Treatment of childhood phimosis with a moderately potent topical steroid

Background : Recently, topical steroid application has been shown by a small number of studies to be an effective alternative to circumcision for the treatment of phimosis. However, only potent or very potent corticosteroids have been more thoroughly studied in this treatment option. A prospective study was conducted to determine whether comparable results could be achieved using a weaker steroid cream. Methods : Boys, 3–13 years of age, with non‐retractable foreskin due to a tight ring at the tip were offered the regimen of twice‐daily preputial retraction and topical application of 0.02% triamcinolone acetonide cream. The degree of preputial retractability was assessed at presentation and at 4 and 6 weeks of treatment. Success was defined as full retraction or free retraction up to agglutination of the foreskin to the glans. Results : Eighty‐three boys completed the treatment. Successful retraction was achieved in 48/83 (58%) patients after 4 weeks and 70/83 (84%) patients after 6 weeks of application. The overall response rate aggregated from six published series using 0.05% betamethasone was 87% at 4 weeks and 90% on completion of treatment. Thus, the results appear inferior when analysed at 4 weeks but compare favourably with those reported for a more potent steroid on completion of the full course of treatment. Conclusions : Even though the triamcinolone cream used in the present study is less potent than the more commonly used 0.05% betamethasone valerate cream, it could effect comparable improvements in foreskin retractability after 6 weeks of treatment.     

Early effect of non-surgical treatment using betamethasone valerate ointment for phimosis in childhood

We evaluated the early efficacy of non-surgical treatment using 0.07% betamethasone valerate ointment on, 34 boys with phimosis between January 2001 and June 2005. Patients were treated with 0.07% betamethasone valerate ointment applied to the distal aspect of the prepuce every other day for 2-6 weeks. During the treatment period, patients were instructed to retract the foreskin to penis root without overstraining. The overall success rate was 94.1% and therapeutic effects were observed in 58.8% of the patients in two weeks. There were no medical side effects. Treatment using betamethasone valerate ointment is very effective, easy and safe. We recommend this treatment for patients with phimosis and/or those with recurring balanoposthitis.     

An 18-month follow-up study after randomized treatment of phimosis in boys with topical steroid versus placebo

OBJECTIVE: To evaluate the treatment of phimosis using topical steroid. MATERIAL AND METHODS: This was a follow-up study after a prospective, randomized, double-blind study. A total of 137 boys with phimosis were randomly assigned to either betamethasone treatment or placebo for 4 weeks, with application of the cream twice daily. Non-responders to treatment were offered steroid treatment for a further 4 weeks. All patients were invited to a follow-up examination after 18 months. RESULTS: The mean pre-treatment phimosis grades in the steroid and control groups were 5.08+/-0.66 and 4.97+/-0.70, respectively. At the 4-week follow-up, 49 boys (74%) in the steroid group were cured, compared to only 31 (44%) in the control group. Fourteen boys were circumcised after another 4 weeks of treatment; 43 of the remaining 57 boys (17 in the steroid group; 40 in the control group) had been cured. After a total of 92 boys took part in the 18-month follow-up study: 79 had been cured and 13 had suffered a relapse. Twenty-six patients did not took part in the follow-up investigation. No side-effects were noted. CONCLUSIONS: When treatment is necessary for phimosis, we recommend application of topical steroid as first-line treatment because surgery can then be avoided in 85% of cases. This first randomized, double-blind, follow-up study shows that the treatment effect persists for at least 18 months.     

Cost-effectiveness analysis of treatments for phimosis: a comparison of surgical and medicinal approaches and their economic effect

