Key Components of History and Physical Exam for a 3-Year-Old with Penile Swelling and Refusal to Void
A thorough history and physical examination focusing on urinary and genital findings is essential for proper diagnosis and management of a 3-year-old presenting with penile swelling and refusal to void, as these symptoms suggest possible urethral injury or obstruction requiring prompt evaluation.
History Components
| Component | What to Ask | Clinical Significance |
|---|---|---|
| Onset and Duration | • When did the swelling begin? • Was it sudden or gradual? • Any preceding trauma or injury? |
Sudden onset suggests trauma; gradual onset may indicate infection or inflammatory process [1] |
| Trauma History | • Any straddle injury? • Fall onto perineum? • Any manipulation of genitalia? |
Penile fracture or urethral injury may occur with trauma, even in non-erect penis [2] |
| Urinary Symptoms | • When was last void? • Any blood in urine? • Any pain with urination? • Changes in urine stream? |
Blood at meatus, inability to void suggest urethral injury requiring prompt evaluation [1] |
| Associated Symptoms | • Fever? • Pain? • Behavioral changes? • Abdominal pain? |
Fever suggests infection; behavioral changes may indicate pain severity |
| Bowel Habits | • Recent constipation? • Changes in bowel movements? • Straining with defecation? |
Constipation can contribute to voiding dysfunction in 66% of cases [1] |
| Medical History | • Prior UTIs? • Congenital abnormalities? • Recent illnesses? • Skin conditions? |
Recurrent UTIs may suggest underlying anatomical abnormality |
| Family History | • Family history of urological conditions? • Genetic disorders? |
May indicate hereditary component to urological issues [3] |
Physical Examination
| Component | What to Observe | Assessment Approach |
|---|---|---|
| General Appearance | • Level of distress • Vital signs • Hydration status |
Assess severity and urgency; check for signs of systemic illness |
| Abdominal Exam | • Bladder distension • Tenderness • Masses • Bowel sounds |
Palpate for distended bladder; assess for constipation [1] |
| Genital Examination | • Pattern and extent of swelling • Color changes (ecchymosis) • Skin integrity • Urethral meatus |
Note distribution of swelling, presence of ecchymosis suggesting trauma [1] |
| Urethral Assessment | • Blood at meatus • Discharge • Position and appearance |
Blood at meatus strongly suggests urethral injury requiring further evaluation [1] |
| Scrotal Examination | • Swelling • Tenderness • Testicular position |
Assess for associated scrotal trauma or testicular involvement [1] |
| Perineal Area | • Bruising • Swelling • Evidence of trauma |
Look for signs of straddle injury or other trauma [1] |
| Rectal Examination | • Consider only if necessary • Assess for fecal impaction • Prostate position (if palpable) |
High-riding prostate suggests urethral injury; may assess for constipation if indicated [1] |
| Neurological | • Lower extremity strength/sensation • Anal tone • Sacral dimpling |
Rule out neurological causes of voiding dysfunction [3] |
Immediate Assessment Priorities
Evaluate for urethral injury: Blood at meatus, inability to void, and penile swelling are concerning for urethral trauma 1
Assess for bladder distension: Palpate abdomen for distended bladder requiring urgent decompression
Rule out penile fracture: Even in children, trauma can cause corporal injury requiring surgical exploration 1, 2
Consider constipation: Treatment of constipation alone resolves urinary symptoms in up to 89% of cases 1
Diagnostic Considerations
- Ultrasound: First-line imaging for equivocal cases to assess post-void residual and penile structures 1
- Uroflowmetry: Consider in follow-up to assess voiding pattern if dysfunctional voiding suspected 1
- Urinalysis/Culture: Essential to rule out infection 3
- Retrograde urethrogram: Consider if urethral injury suspected based on blood at meatus or inability to void 1
Common Pitfalls to Avoid
- Delaying urinary drainage: In cases of urinary retention, prompt drainage is essential to prevent complications
- Missing urethral injury: Blood at meatus warrants evaluation for urethral injury 1
- Overlooking constipation: Treatment of constipation alone may resolve urinary symptoms 1
- Neglecting non-traumatic causes: Consider inflammatory or infectious etiologies if no trauma history
- Performing invasive tests prematurely: Start with non-invasive assessment before proceeding to invasive studies 1
This structured approach ensures comprehensive evaluation while prioritizing the most critical aspects for a child presenting with these concerning symptoms.