Balanoposthitis
Balanitis is inflammation of the glans penis; posthitis is inflammation of the prepuce. Balanoposthitis, which is inflammation of both sites, occurs in up to 3% of uncircumcised boys. The etiology in most cases is poor hygiene and accumulation of smegma, which can lead to a secondary bacterial infection. In circumcised boys without residual foreskin or glans penis adhesions, balanitis may be secondary to contact dermatitis from urine, laundry soaps, powders, or ointments. In an adolescent with a retractable foreskin, risk factors are poor hygiene and sexually transmitted infections.
Clinical Presentation and Diagnosis
Balanoposthitis presents with erythema, edema, and pain of the distal phallus, particularly the glans penis. There may be secondary meatitis with resultant dysuria and reluctance to void. The foreskin will be more difficult to retract than it was prior to the onset of the inflammation and a discharge may be present. In severe cases, the cellulitis can extend down the shaft of the penis and onto the lower abdominal wall or the scrotum. Inguinal lymphadenopathy or adenitis is often present.
Recurrent episodes of posthitis can result in phimosis, whereas repeated episodes of balanitis may result in meatal stenosis, with a poor stream and dribbling of urine.
ED Management
Acute localized infections usually respond to frequent warm-water sitz baths followed by drying of the penis and the application of topical antibiotics (bacitracin tid or mupirocin bid) and topical antifungal cream (nystatin) bid for two weeks. Reinforce proper hygiene and the avoidance of forceful retraction of the foreskin. If there is voluntary retention, fever, or cellulitis extending onto the penile shaft, treat with oral antibiotics for seven days. Prescribe 40 mg/kg/day of either cephalexin (div bid) or cefadroxil (div bid), but in communities where MRSA is prevalent either use clindamycin (20 mg/kg/day div q 6h) or add trimethoprim-sulfamethoxazole (8 mg/kg/day of trimethoprim div bid) to one of the above regimens.
More severe infections with purulent discharge and widespread cellulitis require admission and treatment with parenteral antibiotics (nafcillin 150 mg/kg/day div q 6h) or clindamycin (30–40 mg/kg/day div q 6–8h).
Failure of balanoposthitis to respond to warm soaks and systemic antibiotics may be due to inadequate drainage secondary to phimosis. An urgent incision of the dorsal inner foreskin is indicated if there is a poor urinary stream or dribbling.
Follow-up
Inability to void: immediate; otherwise primary care follow-up in one week
Indications for Admission
Bibliography
Meatal Stenosis
Meatal stenosis is a narrowing of the urethral meatus, usually secondary to recurrent episodes of subclinical meatitis. Etiologies include ammoniacal diaper dermatitis (circumcised boys) and recurrent balanoposthitis (uncircumcised boys). Acquired meatal stenosis occurs very rarely in uncircumcised boys because the foreskin acts as a protective cover for the meatus. Congenital meatal stenosis is also very rare.
Clinical Presentation
Obstructive symptoms occasionally occur, including hesitancy, straining, urgency, frequency, and post-voiding dribbling. An abnormal urinary stream may be seen, with either spraying or upward deflection. There may be pain at the initiation of urination or burning at the meatus, although urinary retention is rare. If there is an associated meatitis, an erythematous, swollen meatus is noted, often with a purulent discharge.
Diagnosis
The diagnosis of meatal stenosis can be made upon direct observation of the urinary stream, although a narrowed meatus on visual inspection does not confirm the diagnosis.
ED Management
Treat purulent meatitis with warm-water sitz baths and oral antibiotics for seven days. Use 40 mg/kg/day of either cephalexin (div qid) or cefadroxil (div bid). Refer all patients to a urologist for confirmation of the diagnosis and further evaluation. Immediately consult a urologist for the rare case of acute urinary retention.
Follow-up
Meatitis without retention: urology follow-up in 1–2 weeks
Indication for Admission
Urinary retention
Paraphimosis
Paraphimosis is entrapment of the foreskin behind the coronal sulcus of an uncircumcised or inadequately circumcised penis. It occurs when a tight foreskin is retracted proximal to the glans penis and then is not returned to its normal position. This produces a tourniquet effect with resultant venous congestion and edema of the glans.
Clinical Presentation and Diagnosis
On examination, there is edema and tenderness of the glans penis with a tight proximal collar of swollen tissue. The glans congestion will progress over time and skin color will change from the normal pink to blue to white (ischemia), with eventual gangrene. The penile shaft is unaffected. The constriction by the foreskin along with resultant edema may lead to urethral obstruction at the coronal level. The patient then complains of difficulty voiding and urinary retention. Direct erosion into the urethra rarely occurs.