OBJECTIVE: To compare the cost-effectiveness of surgery and topical steroids as treatments for phimosis (defined as a clinically verifiable, pathological, cicatricial stenosis of the prepuce) and to evaluate the financial basis of these treatments. METHODS: Data on treatment using topical steroids was obtained from published reports and those for circumcision from claims by private hospitals for children < 13 years old registered at the health insurance department of our facility. The estimate of the French national financial cost of the treatments for 1998 was calculated from public and private institutional information. RESULTS: Treatment with topical steroids for 4-8 weeks was successful in approximately 85% of patients (mean age 5 years) and had no side-effects; the remaining 15% were treated by circumcision. Topical steroid therapy costs (in French francs) F 360 per patient. For those primarily treated by circumcision (81 boys, mean age 4.3 years) and diagnosed as having phimosis, the cost was F 3330 per patient in the private sector. The total number of circumcisions performed in France, regardless of sector (public or private) for 1998 was estimated to be 51 080, which represents an annual cost of F 195.7 million. CONCLUSION: As topical pharmacological treatment avoids the disadvantages, trauma and potential complications of penile surgery, including anaesthesia-related risks, the use of topical steroids as a primary treatment appears to be justified in boys with clinically verifiable phimosis. This treatment could reduce costs by 75%, which represents a potential annual saving of approximately F 150 million.     

局部类固醇治疗小儿包茎临床疗效分析

目的评价局部类固醇治疗小儿包茎的临床疗效。方法随机选取2001年10月至2003年4月门诊包茎患儿40例，年龄2～14岁，平均8．7岁。其中外口狭窄型15例、粘连型25例，粘连分级Ⅰ级9例、Ⅱ级9例、Ⅲ级7例。给予0．05％倍他米松软膏，早晚各一次涂抹于包皮狭窄开口及粘连处，5d后每次用药时可轻微用力上翻包皮，1个月后门诊随访评价疗效。结果40例患儿中完全治愈26例、好转10例、无效4例，治愈率65％，总有效率90％。其中包皮粘连Ⅰ级治愈率100％、Ⅱ级78％、Ⅲ级29％，总有效率92％，包皮外口狭窄型治愈率为53％，总有效率86％。患儿治疗期间均无不良反应。结论局部类固醇治疗小儿包茎是一种安全、简便、无痛、有效的新方法。     

Conservative treatment of childhood phimosis with topical conjugated equine estrogen ointment

PURPOSE: To assess the application of topical conjugated equine estrogen for the treatment of boys with phimosis. METHODS: Fifteen boys with phimosis were included in the study. Conjugated equine estrogen (Premarin) 0.1% ointment was applied on the prepuce once daily. The treatment was continued until the prepuce was fully retractable. The patient was examined each second week up to a maximum treatment of 8 weeks. Retractability and the appearance of the foreskin were graded before and after treatment. RESULTS: Thirteen of 15 boys (87%) referred with phimosis were successfully treated with conjugated equine estrogen ointment. An adverse effect of gynecomastia was seen in one boy (7%). CONCLUSION: Conjugated equine estrogen ointment application for phimosis may be an alternative to surgery.     

Treatment of phimosis with topical steroids in 194 children

PURPOSE: Topical steroids have been advocated as an effective economical alternative to circumcision in boys with phimosis. We evaluated the effectiveness of topical steroid therapy as primary treatment in 194 patients with phimosis. METHODS: Between January 1996 and November 2000, 228 boys 16 years old or younger were referred for consideration of circumcision. When intervention was determined to be necessary, a 6-week course of topical steroids was used as primary treatment. Efficacy of treatment was evaluated at 3 months from initiation of therapy. RESULTS: Of the 228 patients 15 had such a mild degree of phimosis that no intervention was believed to be necessary, 19 were scheduled directly for circumcision due to cosmetic reasons, parent wishes, or severe phimosis with associated voiding problems and the remaining 194 received topical steroids as primary treatment. Of these 194 patients 25 had coexisting balanitis and 4 had a history of urinary tract infection. Conservative treatment was successful in 87%, 88% and 75% of patients with phimosis alone, coexisting balanitis and history of urinary tract infection, respectively. Overall, circumcision was avoided in 87% of patients treated with topical steroids. CONCLUSION: Topical steroids are becoming the standard conservative measure for treating phimosis. Our study supports this trend, with an overall efficacy of 87%.     

