What is the management of a swollen penis in pediatrics?

Management of Swollen Penis in Pediatrics

The management of a swollen penis in pediatrics requires prompt evaluation to identify the underlying cause, with immediate surgical intervention indicated for conditions like penile fracture, priapism, and paraphimosis due to their potential to cause permanent damage to erectile function and penile tissue.

Differential Diagnosis and Initial Assessment

When evaluating a child with penile swelling, consider these key conditions:

1. Penile Fracture

   • Look for: Penile ecchymosis, swelling, cracking/snapping sound during trauma, and immediate detumescence 1
   • Diagnostic approach: History and physical examination are often sufficient; ultrasound may be used in equivocal cases 1

2. Priapism

   • Look for: Persistent, painful erection unrelated to sexual stimulation lasting >4 hours
   • Types: Ischemic (painful, rigid, emergency) vs. non-ischemic (less rigid, non-painful) 1
   • Occurs in 2.5-3.3% of boys with chronic myeloid leukemia 1

3. Paraphimosis

   • Look for: Foreskin retracted behind glans that cannot be reduced, progressive edema distal to constriction 2
   • Presents as an urologic emergency with increasing pain and swelling

4. Epididymitis/Epididymo-orchitis

   • Look for: Gradual onset of scrotal pain that may involve the penis, positive Prehn sign (pain relief with elevation) 3
   • Differentiate from testicular torsion (sudden onset, high-riding testis, absent cremasteric reflex) 3

5. Other causes

   • Smegma retention cyst: Subcutaneous yellowish swelling 4
   • Crohn's disease: Can present with penile swelling before intestinal symptoms 5, 6
   • Balanitis: Inflammation of the glans penis 7

Management Algorithm by Condition

1. Penile Fracture

• Intervention: Prompt surgical exploration and repair is the standard of care 1
• Approach: Expose injured corpus cavernosum through ventral midline or circumcision incision
• Repair: Perform tunical repair with absorbable suture at time of presentation 1
• Evaluation: Check for concomitant urethral injury if blood at meatus, gross hematuria, or inability to void 1

2. Priapism Management

• Emergency treatment for ischemic priapism:

  1. Penile puncture and blood aspiration from cavernous tissue
  2. Flushing with saline
  3. Suprarenin (epinephrine) injection if detumescence not achieved 1
  4. Consider dissociative sedation with low-dose ketamine 1
  5. Spongio-cavernous shunt operation if priapism persists 1

• For priapism associated with CML:

  • Implement rapid leukoreduction via exchange transfusion or leukapheresis 1
  • Initiate cytoreductive therapy simultaneously 1

3. Paraphimosis Management

• Immediate intervention required to prevent tissue necrosis:
  1. Manual reduction after pain control and edema reduction
  2. Apply gentle, steady pressure to the edematous tissue while pulling the foreskin forward
  3. Surgical intervention (dorsal slit) if manual reduction fails 2

4. Epididymitis Management

• Antibiotic therapy:

  • First-line: Ceftriaxone 250 mg IM (single dose) PLUS doxycycline 100 mg orally twice daily for 10 days 3
  • Alternative: Ofloxacin 300 mg orally twice daily for 10 days (contraindicated in patients ≤17 years) 3

• Supportive care:

  • Bed rest until fever and local inflammation subside
  • Scrotal elevation
  • Adequate analgesics and fluid intake 3
  • Re-evaluation within 72 hours to assess improvement 3

5. Other Conditions

• Smegma retention cyst: Often resolves spontaneously; gentle hygiene 4
• Crohn's disease-related swelling: Treat underlying Crohn's disease with systemic medications 5, 6
• Balanitis: Topical antifungals or antibiotics depending on cause; improved hygiene 7

Key Considerations and Pitfalls

1. Do not delay treatment for ischemic priapism - erectile dysfunction can occur if left untreated for 24-48 hours 1

2. Always evaluate for urethral injury in penile trauma cases with blood at meatus, hematuria, or voiding difficulty 1

3. Ultrasound with Doppler is valuable for assessing blood flow and distinguishing between inflammatory conditions and torsion 1

4. Consider underlying systemic conditions like chronic myeloid leukemia in cases of priapism 1

5. Follow up appropriately - persistent swelling or tenderness after completing antimicrobial therapy warrants evaluation for other conditions 3

By following this structured approach to the evaluation and management of penile swelling in pediatric patients, clinicians can ensure timely intervention and minimize the risk of complications and long-term sequelae.