The Use of Steroid Cream for Physiologic Phimosis in Male Infants with History of Febrile UTI and Normal Renal Ultrasound is Associated with Decreased Risk of Recurrent UTI
Catherine J. Chen, MD, Arthi Satyanarayan, MD, Bruce J. Schlomer, MD.
University of Texas Southwestern Medical Center, Dallas, TX, USA.
Background: Uncircumcised male infants are commonly evaluated by pediatric urologists for urinary tract infection (UTI). Radiographically, many of these uncircumcised male infants may have no anatomical anomalies but have physiologic phimosis on physical exam. Topical steroid creams have been shown to release phimosis, which may decrease risk of recurrent UTIs. Currently, there is no consensus on the efficacy of routine steroid cream use for physiologic phimosis to reduce the risk of recurrent UTIs. We hypothesized that use of steroid cream for physiologic phimosis is associated with a lower rate of UTI recurrence in male infants with normal renal ultrasounds.
Methods: We identified uncircumcised males less than 12 months of age who were referred to pediatric urology for a febrile UTI from 2009 - 2018. Patients with a normal renal ultrasound, inflammation on a catheterized urinalysis specimen, and >50,000 colony forming units of uropathogen were included. A normal renal ultrasound was defined as no hydronephrosis, hydroureter, or duplication anomalies. Those with concern for neurogenic bladder were excluded. A longitudinal dataset was created and follow-up UTIs identified. The proportion with recurrent UTI was compared between those who received a course of steroid cream for phimosis and those who did not. The morbidity of initial and recurrent UTIs was also described.
Results: 193 males with a median age of 5.4 months (interquartile range 3.5-7.9 months) were included; 27 were treated with a 6-8 week course of betamethasone valerate 0.1% cream and 166 were not. Of those treated, 0/27 (0%) had a recurrent UTI compared to 27/166 (16%) in those who were not treated (p=0.02). Based on failure curve analysis, the cumulative incidence of a recurrent UTI in those not treated at 1 year was 29% (95% CI 19%-43%). For the entire cohort, 87 were admitted for their initial UTI, 90 were treated with IV antibiotics, including 17 with PICC line, and 23 had a lumbar puncture. Among the 27 who had a recurrent UTI, 6 were admitted, 1 had lumbar puncture, and 11 received IV antibiotics. A VCUG was obtained in 20/27 (74%) who were treated with steroid cream compared to 98/166 (59%) who were not treated (p=0.2). Vesicoureteral reflux (VUR) was diagnosed in 5/27 (19%) treated with steroid cream compared to 34/166 (20%) in those not treated (p=0.9). Among those with VUR, 12/39 (31%) had a recurrent UTI compared to 15/154 (10%) of patients without VUR (p=0.001).
Conclusion: The use of steroid cream for physiologic phimosis was associated with a decrease risk of recurrent UTIs in uncircumcised male infants with a normal renal ultrasound. The estimated cumulative incidence of recurrent UTIs in those not treated with steroid cream was around 30% at 1 year. VUR was also associated with recurrent UTI. The morbidity of the initial and recurrent UTIs can be significant, with many undergoing hospital admission and IV antibiotic therapy. Steroid cream for phimosis offers a non-invasive option to potentially decrease recurrent UTI risk in this group.
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