The Toddler/Preschool Child
Case 3.6 Lesion on Penis
84 The Toddler/Preschool Child
Medications: Lionel is not currently taking any over - the - counter, prescription, or herbal medications.
His mother does apply diaper rash cream to genital area during diaper changes. Lionel has no known allergies to medication, food, or the environment. He is up to date on required immunizations.
OBJECTIVE
Lionel ’ s vital signs are taken, and his weight in the offi ce is 17 kg. His temperature is 37.0 ° C (tempo- ral). He is alert, playful, and interactive. When crying, he is easily consolable. He appears well hydrated and well nourished. There is no cyanosis of his skin, lips, or nails. There is no diaphoresis noted, and Lionel has good skin turgor on examination.
HEENT : Lionel ’ s head is normocephalic. His red refl exes are present bilaterally; and his pupils are equal, round, and reactive to light. There is no ocular discharge noted. Lionel ’ s external ear reveals that the pinnae are normal, and there is no tenderness to touch on the external ear. On otoscopic examination, the tympanic membranes are gray bilaterally, in normal position with positive light refl exes. Bony landmarks are visible, and there is no fl uid noted behind the tympanic membranes.
Both nostrils are patent. There is no nasal discharge, and there is no nasal fl aring. Lionel ’ s mucous membranes are noted to be moist. He has 18 teeth present. There are no visible caries or other lesions present in the oral cavity.
Neck: Lionel ’ s neck is supple and able to move in all directions without resistance. There is no cervi- cal lymphadenopathy noted.
Respiratory: Lionel ’ s respiratory rate is 24 breaths per minute, and his lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No deformities of the thoracic cage are noted.
Cardiovascular: Lionel ’ s heart rate is 96 beats per minute with a regular rhythm. There is no murmur noted upon auscultation.
Abdomen: Normoactive bowel sounds are present throughout, and Lionel ’ s abdomen is soft and nontender. There is no evidence of hepatosplenomegaly.
Genitourinary: Uncircumcised male genitalia with erythema and mild edema on the foreskin. The affected area is mildly tender to touch. A portion of the glans is visible; and there is no discharge, erythema, or swelling noted. His testes are descended bilaterally. There is no erythema or edema of the scrotum. He has shotty lymph nodes present in the inguinal area.
Neuromusculoskeletal: Good tone and full range of motion in all extremities; extremities are warm and well perfused. Capillary refi ll is less than 2 seconds, and his spine is straight.
CRITICAL THINKING
Which diagnostic or imaging studies should be considered to assist with or confi rm the diagnosis?
___Bacterial culture ___Gram stain
___Microscopic examination ___ Potassium hydroxide ( KOH ) ___Urinalysis
What is the most likely differential diagnosis and why?
___Balanitis ___Phimosis ___Paraphimosis ___Balanoposthitis
Lesion on Penis 85
What is your plan of treatment, referral, and follow - up care?
Does this patient ’ s psychosocial history affect how you might treat this case?
What if the patient lived in a rural setting?
Are there any demographic characteristics that might affect this case?
Are there any standardized guidelines that you should use to assess or treat this case?
RESOLUTION
Diagnostic t ests: To rule out a microbial cause, a swab of the skin under the foreskin and of any discharge should be analyzed for culture and sensitivity. Gram staining may be used to identify the causative microorganism and guide treatment. Dark fi eld microscopy may be ordered to observe the presence of spirochetes, specifi cally Treponema pallidum. A potassium hydroxide test may be per- formed to look for hyphae if candida is suspected. In addition, a urinalysis should be performed for the detection of microorganisms from the bladder, urethra, meatus, or glans penis and to rule out a urinary tract infection and diabetes.
What is the most likely differential diagnosis and why?
Balanoposthitis:
Conditions to consider in the differential diagnosis of erythema and swelling of the foreskin include balanitis, phimosis, paraphimosis, and balanoposthitis. Balanitis refers to the infl ammation of the glans penis. The foreskin is not swollen in balanitis, thus it may occur in both circumcised and uncir- cumcised males. Balanitis often presents in conjunction with diaper dermatitis. In phimosis, the foreskin cannot be retracted due to adhesion between the prepuce and glans penis, which becomes chronically swollen. This condition is physiologic at birth and should resolve between 3 and 6 years of age. Paraphimosis is a less likely diagnosis for Lionel, but it is one that should be considered for patients with swollen foreskin. In this condition, the foreskin is retracted past the coronal sulcus.
