Genevieve Santillanes and Marianne Gausche-Hill
Pediatric genitourinary and gynecologic evaluations pose specific challenges to the emergency practitioner. The physician must incorporate knowledge about stages of development, likely diagnoses for different age groups, and the patient’s specific history to tailor an appropriate examination. Any child presenting with abdominal pain should undergo a genitourinary examination. In addition, the emergency physician should maintain a high index of suspicion for sexual abuse as children who are abused may present with unusual or vague complaints.
FEMALE GENITOURINARY DISORDERS
The response of the premenarchal female to the genitourinary examination depends upon her stage of development. Younger children generally cooperate easily, whereas older children tend to be more private, especially in the early stages of puberty. Putting the child at ease to make the evaluation as atraumatic as possible is crucial. Infants can be examined in a parent’s lap. Older girls are more easily evaluated on the examination table. Two positions commonly used to facilitate evaluation of young girls are the frog-leg position and, for girls old enough to cooperate, the knee-chest position. In the frog-leg position, the child is supine on the table with her heels together with her knees and hips flexed (Fig. 287.1). With gentle lateral and outward traction on the labia majora, the hymen and introitus are more easily visualized. The knee-chest position generally affords a better view of the vaginal vault. The child is instructed to get on her hands and knees, fold her arms, rest on her elbows, and place her head on her arms.
FIGURE 287.1 Positions for genitourinary examination of the female child. A, B: Frog-leg position and (C) knee-chest position.
A thorough gynecologic examination under procedural sedation or anesthesia may be necessary in young children if vaginal bleeding is present without an obvious source on external examination, if a vaginal foreign body is suspected but not visualized, or if significant trauma is suspected. For most complaints in premenarchal girls, a careful history and physical with a thorough evaluation of the external genitalia and culture of any vaginal discharge is adequate.
When evaluating an adolescent with a genitourinary complaint or abdominal pain, the history must include age of menarche, menstrual history, sexual activity, pregnancies, history of sexually transmitted diseases, and contraception. The adolescent should be interviewed alone. Every postmenarchal girl should have a pregnancy test performed. Virginal females will rarely require bimanual or speculum examinations as pelvic pain in virginal girls generally can be evaluated with transabdominal ultrasonography. Sexually experienced adolescents require a full gynecologic evaluation, given the high rate of sexually transmitted infections in this age group.
PEDIATRIC VULVOVAGINITIS
CLINICAL PRESENTATION
Inflammation of the vulva and vagina is the most common gynecologic complaint in the prepubertal female. Prepubertal patients are predisposed to inflammation due to the absence of labial fat pads and pubic hair for protection and a low estrogen level, leading to a more alkaline vaginal pH. In addition, vaginal proximity to the anus and poor local hygiene increase the risk of inflammation. There generally is no appreciable physiologic vaginal discharge from approximately 1 month of age until the initiation of puberty, although estrogen effects passed from the mother to the female child may last through infancy. Thus, a prepubertal girl with the chief complaint of vaginal discharge warrants a medical evaluation. Patients may also present with pruritus, vaginal redness, soreness, and, rarely, bleeding (1). The postpubertal female may present with a change in vaginal discharge, pruritus, or pain. Frequency and dysuria can be associated symptoms.
The normal prepubertal vaginal flora has not been well studied, and thus the determination of a causative agent can be difficult. Classically, the etiology of vulvovaginitis in pediatrics is usually divided into two groups, specific and nonspecific. Nonspecific vaginitis is usually attributed to poor hygiene, chemical irritation, or tight-fitting clothing. The majority of cases of vulvovaginitis in prepubertal girls are due to nonspecific vaginitis (2). Nonsexually transmitted infections thought to cause vulvovaginitis include Group A β-hemolytic streptococcus, Staphylococcus aureus, and Shigella (2,3). Candida albicans is a rare cause of vulvovaginitis in the prepubertal patient.