ED Management
Place an ice bag on the foreskin and administer a topical (EMLA cream) or regional (penile block with lidocaine without epinephrine) anesthetic, and/or sedate the patient (see Sedation and Analgesia, pp. 712–722). Reduce the edema by applying manual circumferential compression for several minutes. Next, grasp the penile shaft with the index and third fingers of each hand, with the thumbs on the glans. Apply firm downward pressure on the glans against counterpressure on the shaft, which will usually advance the foreskin back over the glans. Alternatively, following the application of EMLA cream with an occlusive dressing (30 min to 1 hour), inject 1 mL of hyaluronidase (150 U/mL) into one or more sites in the edematous prepuce. Resolution of the edema is almost immediate, and the foreskin can be gently retracted over the glans. It is critical to attempt to advance the most distal foreskin ring (the portion closest to the coronal margin). If this tight ring can be reduced, then the remainder of the foreskin will follow. Occasionally, there is tearing of the skin with bleeding, which can be controlled by compression. Instruct the patient to avoid retracting his foreskin for several days. Refer the patient to a urologist for follow-up and evaluation of the need for an elective circumcision.
If the paraphimosis cannot be reduced, consult a urologist immediately to perform a dorsal slit to release the constricting ring of tissue.
Follow-up
Reducible paraphimosis: urology follow-up in 1–2 weeks
Bibliography
Phimosis
Phimosis is the inability to retract the tight foreskin over the glans penis. In 50% of uncircumcised boys the foreskin is retractable at one year of age, and 90% are retractable by four years. The remaining 10% may not become retractable until puberty. If associated infections (local or more proximally in the urinary tract) or voiding difficulties occur, correction may be indicated.
Clinical Presentation and Diagnosis
Acquired phimosis is a result of poor hygiene with inflammation of the glans. Accumulated smegma may form aggregates that appear as whitish, globular masses under the nonretractile foreskin. Associated inflammatory conditions may coexist, including balanoposthitis (pp. 294–296) and meatitis (pp. 295–296). With severe phimosis, the foreskin may balloon during voiding as the urine collects under it and then dribbles out from the tight opening. The adolescent may complain of pain on erection, secondary to tension on the foreskin from the glandular adhesions.
ED Management
Treat accumulated smegma without any associated infection with gentle retraction of the foreskin during bathing. Depending on the patient’s age, if there is no infection, refer him to a urologist for consideration of elective circumcision. If there is ballooning of the foreskin with a dribbling urinary stream, or an associated UTI, consult a urologist. Gentle dilation may be necessary, after which an elective circumcision or preputial plasty (surgical widening of the phimotic ring) is indicated.
Follow-up
Phimosis without associated difficulty voiding: urology follow-up in 1–2 weeks
Bibliography
Priapism
Priapism is a sustained and painful penile erection that results from either increased arterial flow (high flow) or, more commonly, from decreased venous outflow (low flow). It most frequently occurs as a complication of sickle cell disease (pp. 370–375) with a reported incidence of 30% before the age of 20 years. It may also result from spinal cord injury, leukemic infiltration, medications, or trauma.
Clinical Presentation and Diagnosis
The patient presents with a sustained, painful erection. Urinary retention may result with a distended bladder palpable on examination. Persistence of the priapism can lead to corporal fibrosis, with resultant erectile dysfunction. In boys with sickle cell disease, other manifestations of the crisis may be present.
ED Management
Initial management includes analgesia or sedation, hydration, and oxygenation. If the patient has sickle cell disease, determine the percentage of HgbS. Consult with a pediatric hematologist to promptly arrange an exchange transfusion to reduce the HgbS to 30–35%. If the priapism persists in spite of adequate reduction of HgbS, consult a urologist to perform aspiration of blood from the corpora cavernosa, followed by irrigation with a dilute epinephrine solution. Most commonly, however, reduction of HgbS is sufficient to effect resolution of the priapism. On occasion, acute bladder drainage with a Foley catheter may be necessary.
Indication for Admission
Priapism
Bibliography
Renal and Genitourinary Trauma
Renal Trauma
Blunt trauma, secondary to motor vehicle accidents, falls, and athletic injuries, is the major cause of renal injuries in children The pediatric kidney is particularly susceptible to injury due to the relative paucity of surrounding fat, its size in relation to surrounding organs, and an immature thoracic cage, which provides inadequate protection. An underlying congenital anomaly, including ureteropelvic junction obstruction, primary obstructive megaureter, or ectopic or solitary kidneys, is found incidentally in up to 20% of patients with traumatic hematuria. Associated intraperitoneal injuries occur in approximately 25% of cases of blunt and 80% of penetrating renal trauma.
Ureteral Trauma
Ureteral trauma is relatively uncommon, and when present is usually associated with multiple intra-abdominal injuries. Children are at higher risk for avulsion of the ureter at the junction of the renal pelvis (ureteropelvic junction), which is a relatively fixed point in the course of the ureter.
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