Management of Pediatric Penile Problems in the Emergency Department (Trauma CME and Pharmacology CME)

Table of Contents

 

About This Issue

Pediatric penile problems range from congenital anomalies to acquired and emergent conditions that require prompt recognition and management. Emergency clinicians must be comfortable evaluating these sensitive presentations across all pediatric age groups, from neonates with postcircumcision bleeding to adolescents with paraphimosis or priapism. This issue presents a structured, evidence-based approach to the diagnosis and management of common pediatric penile problems, with emphasis on pain management, recognizing emergent conditions, and timely urologic consultation. In this issue, you will learn:

How to distinguish emergent from nonemergent pediatric penile conditions and to identify indications for immediate urologic consultation

Evidenced-based recommendations for selecting appropriate systemic, local, and regional analgesia, and when anxiolytic medications or procedural sedation are indicated

Guidance for recognizing and managing infectious and inflammatory conditions, including balanitis, balanoposthitis, and urethritis

How to classify and treat priapism, including techniques for corporeal aspiration and intracavernosal sympathomimetic injection

Recommendations for managing strangulation conditions, including hair tourniquet removal and manual reduction of paraphimosis

Recommendations for evaluating and managing traumatic and surgical injuries, including straddle injuries, zipper entrapment, penile fracture, and postcircumcision bleeding

How to screen for nonaccidental trauma and when to involve Child Protective Services or a child abuse team

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
7. Differential Diagnosis
   1. Congenital Penile Conditions
   2. Acquired Penile Conditions
      1. Infectious and Inflammatory Conditions
      2. Hematologic Conditions
      3. Strangulation Conditions
      4. Trauma and Surgical Injuries
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
10. Diagnostic Studies
    1. Laboratory Studies
    2. Imaging Studies
11. Treatment
    1. General Principles
       1. Pain Management
       2. Anxiolytic Medications and Sedation
    2. Diagnosis-Specific Treatment
       1. Congenital Penile Conditions
       2. Acquired Penile Conditions
          1. Infectious and Inflammatory Conditions
          2. Hematologic Conditions
          3. Strangulation Conditions
             • Hair Tourniquet
             • Paraphimosis
          4. Trauma and Surgical Injuries
             • Zipper Entrapment
             • Straddle Injury
             • Penile Fracture
             • Postcircumcision Bleeding
12. Special Considerations
13. Controversies and Cutting Edge
14. Disposition
    1. General Considerations
    2. Consultation
    3. Infectious and Inflammatory Conditions
    4. Hematologic Conditions
    5. Strangulation Conditions
    6. Trauma and Surgical Injuries
       1. Zipper Entrapment
       2. Straddle Injury
       3. Penile Fracture
       4. Postcircumcision Bleeding
15. Summary
16. 5 Things That Will Change Your Practice
17. Risk Management Pitfalls for Emergency Department Management of Pediatric Patients With Penile Problems
18. Time- and Cost-Effective Strategies
19. Case Conclusions
20. Clinical Pathway for Evaluation and Management of a Child With a Penile Problem in the Emergency Department
21. Tables and Figures
22. References

Abstract

Pediatric penile problems range from congenital anomalies to acquired and emergent conditions. Acquired conditions can result from various causes, including infectious and inflammatory conditions, hematologic conditions, strangulation conditions, trauma, and surgical injuries. This review provides an overview of the presentation, diagnosis, and management of pediatric penile problems that may present to the emergency department. Recommendations are given for evaluation and management, with emphasis on pain relief, restoration of normal anatomy, and timely treatment. Guidance is also provided on indications for emergent urologic consultation. Optimizing outcomes for pediatric patients with penile conditions requires addressing key challenges, including effective pain and anxiety management, thoughtful use of imaging, and careful evaluation for possible abuse.

Case Presentations

A 3-day-old boy presents for persistent bleeding after circumcision completed 8 hours earlier…

• The boy was born at full term with no complications. The parents tell you the circumcision was completed without complications at the delivering hospital prior to discharge. Since the procedure, they have seen a “significant amount” of bright-red blood with each diaper change. They have been applying petroleum jelly as directed. There is no family history of bleeding diatheses. The baby received vitamin K after delivery. The newborn screen is pending.
• On examination, there is a small amount of bright-red blood dripping from the circumcision site.
• What workup is warranted at this time, and what are the next steps in management?

A 4-year-old uncircumcised boy presents with the complaint of penile pain for the last 4 days and difficulty urinating for the last 24 hours...

• The boy has no prior history of urinary tract infections. He is toilet-trained. His parents report dribbling of urine for the last few days and inability to void when attempting to urinate.
• On examination, there is edema and ballooning of the foreskin of the penis. The foreskin is unable to be retracted to visualize the tip of the penis; however, there is scant discharge from the end of the penis. There are a few erythematous “satellite lesions” on the inguinal creases. His urine is positive for 1+ leukocytes and negative for nitrites.
• What is the appropriate management for this patient?

A 14-year-old uncircumcised boy presents with penile pain, swelling, and difficulty urinating for the last 12 hours...

• The boy takes no medications and denies being sexually active.
• The physical examination is notable for a donut-shaped, erythematous, and exquisitely painful circumferential swelling at the base of the glans, with moderate swelling of the glans and flaccidity proximal to it. There is no discharge.
• What pain control measures and techniques should be considered for management of this patient’s condition?

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Clinical Pathway for Evaluation and Management of a Child With a Penile Problem in the Emergency Department

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

8. * Chan IH, Wong KK. Common urological problems in children: prepuce, phimosis, and buried penis. Hong Kong Med J. 2016;22(3):263-269. (Review) DOI: 10.12809/hkmj154645

11. * Donaldson JF, Rees RW, Steinbrecher HA. Priapism in children: a comprehensive review and clinical guideline. J Pediatr Urol. 2014;10(1):11-24. (Review) DOI: 10.1016/j.jpurol.2013.07.024

16. * Leslie JA, Cain MP. Pediatric urologic emergencies and urgencies. Pediatr Clin North Am. 2006;53(3):513-527. (Review) DOI: 10.1016/j.pcl.2006.02.007

23. * McGrath NA, Howell JM, Davis JE. Pediatric genitourinary emergencies. Emerg Med Clin North Am. 2011;29(3):655-666. (Review) DOI: 10.1016/j.emc.2011.04.003

34. * Morey AF, Metro MJ, Carney KJ, et al. Consensus on genitourinary trauma: external genitalia. BJU Int. 2004;94(4):507-515. (Review) DOI: 10.1111/j.1464-410X.2004.04993.x

49. * Adjei NN, Lynn AY, Grimshaw A, et al. Systematic literature review of pediatric male and female genital hair thread tourniquet syndrome. Pediatr Emerg Care. 2022;38(2):e799-e804. (Literature review) DOI: 10.1097/PEC.0000000000002383

58. * Hobbs CJ, Osman J. Genital injuries in boys and abuse. Arch Dis Child. 2007;92(4):328-331. (Review) DOI: 10.1136/adc.2006.111195

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Keywords: pediatric penile problems, phimosis, paraphimosis, priapism, balanitis, balanoposthitis, urethritis, hair tourniquet, zipper entrapment, straddle injury, penile fracture, postcircumcision bleeding, hypospadias, epispadias, chordee, buried penis, pediatric genitourinary emergency, penile block, corporeal aspiration, sickle cell priapism, nonaccidental trauma, pediatric urology