DIFFERENTIAL DIAGNOSIS
The differential diagnosis varies depending upon the age and the patient’s risk factors. An infant is more likely to have neonatal leukorrhea, diaper dermatitis, impetigo, chemical–mechanical irritation, seborrheic dermatitis, or a genitourinary malformation. Vaginal foreign bodies are generally seen after infancy. Chronic irritation may be secondary to lichen sclerosis, labial adhesions, or a vaginal foreign body. Pinworms that migrate to the vagina can lead to vulvovaginitis, and should be suspected when nighttime symptoms predominate or there is associated anal pruritis. Pinworms are discussed in greater detail in Chapter 284. In adolescents, urethritis, cervicitis, or pelvic inflammatory disease should be considered.
ED EVALUATION
Visible discharge in a premenarchal patient should be sent for wet mount, cytology, and bacterial cultures. Cultures may be obtained with a moist swab placed in the introitus. The prepubertal hymen and clitoris are extremely sensitive so a small swab should be used, avoiding contact with the hymen, or lidocaine jelly can be applied for analgesia. A culture for chlamydia is usually sent only if other cultures are negative or sexual abuse is suspected. Urine tests are now available for gonorrhea and chlamydia, and can be used to screen for disease. Because diagnosis of a sexually transmitted infection in a prepubertal child is an evidence of sexual abuse, highly specific tests that will be acceptable as evidence in legal proceedings should be obtained before treatment of sexually transmitted infections (4). Appropriate forensic testing is discussed in Chapter 292. Patients who have been sexually active should have a bimanual and speculum pelvic examination and should be tested for sexually transmitted infections.
ED MANAGEMENT
Culture-proven–specific vaginitis can be treated with targeted antimicrobial therapy. Isolation of sexually transmitted organisms in a prepubertal child necessitates child abuse workup and reporting. The treatment of nonspecific vaginitis is focused on proper hygiene (i.e., front-to-back wiping), sitz baths, and avoidance of chemical irritants such as bubble bath and harsh detergents. A diagnosis of candidal vaginitis in a toilet-trained prepubertal patient is unusual, and a workup for diabetes or immunodeficiency should be considered.
DISPOSITION
Patients should follow-up with their pediatrician for culture results and to ensure that symptoms have resolved or with a subspecialist as indicated.
IMPERFORATE HYMEN
CLINICAL PRESENTATION
Imperforate hymen is a rare disorder. In infants and young girls, it is most often discovered incidentally during physical examination. In the neonate, circulating maternal hormones stimulate vaginal mucus secretion. If the imperforate hymen is not recognized at birth, it may present within days to weeks of life when the obstructed vagina becomes distended, resulting in hydrocolpos or mucocolpos. If the distension extends to the uterus, it is referred to as hydrometrocolpos. The infant may present with a lower abdominal mass or mass at the introitus, urinary retention secondary to extrinsic obstruction, or constipation. Girls who remain undiagnosed in childhood will present during or after menarche when the vagina fills with blood resulting in hematocolpos or hematometrocolpos. They will have normal pubertal development with primary amenorrhea. The chief complaint may be lower abdominal pain that may or may not be cyclic, back pain, a pelvic mass, constipation, or urinary retention (5).
DIFFERENTIAL DIAGNOSIS
The diagnosis of imperforate hymen is generally made upon examination of the external genitalia. However, other causes of vaginal obstruction must be considered. Transverse vaginal septum, labial adhesions, pelvic mass, agenesis of the vagina, testicular feminization, and Gartner duct cysts should be included as possible diagnoses. Sexual or physical abuse also rarely mimics the presentation of imperforate hymen.
ED EVALUATION
A thorough history and physical should lead to the diagnosis. In infants, imperforate hymen may appear as a whitish bulging membrane. Infants should be evaluated for the complications due to mass effect including evaluation for respiratory distress, inferior vena cava compression, and hydronephrosis. A urinalysis should be performed to assess for concomitant infection. Hematocolpos in adolescents is classically described as a bulging membranous dark blue mass at the introitus. An adolescent with severe pain may require an ultrasound evaluation, as case reports of ruptured hematosalpinx have been documented (5).
ED MANAGEMENT
The treatment for imperforate hymen is surgical incision and resection. The urgency of gynecology consultation or referral is based on patient symptoms.
DISPOSITION
Asymptomatic infants and prepubertal children can be scheduled for elective repair. Patients with complications such as renal insufficiency, respiratory distress, or shock from inferior vena compression require admission to the hospital and emergent intervention. Adolescents with hematocolpos should undergo surgical treatment promptly. In addition, all female siblings should undergo an external examination, as familial occurrences have been reported (6).