Effect of topical steroid on non-retractile prepubertal foreskin by a prospective, randomized, double-blind study

OBJECTIVE: The present study, conducted in Hong Kong, aimed to evaluate the effect of topical steroid in non-retractile prepubertal foreskin by a prospective, randomized, double-blind design. MATERIAL AND METHODS: 137 boys with non-retractile foreskin were randomized to betamethasone (n = 66) or placebo (n = 71 ) for 4 weeks with application of the cream twice daily. Non-responders to treatment were offered steroid treatment for a further 4 weeks. RESULTS: The mean pretreatment grade of the foreskin in the steroid and control groups was 5.08 +/- 0.66 and 4.97 +/- 0.70, respectively. At the 4-week follow-up, 49 of the former (74%) had a retractile foreskin (grade less than or equal to 3, mean 2.38 +/- 1.41). In contrast, only 31 of the control group (44%) had a retractile foreskin (less than or equal to 3, mean 3.55 +/- 1.55) (p < 0.001). Only 14 boys were circumcised because 43 of the remaining 57 boys had a retractile foreskin after 4 weeks of treatment. CONCLUSION: when treatment is necessary, application of topical steroid as a first line of treatment may avoid surgery in almost 90% of cases.     

儿童包茎的内科治疗

目的：局部使用四环素可的松软膏治疗男孩包茎。　材料和方法：对患包茎３～７ 岁男孩４０ 例随机分成两组,治疗组２０例,从包皮孔挤入四环素可的松软膏,对照组２０ 例使用凡士林油膏,治疗６ 周,观察包皮上翻程度及不良反应。　结果：治疗组１８ 例效果良好（占９０％ ）,对照组４ 例有效（占２０％ ）。无不良反应。　结论：对３ 岁以上男孩包茎局部使用四环素可的松软膏治疗,方法简单可靠。     

A conservative treatment of phimosis in boys

OBJECTIVE: The aim of this study was to evaluate the efficacy of topical applications of clobetasol propionate cream in the treatment of phimosis in boys and a comparison of the results presented with an overview of the current studies. METHODS: In a prospective study, 94 boys (mean age 5.5 years) were treated with topical applications of 0.05% clobetasol propionate cream twice daily. The prepuce was treated for 1 month, with an attempt at prepuce retraction after 14 days. The boys were evaluated after 1 month of treatment and every 3 months during follow-up. RESULTS: Of the 94 boys, 91 were available for follow-up, of whom 42 boys (46.1%) achieved complete retraction of the prepuce, 24 (26.4%) had only preputial adhesions and 4 (4.4%) had partial retraction. Twenty-one boys (23.1%) had no response. The treatment was continued in 13 boys with good results eventually. Seven boys (7.7%) had recurrence after a mean follow-up of 4.3 months (range 2-7). No side effects were noted. Circumcision was necessary in 24 of the 91 boys (26.4%). The mean follow-up was 11.0 months (range 3-18). CONCLUSIONS: Local application of clobetasol propionate cream is a simple, safe and effective treatment for phimosis in boys and avoids circumcision and its associated risks. It should be offered first instead of circumcision.     

Topical steroid application versus circumcision in pediatric patients with phimosis: a prospective randomized placebo controlled clinical trial

Objectives Topical steroids have been advocated as an effective alternative treatment to circumcision in boys with phimosis. We evaluated the effectiveness of topical steroid therapy compared to a placebo neutral cream in 240 patients with phimosis. Methods A prospective study was carried out over a 24-months period, on an out-patient basis on two groups of patients with phimosis. One-hundred twenty patients applied a steroid cream twice a day for 4 weeks, and another group of 120 pts used a placebo cream twice a day for 4 weeks. Patients were assigned to either group by a computer-generated random choice. Results All patients in our series completed the two treatment periods without interruption. At a median follow-up of 20 months (6–30 months) therapeutic success was obtained in 43.75% (99/240) of cases, independently of the protocol. In particular, therapeutic success was obtained in 65.8% (79/120) of cases in the steroids group and in 16.6% (20/120) of cases in the placebo group, the difference being statistically significant (P < 0.0001, Mann–Withney test). Conclusion Our study shows that topical steroids represent a good alternative to surgery in case of phimosis. Steroid therapy using monometasone furoate 0.1% in our series gave better results that placebo with an overall efficacy of 65.8%. In patients where a phimotic ring persist after steroid therapy, circumcision is mandatory.     

