What are the recommended management strategies for a child diagnosed with phimosis who is experiencing recurrent infections?

For a child diagnosed with phimosis who is experiencing recurrent infections, the management strategies depend on the type of recurrent infection.

• Management of Phimosis with Recurrent Balanitis
  • Referral to a paediatric urologist or surgeon is recommended for consideration of circumcision if there is persistent phimosis, suspected lichen sclerosus, or severe, recurrent attacks of balanitis that do not respond to management in primary care ¹.
  • Circumcision may be curative for persistent balanitis that does not respond to optimal treatment in primary care ¹.
  • Initial primary care management for balanitis involves advising on good daily hygiene, washing daily with lukewarm water, and keeping the foreskin retracted until the glans penis is dry where possible ¹. It is important not to attempt to retract the foreskin if it is still fixed ¹. Avoid irritants such as soap, bubble bath, or baby wipes, and consider using an emollient as a soap substitute ¹.
  • Treatment for acute balanitis depends on the likely underlying cause ¹. For suspected non-specific dermatitis, topical hydrocortisone 1% cream or ointment can be prescribed once a day for up to 14 days ¹. If candidal balanitis is suspected or confirmed, an imidazole cream should be prescribed for up to 14 days ¹. For suspected or confirmed bacterial balanitis, a topical antibiotic like mupirocin 2% ointment can be considered for mild infections, or oral phenoxymethylpenicillin for severe infections while awaiting swab results ¹. If inflammation causes discomfort, topical hydrocortisone 1% cream or ointment can be considered in addition for up to 14 days ¹.
• Management of Recurrent Urinary Tract Infections (UTIs)
  • All children with recurrent UTIs should be referred to a paediatric specialist for assessment and investigations ²,⁴. Recurrent UTI is defined as two or more episodes of UTI with acute pyelonephritis/upper urinary tract infection, or one episode of UTI with acute pyelonephritis/upper urinary tract infection plus one or more episodes of UTI with cystitis/lower urinary tract infection, or three or more episodes of UTI with cystitis/lower urinary tract infection ²,⁴.
  • Investigations include arranging an ultrasound of the urinary tract during the acute infection for children under 6 months with recurrent UTI, or within 6 weeks for children aged 6 months and over with recurrent UTI ²,⁴. A dimercaptosuccinic acid (DMSA) scintigraphy scan to detect renal parenchymal defects should be carried out within 4–6 months following the acute infection in all children with recurrent UTI, arranged by paediatric specialists ²,⁴.
  • After specialist advice, a trial of daily antibiotic prophylaxis may be considered if behavioural and personal hygiene measures alone are not effective or appropriate ². Preferred treatment options for prophylaxis include trimethoprim or nitrofurantoin ².
  • General preventative measures include managing dysfunctional elimination syndromes and constipation ⁴. Children who have had a UTI should be encouraged to drink enough water to avoid dehydration and have access to clean toilets when needed, avoiding unnecessary delay in voiding ⁴.
  • Routine surgical intervention for vesicoureteral reflux (VUR) is not recommended ⁴.