URETHRAL PROLAPSE
CLINICAL PRESENTATION
Urethral prolapse is a disorder seen in prepubertal girls and postmenopausal women. In children, the diagnosis is most commonly seen in prepubertal African American girls. The patient presents with painless vaginal bleeding, a vaginal mass, or urinary symptoms of straining or dysuria. The mass is generally swollen, purple or deep red, and doughnut shaped. A central depression representing the lumen of the urethra may or may not be evident. The area may have evidence of thrombosis and necrosis.
DIFFERENTIAL DIAGNOSIS
Urethral processes that can present similarly are urethral polyps, prolapsed ureteroceles, and rarely urethral carcinomas. Dermatologic causes include condylomata and hemangiomas. Accidental and nonaccidental trauma can cause a hematoma that mimics prolapse. Imperforate hymen and hair tourniquets are other possibilities. An important entity on the differential that must be excluded is botryoid sarcoma, as it requires immediate referral and management.
ED EVALUATION
If the origin of the mass is in question, a catheter can be passed through the mass to verify the diagnosis.
ED MANAGEMENT
Appropriate treatment is debated in the literature with some experts recommending surgical treatment in all cases and others advocating conservative treatment for most patients. In general, if the prolapse is small, without evidence of necrosis and asymptomatic or only mildly symptomatic, sitz baths or warm moist compresses can be recommended. A topical estrogen cream applied twice a day for 2 weeks may aid in resolution. If there is evidence of extreme congestion, necrosis, or if symptoms are significant, a urologic evaluation is indicated for reduction under anesthesia and/or excision (7).
DISPOSITION
The uncomplicated urethral prolapse will generally resolve in 3–6 weeks but may take up to 3 months. Follow-up should be given to all patients to ensure resolution has occurred. Patients with necrosis, severe symptoms or failure to resolve need urologic referral.
VAGINAL FOREIGN BODY
CLINICAL PRESENTATION
The classic presentation of a retained foreign body is vaginal bleeding or blood-stained or foul-smelling vaginal discharge. A prepubertal girl with chronic vaginal discharge should have a thorough workup for vaginal foreign body (8). More commonly reported foreign bodies in prepubertal girls include toilet paper, cloth, and other small items. Adolescents are more likely to present with retained tampons and condoms.
DIFFERENTIAL DIAGNOSIS
The presenting symptoms of a patient with a vaginal foreign body include vaginal bleeding, discharge, and abdominal/pelvic pain. Vulvovaginitis, urethral prolapse, dysfunctional uterine bleeding, labial adhesions, tumor, trauma, and urinary tract infection (UTI) can all present similarly.
ED EVALUATION
The patient should undergo a full genitourinary evaluation. The knee-chest position with a good light source will facilitate the best vaginal examination of a premenarchal patient. The use of an otoscope placed carefully into the hymen may enhance visualization. If a vaginal foreign body is highly likely but not visualized with the foregoing methods, an examination under procedural sedation or anesthesia may be indicated. Postmenarchal patients can undergo a speculum and bimanual examination. An x-ray or ultrasound can be considered, although the objects found are generally not radiopaque.
The relationship between vaginal foreign bodies and sexual abuse has not been well studied or described in the literature. A retrospective case review suggests a possible correlation in some cases; therefore, patients should be questioned about and screened for signs of sexual abuse, especially if the patient has recurrent vaginal foreign bodies (8).
ED MANAGEMENT
If a vaginal foreign body is suspected, a gentle vaginal lavage should be performed. A 50-mL syringe with the plunger removed can be attached to a catheter that is inserted in the introitus. Normal saline poured into the syringe will provide a continuous flow to flush the object out of the vagina. If this procedure is not tolerated or fails to remove the object, a gynecologist can perform vaginoscopy under anesthesia.
DISPOSITION
Most patients are managed as outpatients. Patients with persistent complaints of vaginal discharge or bleeding should be referred to a gynecologist for further evaluation (9).
