The Journal of Emergency Medicine, no.Volume 79, pp.603-609, 2026 (Peer-Reviewed Journal)
We read with interest the article by Tu et al. entitled “Balanoposthitis in Children: Does Treatment Matter?”
1, which addresses an important and common clinical problem in pediatric emergency medicine. The authors should be commended for presenting a large single-center experience over an extended study period. However, we would like to raise several methodological concerns that may significantly limit the interpretation and generalizability of the study’s conclusions.
First, the definition of “treatment failure” used in the study appears overly restrictive and may underestimate clinically meaningful outcomes. Treatment failure was defined solely as a return visit within 30 days accompanied by a change in therapy. Persistence of symptoms without treatment modification, incomplete resolution, recurrence managed by primary care providers, or parental dissatisfaction were not captured as failure outcomes. This narrow endpoint risks misclassifying ongoing or recurrent disease as successful treatment and may artificially lower reported failure rates.
Second, treatment allocation was entirely physician-dependent, without adjustment for baseline disease severity. Key clinical variables such as extent of inflammation, degree of edema, urinary obstruction, or systemic involvement were neither standardized nor quantified. Consequently, patients managed with supportive care alone were likely those with milder presentations, introducing substantial confounding by indication. The absence of severity stratification limits meaningful comparison across treatment groups and weakens inferences suggesting equivalence between therapeutic approaches.
Third, the lack of microbiological confirmation represents a major limitation in evaluating the appropriateness of antimicrobial use. No local cultures were obtained, yet a considerable proportion of patients received systemic or topical antibiotics. Without pathogen identification, it is not possible to distinguish infectious from inflammatory or irritant etiologies, nor to assess whether clinical improvement was attributable to antimicrobial therapy or natural disease resolution. This limitation is particularly relevant in the context of antimicrobial stewardship.
In summary, while the study provides valuable descriptive data regarding current practice variability, its methodological constraints preclude firm conclusions regarding the necessity or effectiveness of specific treatments for pediatric balanoposthitis. Future prospective studies incorporating standardized severity assessment, broader and clinically relevant outcome measures, and etiologic evaluation are needed to determine optimal management strategies.
We appreciate the opportunity to contribute to the discussion of this important topic.
Sincerely.