The response of balanitis xerotica obliterans to local steroid application compared with placebo in children

PURPOSE: We evaluated the clinical effectiveness of topical steroid application for balanitis xerotica obliterans in children and analyzed the association of any clinical response with histological findings. MATERIALS AND METHODS: Our double-blind, placebo controlled, randomized study included 40 boys in whom balanitis xerotica obliterans was diagnosed clinically by cicatricial phimosis. The severity of phimosis was graded into 4 groups. Patients were randomized to receive the topical application of 0.05% mometasone furoate or placebo. After 5 weeks phimosis severity was reevaluated and all patients underwent circumcision. Surgical specimens were histologically typed as an early, intermediate or late form of balanitis xerotica obliterans. RESULTS: Seven patients were withdrawn from the study. In the steroid group 7 boys had clinical improvement and 10 had no change. Histological study showed an early, intermediate and late form of balanitis xerotica obliterans in 5, 5 and 7 cases, respectively. Of cases with clinical improvement 5 were the early and 2 the intermediate type. In the placebo group 5 cases worsened clinically and 11 did not change. Histological evaluation revealed an early, intermediate and late form of balanitis xerotica obliterans in 3, 7 and 6 boys, respectively. Of the 5 cases with histological worsening, disease was the early, intermediate and late type in 2, 2 and 1, respectively. CONCLUSIONS: Applying a potent topical steroid affects improvement in balanitis xerotica obliterans in the histologically early and intermediate stages of disease, and may inhibit further worsening in the late stage.     

Psychological trauma of circumcision in the phallic period could be avoided by using topical steroids

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. The 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.     

Foreskin development before adolescence in 2149 schoolboys

BACKGROUND: We examined the external genitalia of 2149 elementary schoolboys in the suburban area of Taichung in Taiwan for an understanding of foreskin development before adolescence. METHODS: The study's subjects comprised 692 first-grade boys, 725 fourth-grade boys, and 732 seventh-grade boys. The foreskin's condition was classified as: type I (normal prepuce), type II (adhesion of prepuce), type III (partial phimosis), type IV (phimosis) and type V (circumcised foreskin). Other abnormalities of the genitalia also were recorded. All of the examinations were performed by the same urologist. RESULTS: The incidence of type I foreskin was 8.2% in first-grade boys, 21.0% in fourth-grade boys, and 58.1% in seventh-grade boys. The incidence of type IV foreskin was 17.1% in first-grade boys, 9.7% in fourth-grade boys, and 1.2% in seventh-grade boys. Only one boy had balanoposthitis. Other abnormalities included inguinal hernia (n = 2), hydrocele (n = 12), cryptorchitism (n = 8), varicocele (n = 22), and subcoronal-type hypospadia (n = 1). CONCLUSIONS: Physiological phimosis declines with age. Most boys with phimosis in this study did not require treatment.     

Referrals from primary care with foreskin symptoms: Room for improvement

AimsReferrals to secondary care for boys with foreskin symptoms require face-to-face review, resulting in time out of school / work and costs to the family. This study aimed to review outcomes of referrals to ascertain if there was scope to reduce referrals.MethodsNew patients referred to a UK regional paediatric surgery clinic during 2019 were identified and screened retrospectively. Medical records for boys over one year of age referred due to foreskin symptoms were reviewed.ResultsOf 2598 referrals, 1939 (75%) were boys & 1094 were > 1 yr; 398 (21%) were referred with foreskin symptoms at median age 7.2 yrs (IQR 4–10). 307 (77%) were diagnosed with physiological phimosis, 67 (18%) with pathological phimosis, 9 (2%) with balanitis (the remainder had ‘smegma’ retention cysts, preputial adhesions, tight frenulum or anatomical abnormalities). 211 (53%) were discharged at the initial appointment, this was significantly more likely for younger boys, and those with physiological phimosis (p<0.001). 62 (16%) were prescribed topical steroids (more likely in older boys, p<0.001). 70 (18%) were offered surgery: circumcisions (n = 51), preputioplasties (n = 13), other (n = 4). The circumcision rate was therefore 12%. Age at referral was positively correlated with GP trial of steroid (older more likely), diagnosis (physiological phimosis more likely if younger) and outcome (topical steroids or surgery more likely if older): Spearman's rank correlation p<0.001.ConclusionsOver 75% of boys referred had a normal foreskin, over half were discharged at their first review. Improved knowledge amongst parents and primary care providers could reduce referrals and save money and resources.Level of evidenceLevel IV - Case series with no comparison group.     

