 1 month and again after 2 months in the steroid and placebo groups. Of the 51 patients in groups I, 22 had a retractable prepuce, 16 had non-retractable prepuce and 13 had pinpoint opening prepuce. Types of phimosis and success rates in groups II and III are shown in Tables 1 and 2.
Castration anxiety was assessed by questioning the parents and evaluating the child by DSM-III-R. In the circumcision group, during the 1 month period before circumcision, 44 children displayed some degree of isolation, aggression towards the family members, disruption in relations with friends and fear of being alone. However, in the topical corticosteroid and placebo groups these type of disorders were detected in only three and two of the children, respectively. The results of the DSM-III-R test, which was performed 1 month before and just before the therapy are shown in Table 3. The difference in anxiety rates between 1 month before and just before treatment in group I were statistically significant for any kind of anxiety disorder (P = 0.000).
In group II, 42 (84%) of 50 children benefited from topical corticosteroid application after 1 month and five additional cases of phimosis were resolved after subsequent monthly topical corticosteroid therapy, yielding a final success rate of 94%. Three patients required circumcision because they did not respond to the treatment.
In group III, four patients (8.33%) showed remarkable improvement and the remaining 44 patients underwent another monthly course of topical placebo which rendered four more cases of satisfactory preputial retraction. The remaining 40 patients underwent circumcision. Eventually, 50 patients had topical corticosteroids and in 47 (94%) of them the need for surgery was eliminated. Patient age groups and success rates are shown in Tables 4 and 5.
Circumcision, a ritual as old as written history, has been applied extensively in many countries, predominantly for religious and traditional reasons. However, in cases of phimosis, paraphimosis and various infective disorders of the prepuce, circumcision is applied as a medical procedure. Regardless of the reason for circumcision, it is commonly accepted that the most appropriate periods in which to perform the surgery are the newborn and primary school periods. Surgical operations and circumcision on genitalia throughout the phallic period are not recommended and should be performed only if they are unavoidable.5 In some communities, where almost every male has undergone circumcision and the timing of the operation has not been a concern, the hazardous effects of circumcision, particularly during the phallic period, should be considered. During child development, despite the controversy that surrounds the theory, the Oedipus phenomenon is defined as one of the most important periods of life. Many psychiatric methods study childhood developmental stages to detect various psychological and behavioral disorders. Moreover, in Freud’s theory about psychosexual development, differences in particular stages cause differences in adult sexual behavior. In addition, many psychological disturbances are linked to the developmental stage. At around the age of 3 years, the child enters the phallic stage, which is characterized by genital pleasure and the primary task of finding a love object that will later establish the child’s object choice.1
Freud named the psychodevelopmental stage between the ages of 3 and 5 years as the Oedipal stage and gave special importance to the pathogenesis of neuroses, anxiety disorders, hysterical personality and obsessive-compulsive personality during this period. Resolution of this stage in males begins at around 6 years of age. A boy during this stage fears that the father will remove the boy’s penis because of the envy that exists between them. Therefore, this stage referred to as the stage of genital fears.1,14 We think that circumcision at the Oedipus complex stage may affect or disturb childhood psychosexual development and eventually is the basis for future disorders. In the late 19th and early 20th century, Freud identified castration anxiety as the result of fear of operations on the genitals.14 As early as 1929, Glover reported a case of impotence secondary to castration anxiety caused by a particularly brutal circumcision.15 Richards et al. observed behavior differences in boys in the USA that were not found in boys in Europe. The USA male children were circumcised while the European children were not circumcised; therefore it was suggested that the changes were due to circumcision.16
The 1987 DSM-III-R describes conditions for the pathogenesis of post-traumatic stress disorder. These were deemed to be exactly the same as those experienced by a helpless infant undergoing circumcision.17 DSM-III-R results in our study showed that the rate of anxiety disorders such as multiple anxieties, overanxious disorder, simple and social phobias and separation anxiety were remarkably higher in the circumcision group.
McFadyen reported the psychological trauma experienced by her son following circumcision. McFadyen’s description of her son’s trauma is consistent with early reports from Freud and Cansever.14,18 Maguire and Parkes reported on the need to grieve the loss of body parts. Failure to grieve the loss leaves the individual in a state of denial of loss and disconnected from the reality of loss and injury.19 Even though these authors did not establish the link between circumcision during the phallic term and psychological disturbances, it can be inferred that circumcision during the phallic term may have psychological effects.
Topical steroids are well established agents for the treatment of phimosis and are a good alternative to surgery.10 The success rate of topical therapy ranges from 67 to 95% with no reported side-effects.6-9,11 In our study, the efficacy of topical steroids in phimosis after one or two courses of monthly treatment was 94% and only three of 50 patients required surgical circumcision. Golubovic et al. reported that 95% of phimosis disappeared after topical application of bethamethasone.6 This rate was 80% in a larger study of 111 patients.11 Another topical steroid, clobetasol propionate, yielded success rates between 67 and 70% in different studies.7,12 Non-steroidal ointment has also proved to be effective in the treatment of phimosis, yielding a 75% response rate.20 The 94% overall treatment success in our study seems to be higher compared to other studies. However, daily retraction and strict hygiene procedures with clean saline solution and appropriate information given to the patient’s family describing the importance and conditions of daily prepuce care could have contributed to our high success rate.
The application of topical steroids is an easy, effective and low-cost treatment for phimosis. Circumcision is a traumatic experience and anxiety scores in a child tested by DSM-III-R increase preoperatively and perioperatively. In populations where circumcision is a cultural necessity, medical therapy for phimosis with topical steroids can be justified, particularly during the phallic period.
Correspondence: Erdal Yilmaz MD, Kirikkale Universitesi, Tip Fakultesi Uroloji ABD, 71100 Kirikkale, Turkey. Email: firstname.lastname@example.org
Received 12 February 2003; accepted 16 June 2003.
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