LABIAL ADHESIONS
Adhesions of the labia minora are a common entity encountered in the pediatric patient. Labial fusion is thought to be due to irritation and inflammation of unestrogenized epithelium with adhesions forming during the healing process. The incidence in prepubertal girls is reported to be less than 5% (10). Most patients are between 1 and 6 years of age. Symptoms may include urinary complaints, recurrent UTIs, vaginitis, or leakage of urine. Labial adhesions may also be noted by parents or on examination by a health care provider. The diagnosis is generally made clinically, with labial tissue with a central line or raphe obstructing the view of the introitus and hymen. The characteristic central thickened line differentiates the diagnosis from congenital malformations.
Appropriate treatment of labial adhesions is controversial. Traditional treatment of labial adhesions was surgical or manual separation of adhesions, or application of topical estrogen cream. Estrogen cream is associated with side effects including vaginal bleeding and breast bud development. Newer literature suggests that betamethasone cream may be more efficacious and associated with fewer side effects than topical estrogen (10). The natural history of labial adhesions is resolution in early puberty when estrogen levels rise. Thus, asymptomatic patients do not require treatment. If the patient is having complications or symptoms, estrogen or betamethasone cream can be applied sparingly to the adhesions at bedtime for several weeks to months. After separation, zinc oxide or petroleum jelly should be applied at bedtime for an additional 2 weeks. Patients should be followed up closely for failure of separation and recurrence. At that time, manual or surgical separation may be performed.
KEY TESTING
CRITICAL INTERVENTIONS
• Rule out pregnancy in every postmenarchal patient with genitourinary symptoms.
• Evaluate prepubertal pediatric patients diagnosed with a sexually transmitted infection for sexual abuse
• Evaluate infants with hydrocolpos for signs of hydronephrosis, respiratory insufficiency, and compression of the vena cava
Common Pitfalls
• Failure to take a complete sexual history or perform a genitourinary examination because of inaccurate assumptions of low risk
• Failure to recognize that candidal infections in prepubertal patients are unusual and may be associated with diabetes or an immune disorder
• Failure to evaluate pediatric patients with recurrent or chronic vaginitis for a vaginal foreign body or other serious pathology
MALE GENITOURINARY DISORDERS
Any male with abdominal or genitourinary complaints must undergo a complete examination. This section focuses on common testicular and foreskin complaints in pediatric patients.
TESTICULAR TORSION
CLINICAL PRESENTATION
Testicular torsion is a critical diagnosis to make in the ED. Testicular torsion has been reported in all ages from in utero through adulthood, but nearly all cases occur before the age of 25 (11). It is most common during adolescence. Patients classically present with acute onset of severe, unilateral, progressive scrotal pain and swelling. Diffuse scrotal erythema, a horizontal lie, or a high-riding testis may be seen. Patients may also present with atypical features, including pain which is intermittent or bilateral or lower abdominal. It is common for patients to have associated nausea and vomiting. The cremasteric reflex is usually absent; however, the cremasteric reflex is commonly subtle or absent in healthy young boys (12). The presence of a cremasteric reflex is suggestive that torsion is not the correct diagnosis; however, its presence in patients with torsion has been reported (13,14). Patients with an undescended testis have a higher incidence of torsion and the diagnosis should be considered in males with undescended testicles presenting with abdominal pain or vomiting (15).
Torsion in adolescence is due to improper attachment of the testicle to the tunica vaginalis resulting in the “bell clapper” deformity. The result is a free-hanging testicle, predisposing to twisting of the spermatic cord. The abnormal attachment is usually bilateral.
DIFFERENTIAL DIAGNOSIS
Two other diagnoses which present as atraumatic acute scrotal pain and swelling in pediatric patients are epididymitis and torsion of a testicular appendage. Epididymitis tends to have a more gradual onset of symptoms, an intact cremasteric reflex, and a vertically oriented testis. None of these findings are diagnostic for epididymitis, however. Torsion of a testicular appendage usually presents with less severe symptoms than testicular torsion. With torsion of a testicular appendage, a firm tender nodule can be palpated on the upper pole of the testis and a “blue-dot sign” may be visualized. Delayed diagnoses of testicular torsion frequently result in testicular loss; therefore, testicular torsion must be considered in any patient who presents with scrotal pain. Table 287.1 lists other causes of painful scrotal swelling.
