ED Pathway for Child With Acute Nontraumatic Scrotal/Testicular Pain URL: https://www.chop.edu/clinical-pathway/scrotal-testicular-pain-nontraumatic-clinical-pathway Authors: R Scarfone, MD; J Lavelle, MD; K Posner, MD; K Kraf, MD Posted: July 2011, last revised May 2018 Evaluation/Treatment of Acute Abnormal Uterine Bleeding URL: https://www.chop.edu/clinical-pathway/uterine-bleeding-acuteabnormal-clinical-pathway Authors: M Zucker, MD; R Hughes, PharmD; A Culyba, MD; L Zinns, MD; J Boyle, RN; C Jacobstein, MD; J Posner, MD; J Lavelle, MD Posted: June 2015, last revised July 2017 ED Pathway for Evaluation of Postpubertal Girls With Lower Abdominal Pain and No Vaginal Bleeding URL: https://www.chop.edu/clinical-pathway/abdominal-pain-lowerpost-pubertal-girls-clinical-pathway Authors: C Mollen, MD; J Lavelle, MD; M Zucker, MD Posted: April 2006, last revised December 2017 ED Pathway for Evaluation and Treatment of Children With Suspected Nephrolithiasis URL: https://www.chop.edu/clinical-pathway/nephrolithiasis-suspectedemergent-care-clinical-pathway Authors: M Zonfrillo, MD; J Lavelle, MD; J Piro, RN; S Kim, MD; K Darge, MD Posted: October 2009, last revised April 2018 PENILE PROBLEMS CLINICAL PEARLS AND PITFALLS It is important to distinguish normal physiologic appearance from pathology Paraphimosis and priapism are true emergencies Penile Care in the Uncircumcised Male Infant Goals of Treatment/Clinical Assessment With the high rate of circumcision in the United States, the recommended care of an intact foreskin is not always clear In uncircumcised male infants, adhesions between the glans and the foreskin are normal ( Fig 119.1 ) The foreskin is not normally retractable in this age group No effort should be made to strip the foreskin back in infants because this produces undue pain for the child and may result in inflammation and scarring Between ages and 4, spontaneous lysis of the adhesions occurs in 90% of boys It is rare for the male infant to have any adverse hygienic consequence from leaving the foreskin in place until that time The small, whitish lumps that may be seen and felt beneath the foreskin represent desquamated epithelium, smegma, and are benign After toilet training, boys should be taught to retract the foreskin enough to expose the meatus during voids —this avoids leaving the inner foreskin wet with urine, which can lead to inflammation, mucosal abrasions, and balanoposthitis By age to years, the foreskin should be drawn back as far as it can go at every bath FIGURE 119.1 Male anatomical landmarks A: Circumcised B: Uncircumcised (Reprinted with permission from Urinary Elimination In: Timby BK Fundamental Nursing Skills and Concepts 11th ed Wolters Kluwer: Philadelphia, PA; 2017:695–727.) Post Circumcision Concerns Immediate Concerns While rare, post circumcision bleeding can be of significant concern, or it can be a minor issue After circumcision done either with a clamp (in the newborn time period), or freehand (older boys), most postoperative bleeding will resolve with manual pressure for to 10 minutes After that, careful inspection will reveal if there is a discrete vessel bleeding, or if there is more general oozing of blood from the suture line Urology consultation is recommended if there is concern for injury to the glans or urethra or if bleeding does not stop with manual pressure Delayed Concerns If there is concern for a skin cicatrix, a thick scar around the edge of the circumcision, encasing the urethral meatus, then the patient should be referred to the urology clinic for outpatient follow-up This can be done as a routine visit unless there is concern for obstruction of the urinary stream, although this is very rare If a scar is caught early, it may respond to gentle release of flimsy adhesions, or, if a more robust scar, it may respond to treatment with betamethasone cream In severe cases, a circumcision revision will have to be performed in order to release the scar around the glans Phimosis and Paraphimosis Goals of Treatment Rule out significant skin or glans infection in cases of phimosis Reduce foreskin back to normal anatomic location in paraphimosis Clinical Considerations Phimosis exists when the distal foreskin becomes scarred so that it cannot be retracted to expose the glans This nonretracted foreskin is a normal physiologic finding in the newborn and infant However, this can also persist or occur later in life as a result of inflammation from chronic urine exposure, previous forceful withdrawing of the foreskin over the glans, or related to lichen sclerosus Children may present with swelling of the foreskin, or with the complaint of seeing ballooning of the foreskin during urination Paraphimosis is the result of retracting foreskin behind the glans and leaving it in that position This leads to venous congestion and edema—thus making it difficult to reduce the foreskin back to its normal position ( Fig 119.2 ) This often results after bathing (often by a provider not used to caring for the child), or is caused by the child himself In iatrogenic settings, this may occur after urethral catheterization, when the foreskin is retracted for the procedure but is not returned to its normal position Clinical Recognition A tight phimosis can result in ballooning of the foreskin during voiding, which in turn traps urine and can lead to inflammation In a child over years old, the foreskin should be able to be retracted to the point where the urethral meatus can be visualized Paraphimosis is evident as a broad, edematous band of skin proximal to the glans This skin is often erythematous and very tender to touch Management Phimosis does not have to be treated emergently Betamethasone cream, 0.05%, applied twice daily for weeks, is the first-line treatment Hydrocortisone cream is an alternative The patient/family must be instructed to pull the foreskin back as far as it will go, then to apply a small amount directly to the tightened area The goal in paraphimosis is to bring the foreskin back into normal location This requires reduction of the edema in the skin The application of ice and steady manual compression on the inflamed ring of foreskin usually reduces the edema and permits manual reduction of the paraphimosis Topical anesthetic cream or a dorsal penile nerve block will reduce the discomfort experienced by the child during compression of the edematous foreskin Once a portion of the edema has been reduced, pressure on the glans (like turning a sock inside out) usually permits reduction of the foreskin back to its normal position If manual reduction fails, a surgical division of the foreskin to permit reduction is indicated; however it is uncommon to need to perform this The family should be counseled not to pull the foreskin back over the glans for at least a week Vaseline can be applied to the raw edges of the foreskin, especially in the setting of small abrasions, to prevent infection The family can be counseled about circumcision, although this is not required