Results of pancreas transplantation after steroid withdrawal under tacrolimus immunosuppression

PURPOSE: The results of steroid withdrawal in pancreas transplant recipients under tacrolimus immunosuppression were analyzed. METHODS: From July 4, 1994 until April 30, 1998, 147 pancreas transplantations were performed in 141 patients, including 126 simultaneous pancreas-kidney transplantations, 13 pancreas after kidney transplantation, and 8 pancreas transplantations alone. Baseline immunosuppression consisted of tacrolimus and steroids without antilymphocyte induction. Twenty-three patients were excluded from analysis because of early graft loss in 17 cases, retransplantation in 5 cases, and simultaneous pancreas-kidney transplantation after heart transplantation in 1 patient. RESULTS: With a mean follow-up of 2.8+/-1.1 years (range 1.0 to 4.8 years), complete steroid withdrawal was achieved in 58 (47%) patients with a mean time to steroid withdrawal of 15.2+/-8 months (range 4 to 40 months after transplantation). Of the entire cohort of 141 patients, overall 1-, 2-, and 4-year patient survival rates were 98%, 95.5%, and 86%, respectively. Overall 1-, 2-, and 4-year graft survival rates were 83%, 80%, and 71% (pancreas) and 95%, 91%, and 84% (kidney), respectively. Of the 124 patients analyzed for steroid withdrawal, 1-, 2-, and 4-year patient survival rates were 98%, 97%, and 92%, respectively. Overall 1-, 2-, and 4-year graft survival rates were 98%, 91.5%, 83% (pancreas) and 97%, 95%, and 91% (kidney). Patient, pancreas, and kidney survival rates at 1 year were 100%, 100%, and 98% (off steroids) versus 97%, 91%, and 96% (on steroids, all NS) and at 4 years were 100%, 94%, and 95% (off steroids) versus 78%, 68%, and 85% (on steroids, P = 0.01, 0.002, and NS, respectively). The cumulative risk of rejection at the time of follow-up was 76% for patients on steroids versus 74% for patients off steroids (P = NS). Seven patients originally tapered off steroids were treated for subsequent rejection episodes, which were all steroid sensitive, and two of these seven patients are currently off steroids. Thirteen patients received antilymphocyte therapy for steroid-resistant rejection, five of whom are now off steroids. Tacrolimus trough levels were 9.3+/-2.4 ng/ml (off steroids) and 9.7+/-4.3 (on steroids, P = NS). Mean fasting glucose levels were 98+/-34 mg/dl (off steroids) and 110+/-41 mg/dl (on steroids, P = NS). Mean glycosylated hemoglobin levels were 5.2+/-0.9% (off steroids) and 6.2+/-2.1% (on steroids, P = 0.02), and mean serum creatinine levels were 1.4+/-0.8 mg/dl (off steroids) and 1.7+/-1.0 mg/dl (on steroids, P = 0.02). CONCLUSION: These data show for the first time that steroid withdrawal can be safely accomplished in pancreas transplant recipients maintained on tacrolimus-based immunosuppression. Steroid withdrawal is associated with excellent patient and graft survival with no increase in the cumulative risk of rejection.     