TABLE 287.1
Causes of Scrotal Swelling and Masses
ED EVALUATION
If the patient presents with a history and physical examination most consistent with torsion, immediate urologic evaluation is warranted without further studies. Only if the diagnosis of torsion is uncertain should imaging be performed. Color Doppler ultrasonography has become the imaging modality of choice as it is noninvasive, uses no radiation, and is readily available. Recently published studies have found that color Doppler ultrasound has 94% to 100% sensitivity and 96% to 97.9% specificity for the diagnosis of testicular torsion (15–17).
Additional information that may aid in diagnosis is a urinalysis. If significant pyuria is demonstrated, a diagnosis of epididymitis becomes more likely. However, the presence of pyuria does not rule out testicular torsion.
ED MANAGEMENT
Testicular torsion is a surgical emergency. If the diagnosis is likely, emergent urologic evaluation should be obtained and the patient should undergo scrotal exploration in the operating room. Imaging studies should not delay urologic evaluation or surgical exploration. The survival of the testis is correlated with duration of symptoms. Manual detorsion to increase blood flow to the testis can be attempted as a temporizing measure if the patient cannot be taken to the operating room promptly. Analgesia should be administered prior to the manual detorsion. This maneuver is performed by facing the patient and rotating the involved testicle outward as if one were opening a book: The left testis is rotated clockwise and the right counterclockwise until the symptoms improve. One study demonstrated that the degree of rotation of torsed testes ranged from 180 to 1,080 degrees, with a median of 540 degrees (18). The classically described torsed testis is rotated in the medial direction; however, the same study reported that one-third of the torsed testes were laterally rotated, a fact that should be kept in mind when undertaking detorsion maneuvers (18). Emergent surgical exploration with detorsion and orchiopexy is the definitive treatment.
DISPOSITION
The patient with testicular torsion must undergo surgical exploration of both testes and bilateral orchiopexy.
EPIDIDYMITIS
CLINICAL PRESENTATION
Acute epididymitis is a common cause of acute scrotal pain. The pain of epididymitis is usually gradual in onset. It may be associated with swelling and erythema of the scrotum, fever, vomiting, and urinary symptoms. It is more common in adolescent males; however, the diagnosis is not uncommon in prepubertal boys. The tenderness is generally posterior and lateral to the testis. The cremasteric reflex is usually intact.
DIFFERENTIAL DIAGNOSIS
The main entity that must be distinguished from epididymitis is testicular torsion. Patients with testicular torsion generally have a more acute onset of symptoms, no fever, and fewer urinary complaints.
ED EVALUATION
Urinalysis may demonstrate white blood cells. A urine culture should be sent. If the patient is sexually active, gonorrhea and chlamydia testing should be performed. If the diagnosis of torsion cannot be excluded, color Doppler ultrasonography should be performed to rule out torsion. Increased blood flow to the epididymis will be visualized on ultrasound.
ED MANAGEMENT
The treatment for acute epididymitis depends upon the patient’s age. Traditional teaching is to treat all cases of prepubertal epididymitis with antibiotics. Younger children with evidence of an associated UTI on urinalysis should be treated with oral antibiotics to cover common urinary organisms (Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa) (see Chapter 290). However, recent studies have demonstrated that most prepubertal cases of epididymitis are not associated with UTI (19,20). Therefore, prepubertal children without evidence of UTI or suspicion of a sexually transmitted disease can be treated with supportive care. Although there is little data on young infants with epididymitis, the authors believe that infants younger than 1 month of age should be admitted for inpatient antibiotics and infants between 1 and 3 months of age should be treated with oral antibiotics until cultures are negative (20). Admission should also be considered for patients who appear ill. Most cases of epididymitis in adolescents are due to sexually transmitted infections, and the patient should be empirically treated for Neisseria gonorrhoeae and Chlamydia trachomatis. Recommended treatment is a single dose of 250 mg of ceftriaxone intramuscularly and 100 mg of doxycycline twice daily for 10 days (4).
DISPOSITION
The patient should be prescribed analgesics, sitz baths, and scrotal elevation, as age permits. Antibiotics should be prescribed as outlined earlier, with a low threshold for admitting young infants. Urologic follow-up should be arranged.
