Differential Diagnosis for a 3-year-old with Penile Swelling and Refusal to Void

Single Most Likely Diagnosis

• Urinary Retention due to Phimosis or Tight Foreskin: This condition is common in young boys and can cause penile swelling and pain, leading to refusal to void. The tight foreskin can obstruct the flow of urine, causing urinary retention.

Other Likely Diagnoses

• Balanitis: Inflammation of the glans penis, which can cause swelling, pain, and refusal to void. It's often associated with poor hygiene or infection.
• Urethral Stricture or Meatal Stenosis: Narrowing of the urethra or meatus can cause obstructive symptoms, including urinary retention and penile swelling.
• Urinary Tract Infection (UTI): UTIs can cause dysuria, frequency, and refusal to void, especially in young children who may not be able to communicate their symptoms effectively.

Do Not Miss Diagnoses

• Testicular Torsion: Although more common in older children and adolescents, testicular torsion can occur in young children and is a surgical emergency. It can cause severe pain, swelling, and refusal to void.
• Epispadias or Hypospadias with Urethral Obstruction: Congenital anomalies of the urethra can cause obstructive symptoms, including urinary retention and penile swelling.
• Trauma to the Genital Area: Accidental or non-accidental trauma can cause penile swelling, pain, and refusal to void.

Rare Diagnoses

• Henoch-Schönlein Purpura (HSP): A systemic vasculitis that can cause penile swelling, pain, and refusal to void, although it's more commonly associated with skin, joint, and gastrointestinal symptoms.
• Penile Cellulitis or Abscess: Bacterial infections of the penile skin or soft tissues can cause swelling, pain, and refusal to void.

Red Flags

• Severe pain or swelling
• Fever or signs of infection
• Trauma to the genital area
• Difficulty walking or sitting due to pain
• Abnormal urine stream or dribbling

Management for Each Diagnosis

• Urinary Retention due to Phimosis or Tight Foreskin: Topical steroids, gentle stretching, or circumcision may be necessary.
• Balanitis: Topical antibiotics, improved hygiene, and circumcision may be necessary.
• Urethral Stricture or Meatal Stenosis: Dilation or surgical repair may be necessary.
• UTI: Antibiotic treatment and pain management.
• Testicular Torsion: Immediate surgical intervention.
• Epispadias or Hypospadias with Urethral Obstruction: Surgical repair.
• Trauma to the Genital Area: Supportive care, pain management, and possible surgical intervention.
• HSP: Supportive care, pain management, and monitoring for complications.
• Penile Cellulitis or Abscess: Antibiotic treatment, drainage of abscess, and supportive care.