What should I do if my baby has a pustular lesion on their testicle?

Immediate Evaluation and Management of Pustular Lesions on Infant Testicle

A pustular lesion on an infant's testicle requires prompt evaluation by a pediatric urologist or appropriate specialist to rule out infection, abscess, or other serious conditions that could threaten testicular viability. 1

Immediate Actions

Refer urgently to a pediatric urologist or pediatric surgeon for same-day or next-day evaluation, as pustular lesions suggest possible:

• Testicular abscess requiring drainage 2
• Infected cyst or epididymo-orchitis 2
• Skin infection overlying the scrotum that could spread 1

Do not delay referral to obtain imaging studies, as ultrasound rarely changes management decisions and should not postpone specialist evaluation 1, 3

Critical Assessment While Awaiting Specialist

Examine for Emergency Conditions

Check both testicles carefully:

• If both testicles are nonpalpable, this constitutes a medical emergency requiring immediate specialist consultation to rule out disorders of sex development, including life-threatening congenital adrenal hyperplasia 1, 3
• A phenotypic male infant with bilateral nonpalpable testes could be a genetic female (46 XX) with congenital adrenal hyperplasia, which can cause shock, hyponatremia, and hyperkalemia 1, 3

Assess for Systemic Infection

Monitor for signs of sepsis:

• Fever, lethargy, poor feeding, or irritability require emergency department evaluation 1
• Pustular lesions can indicate cutaneous or systemic bacterial infection requiring cultures and possible antibiotics 1

What NOT to Do

Avoid the following common pitfalls:

• Do not apply topical antibiotics, steroids, or other medications without specialist guidance, as percutaneous absorption in infants can cause systemic toxicity 1
• Do not squeeze or manipulate the pustule, as this could spread infection 1
• Do not order ultrasound or other imaging prior to referral, as these studies rarely assist decision-making and delay appropriate care 1, 3
• Do not assume this is benign - while benign intratesticular cystic lesions exist, pustular appearance suggests infection requiring urgent evaluation 2

Specialist Evaluation

The urologist will perform:

• Scrotal examination to differentiate intratesticular from extratesticular pathology 4, 2
• Ultrasound if indicated to characterize the lesion (cystic vs solid, intratesticular vs extratesticular) 2
• Surgical exploration if abscess suspected, using inguinal approach with careful examination of testicle, epididymis, and spermatic cord 4
• Testis-sparing surgery when possible for benign lesions, though this requires intraoperative frozen section diagnosis 4, 5

Infection Control Measures

While awaiting specialist evaluation:

• Keep the area clean and dry 1
• Use gentle cleansing with water only 1
• Monitor for spreading erythema, increased swelling, or worsening symptoms 1
• Perform regular assessment for signs of cutaneous or systemic infection 1