HYDROCELE
CLINICAL PRESENTATION
Hydroceles are common findings in infants and young children. The usual presentation is a painless swollen scrotum that tends to increase in size throughout the day and decrease when supine. The fluid collection may appear after coughing or straining. A simple hydrocele is a fluid collection without a patent processus vaginalis. A communicating hydrocele has a patent processus vaginalis and generally has greater fluctuation in size. Communicating hydroceles may be associated with an indirect inguinal hernia (21).
DIFFERENTIAL DIAGNOSIS
See Table 287.1 for the differential diagnosis of nonpainful scrotal swelling.
ED EVALUATION
Palpation of the scrotum should reveal a normal testis and spermatic cord above the mass. To aid in distinguishing a hydrocele from an inguinal hernia, it should be noted that the spermatic cord above the hydrocele should not feel thickened. A hydrocele is fluid filled and should transilluminate (Fig. 287.2). Testicular tumors pathology may be associated with hydroceles, so if a tumor cannot be ruled out by physical examination, ultrasound evaluation is recommended.
FIGURE 287.2 Hydrocele with transillumination of fluid-filled scrotal sac.
ED MANAGEMENT
If the hydrocele is tense or painful, the patient should undergo a surgical evaluation. If the mass fluctuates in size rapidly or the examination is consistent with a communicating hydrocele, the patient should be referred to a surgeon to rule out an inguinal hernia.
DISPOSITION
A small uncomplicated hydrocele can be managed conservatively, as most resolve spontaneously. Failed resolution at age 2 years warrants a surgical referral for repair (21). Any communicating hydrocele with an associated hernia needs surgical closure. It is recommended that parents be counseled on the signs and symptoms of incarceration.
TESTICULAR TUMORS
CLINICAL PRESENTATION
Testicular tumors present as an abnormally large testis or mass and are generally painless, although there may be associated scrotal heaviness or abdominal pain. Lymphadenopathy may also be present.
DIFFERENTIAL DIAGNOSIS
A testicular or paratesticular mass should be evaluated under the assumption that it is a malignancy. Other entities including hernia, hydrocele, varicocele and in neonates, prenatal testicular torsion, may present as painless scrotal enlargement. Rhabdomyosarcomas, teratomas, epidermoid cysts, and yolk sac tumors present as testicular or paratesticular masses (22).
ED EVALUATION
A full physical evaluation should be performed examining carefully for lymphadenopathy and location of the mass. Testicular and paratesticular masses should be evaluated by ultrasound. β-Human chorionic gonadotropin (β-HCG) is rarely elevated in prepubertal testicular tumors, but a urine or serum β-HCG can be checked (22). Alpha-fetoprotein (AFP), is elevated in yolk sac tumors; however, AFP levels in healthy infants may be elevated (22).
ED MANAGEMENT AND DISPOSITION
A pediatric surgeon or urologist should be consulted for further workup and management. Patients should be admitted or very close follow-up must be arranged.
INGUINAL HERNIA
Approximately 15 in 1,000 births result in an abdominal hernia, with a higher incidence in premature infants. Inguinal hernias are more common in males, with bimodal peaks before 1 year of age and then again after age 40. An indirect inguinal hernia occurs when the processus vaginalis does not obliterate in infancy and abdominal contents invaginate through this patent sac. These hernias are more common on the right side. Entrapment of mesentery, bowel, intraperitoneal organs, and the hernial sac can occur and are more common with small hernias. If the contents of the hernia can be returned to their anatomic position, the hernia is termed reducible; if it remains entrapped, it is termed incarcerated or irreducible. Hernias that remain incarcerated can result in strangulation, with resultant bowel necrosis.
CLINICAL PRESENTATION
Patients with incarcerated hernias may present with pain, edema extending to the scrotum, nausea, vomiting and low-grade fever. Physical examination may reveal bowel sounds in the scrotal sac. If the inguinal mass can be palpated separately from the testes, then it is possible to diagnose an inguinal hernia clinically. A strangulated hernia can present as a tense, blue mass in the scrotum.
ED MANAGEMENT AND DISPOSITION
The patient should be placed in the Trendelenburg position with an ice pack placed on the groin, as tolerated, to reduce swelling; pain medication or sedation may be necessary before reduction. Slow gentle pressure should be applied to reduce the hernia. The parent or child may assist in applying. If the hernia cannot be reduced or strangulation is suspected, the patient should receive fluid resuscitation and broad spectrum parenteral antibiotics, and surgical consultation should be obtained (21).