Preputial development in Japanese boys

The natural course of preputial development is still not clearly understood. The preputial retractability was evaluated in 242 Japanese boys. The incidence of having a retractable prepuce gradually increased with age from 0% at age 1 year to 77% by the age of 11 to 15 years. In 48 boys, preputial development was followed up for 2 to 10 years with the self-retract maneuver. Non-retractable prepuce was found in 9 boys, which then became retractable within 2-7 years. The prepuce became retractable in most of the boys with balanoposthitis. In conclusion, forced retraction or circumcision is unnecessary for phimosis in boys with or without balanoposthitis.     

Phimose

Phimosis is a common condition in which the foreskin cannot be retracted over the glans penis. First appearing at 8 weeks gestation as a ridge of thickened epithelium, the prepuce grows forward over the developing glans. Physiological phimosis is common in male patients up to 3 years of age. Balanoposthitis is an inflammation of the foreskin and glans and occurs in 4-11% of uncircumcised boys. Lack of circumcision has been identified as a risk factor for urinary tract infection in infants as well as several sexually transmitted diseases and penile cancer in adults. Local steroid application showed satisfactory success rates of more than 80% and is recommended as first choice therapy. Male circumcision carried out under the age of 14 years without medical indications is unlawful and classified as bodily harm under German law.     

云南省昭通市3221名男性学生外生殖器普查报告

目的：通过对幼儿园至初中男生进行普查,了解生理发育情况、外生殖器相关疾病及卫生状况。方法：对昭通市所辖1所幼儿园、9所小学和1所中学2～18岁男生外生殖器进行体检,包括外生殖器发育、睾丸容积测量、阴茎长度测量、外生殖器相关疾病等。结果：昭通市3221名男性学生中包皮过长和包茎3099名（占96．2％）、精索静脉曲张28名（占0．9％）、腹股沟斜疝42名（占1．3％）、隐睾33名（占1．0％）、鞘膜积液28名（占0．9％）、尿道下裂1名（占0．03％）、隐匿性阴茎25名（占0．8％）。结论：包皮过长、包茎是学生多发病。较多外生殖器疾息未及时进行治疗,外生殖器卫生状况差,男生缺少卫生保健知识。学校及相关卫生部门应加强生理健康知识教育及男性外生殖器发育和保健知识教育的监测工作。     

Ballooning of the foreskin and physiological phimosis: is there any objective evidence of obstructed voiding?

OBJECTIVES To determine whether physiological phimosis with or without ballooning of the prepuce is associated with noninvasive urodynamic or radiological evidence of bladder outlet obstruction. PATIENTS AND METHODS From August 2001 to October 2002 all boys with a foreskin problem and referred to one paediatric surgeon were assessed in special clinics. Those with physiological phimosis were recruited for the study and had upper tract and bladder ultrasonography (US), followed by uroflowmetry and US-determined postvoid residual urine volumes (PVR). Data were compared between boys with and with no ballooning of the prepuce. The project was approved by the local research ethics committee and informed consent was obtained from all study participants. RESULTS In all, 54 patients were referred for circumcision; 32 boys with physiological phimosis completed the uroflow and US investigations. Ballooning of the foreskin was present in 18 boys (mean age 6.8 years, range 3-12); 14 had physiological phimosis with no ballooning (mean age 6.5 years, range 4-11). Upper tract US and bladder wall thickness were normal in all boys. The mean maximum urinary flow rate (Q(max)) was not significantly different in boys with ballooning and those without (mean 15.3 mL/s, sd 4.4, range 9-24, vs 15.4, sd 2.9, range 10.7-20, P = 0.96). In addition, all Q(max) values were within the normal range when correlated with voided volume and compared with age-related nomograms. Most boys had flow rate patterns showing a normal bell-shaped curve; a few (9%) had subtle changes in the flow-rate profile, with either a plateau-type curve or slow initial increase in flow and prolonged time to achieve Q(max). The two groups had comparable mean PVRs (3.5 mL, sd 5.1, range 0-18 with ballooning vs 6.1, sd 10.7, range 0-38 without, P = 0.37). Only one patient had a marginally abnormal PVR. CONCLUSIONS Physiological phimosis with or without ballooning of the prepuce is not associated with noninvasive objective measures of obstructed voiding. Minor abnormalities in the flow-rate pattern in this patient group deserve further study.