Venous stasis results in swelling and pain of the foreskin.
Balanoposthitis refers to any infection of the foreskin. Staphylococcus and Streptococcus are the most common bacterial causes of posthitis. Candidiasis is a common fungal origin of posthitis and often occurs in conjunction with fungal diaper dermatitis. In addition, patients may develop irritant non- specifi c balanoposthitis from poor hygiene, especially related to smegma or prolonged contact with wet diapers. Based on the history and physical examination, Lionel has most likely developed a form of balanoposthitis.
What is your plan of treatment, referral, and follow - up care?
In addition to Lionel ’ s diagnosis of balanoposthitis, he will likely have a concurrent diagnosis of physiologic phimosis. Because there is no discharge present, it is likely that the cause of Lionel ’ s bala- noposthitis is irritation from his diaper. The best treatment for Lionel at this time is a daily bath with a weak salt solution to alleviate infl ammation and the application of bacitracin antibiotic ointment to the affected area 2 – 3 times daily. Lionel ’ s parents should also be instructed to permit him to be without a diaper for 5 – 10 minutes after each diaper change to allow air to the area and to allow his diaper area to fully dry. His parents should also be told not to try to retract the foreskin fully as this may result in paraphimosis. Lionel ’ s parents should be further educated to reinforce proper hygiene of the genital area. Lionel ’ s family should follow up by phone in 2 days to report progress and healing.
They should return to the offi ce if his condition worsens or if there is no improvement in 48 hours after beginning the salt baths and bacitracin treatment. Health care providers should be aware that circumcision is not a preventative treatment of balanoposthitis in children younger than 3 years old.
For chronic or recurrent balanoposthitis, a referral to a pediatric urologist should be considered.
Does this patient ’ s psychosocial history affect how you might treat this case?
Though Lionel ’ s father is involved in his care, his father does not reside with Lionel. Because there is no male fi gure directly caring for Lionel, it is important to educate the mother and grandmother
86 The Toddler/Preschool Child
in male genitourinary health. Proper hygiene of the glans penis and foreskin should be discussed, emphasizing that Lionel ’ s foreskin will not likely be fully retractable at 2 years of age and that they should not forcibly retract the foreskin under any circumstances.
What if the patient lived in a rural setting?
Care of balanoposthitis would not change in a rural setting. Education regarding hygiene should be emphasized as before. For patients living in agricultural settings, hand hygiene after contact with animals should be discussed.
Are there any demographic characteristics that might affect this case?
When considering ethnicity, balanoposthitis has been noted to occur twice as often in African - Americans and Hispanics. The difference in occurrence rates compared to Caucasians is likely related to different circumcision rates between the ethnic groups. Age is not necessarily a factor in the devel- opment of balanoposthitis. This condition can occur in males at any age, and the etiologies will vary depending on the age of the patient.
Are there any standardized guidelines that you should use to assess or treat this case?
The European Association of Urology has issued guidelines on the treatment of balanoposthitis and other pediatric urological conditions (Tekgul et al., 2009).
REFERENCES AND RESOURCES
Gargollo , P. , Kozakewich , H. , Bauer , S. , Borer , J. , Peters , C. , Retik , A. , & Diamond , D. ( 2005 ). Balanitis xerotica obliterans in boys . The Journal of Urology , 174 , 1409 – 1412 .
Kiss , A. , Kiraly , L. , Kutasy , B. , & Merksz , M. ( 2005 ). High incidence of balanitis xerotica obliterans in boys with phimosis: Prospective 10 - year study . Pediatric Dermatology , 22 , 305 – 308 .
Lisboa , C. , Ferreira , A. , Resende , C. , & Rodrigues , A. ( 2009 ). Infectious balanoposthitis: Management, clinical and laboratory features . International Journal of Dermatology , 48 , 121 – 124 .
Tekgul , S. , Riedmiller , H. , Gerharz , E. , Hoebeke , P. , Kocvara , R. , Nijman , R. , . . . Stein , R. ( 2009 ). Guidelines on paediatric urology: Phimosis . Paediatric Urology , Arnhem, The Netherlands: European Association of Urology, European Society for Paediatric Urology, 6 – 8, 18 – 22.