Patients with reducible hernias should be referred for outpatient surgical repair.
PHIMOSIS
Phimosis occurs when the foreskin cannot be retracted over the glans. When caused by normal physiologic adhesions, it is called primary phimosis. Phimosis is normal in infants and young children, with resolution generally by 6 years of life. Secondary phimosis may occur owing to scarring of the foreskin after inadequate circumcision or due to irritation or infection. Patients generally are asymptomatic. However, in some patients, the constriction causes voiding difficulty, UTI, and local infection of the foreskin and glans.
Physical examination establishes the diagnosis. If symptoms of a UTI are present, urinalysis and urine culture are warranted. Renal function tests and a bedside or formal renal ultrasound should be performed if significant urinary obstruction is suspected.
No treatment is needed for asymptomatic patients younger than 6 years of age. Symptomatic phimosis can be treated with topical steroids, or if conservative treatment fails, with circumcision. Steroid treatment has been shown to be effective in 75% to 88% of boys (23–25). Betamethasone 0.05% or other steroid cream applied to the stretched foreskin twice daily for 1 month is commonly recommended. Symptomatic patients and older boys should have urologic follow-up.
PARAPHIMOSIS
Paraphimosis is a condition seen in uncircumcised males when the foreskin is retracted over the glans for a prolonged period. This leads to edema and venous congestion of the foreskin and glans and eventually impairs blood flow to the glans. The patient presents with increasing swelling and pain. Paraphimosis can occasionally occur in males with a history of circumcision if insufficient foreskin tissue was removed. The diagnosis is made clinically, systematically ruling out hair tourniquet syndrome.
Treatment requires reduction of the foreskin to restore its normal position over the glans. This is best accomplished with effective pain control. Options include oral or parenteral pain medication, procedural sedation, topical anesthetic creams, or a penile block. Controversy exists as to methods of reduction of the foreskin. Reduction is facilitated by first reducing swelling by manual compression, use of sugar-soaked solutions to the area, or aspiration of the fluid in the edematous tissue (24,26). The physician should then place both thumbs on the glans with the index and middle fingers on the distal end of the foreskin. Simultaneous persistent pressure is applied to the glans with the thumbs and to the rolled edge of the foreskin with the fingers so as to return the foreskin to its proper position. If the foreskin cannot be reduced, emergent urologic consultation is necessary. If phimosis is successfully reduced in the ED, urologic follow-up is recommended for possible circumcision.
BALANITIS AND BALANOPOSTHITIS
A break in the foreskin caused by local trauma or poor hygiene can lead to posthitis. Extension of the cellulitis or inflammation to the glans is referred to as balanoposthitis. The patient presents with swelling, erythema, and penile pain. Purulent discharge may be present. A culture of any discharge may be sent for identification and proper antibiotic treatment.
The responsible organisms are typically skin flora (i.e., Staphylococcus and Streptococcus). Treatment includes sitz baths and topical antibiotics. In more severe cases, cephalexin (25 to 50 mg/kg/d divided three times daily for 7 days) can be added (24). Follow-up is recommended, as treatment failures, repeated episodes, and scarring can lead to phimosis. Patients not in diapers with candidal balanitis or balanoposthitis should be evaluated for diabetes mellitus. Patients with swelling severe enough to cause obstruction or concern for a more invasive infection should be admitted for urologic evaluation and intravenous antibiotics.
KEY TESTING
CRITICAL INTERVENTIONS
• In patients with suspected testicular torsion, obtain immediate urologic evaluation without waiting for ultrasound confirmation of diagnosis.
• Order an ultrasound in patients with hydroceles if adequate palpation of the testis is not possible as hydroceles can be associated with testicular tumors.
• Obtain an emergent urologic consultation for patients with paraphimosis that cannot be reduced.
Common Pitfalls
• Failure to perform a complete abdominal and GU examination on all males with a complaint of abdominal pain or vomiting
• Delay of urologic consultation in patients with suspected testicular torsion
• Failure to consider testicular torsion in patients with abdominal pain or vomiting and an undescended testicle
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