What are the causes and treatment options for penis pain in a 3-year-old child?

Penis Pain in a 3-Year-Old Child

In a 3-year-old boy with penis pain, immediately assess for testicular torsion, trauma, infection (balanitis/balanoposthitis), and paraphimosis, as these conditions require urgent intervention to prevent permanent damage or complications.

Immediate Life-Threatening Considerations

Testicular Torsion

• Testicular torsion is a surgical emergency requiring intervention within 6-8 hours to prevent testicular loss, though it more commonly presents with scrotal rather than isolated penile pain 1
• Characterized by abrupt onset of severe pain, negative Prehn sign (pain not relieved with testicular elevation), and requires immediate urological consultation 1
• While torsion has a bimodal distribution peaking in neonates and postpubertal boys, it can occur at any age and must be excluded 1

Priapism

• In children with sickle cell disease, priapism presents as prolonged painful erection and requires urgent treatment if lasting more than 4 hours to prevent irreversible tissue damage 2
• Emergency treatment includes penile puncture, blood aspiration, saline flushing, and potential suprarenin injection if detumescence cannot be achieved 2
• However, priapism is rare in the general pediatric population without underlying hematologic conditions 2

Traumatic Injury

• Rupture of the corpus cavernosum, though rare in prepubertal children, is a true urologic emergency that can occur from blunt trauma such as falls 3
• Presents with acute-onset penile pain, ecchymosis, and swelling of the penile shaft after trauma 3
• Ultrasound showing discontinuity of the corpus cavernosum requires urgent surgical repair to prevent erectile dysfunction, fibrosis, and persistent hematoma 3

Common Non-Emergent Causes in This Age Group

Infectious/Inflammatory Conditions

• Balanitis (inflammation of the glans) and balanoposthitis (inflammation of glans and foreskin) are common causes of penile pain in young boys
• Typically presents with redness, swelling, discharge, and pain with urination
• Often related to poor hygiene, retained smegma under foreskin, or irritation from soaps/detergents

Paraphimosis

• Paraphimosis occurs when retracted foreskin becomes trapped behind the glans and cannot be reduced, causing venous congestion, swelling, and pain
• Requires urgent manual reduction or, if unsuccessful, dorsal slit procedure to prevent tissue necrosis
• More common after forceful retraction during cleaning or catheterization

Phimosis with Secondary Inflammation

• Physiologic phimosis is normal in young children, but can become symptomatic with ballooning during urination, pain, or recurrent infections
• Differentiate from pathologic phimosis (scarring from balanitis xerotica obliterans)

Diagnostic Approach

Critical History Elements

• Onset and duration: Sudden onset suggests torsion or trauma; gradual onset suggests infection 1
• Trauma history: Falls, zipper injuries, or straddle injuries 3
• Associated symptoms: Fever (infection), urinary symptoms, scrotal swelling or pain
• Underlying conditions: Sickle cell disease increases priapism risk 2
• Foreskin manipulation: Recent retraction attempts may cause paraphimosis

Physical Examination Priorities

• Inspect for: Swelling, erythema, discharge, ecchymosis, foreskin position (paraphimosis), and any visible trauma 3
• Palpate: Testicles for position, tenderness, and masses; assess cremasteric reflex if torsion suspected 1
• Transillumination: Can help differentiate hydrocele (transilluminates) from solid masses or hematomas (do not transilluminate) 4

Imaging When Indicated

• Duplex Doppler ultrasound is first-line for suspected torsion, showing decreased/absent testicular blood flow and potential "whirlpool sign" 1
• Ultrasound can identify corpus cavernosum discontinuity in traumatic rupture 3
• Generally not needed for obvious balanitis or paraphimosis with clear clinical diagnosis

Treatment Algorithm

For Suspected Torsion or Trauma

• Immediate urological consultation without delay for imaging if high clinical suspicion 1
• Surgical exploration within 6-8 hours for torsion; urgent repair for corpus cavernosum rupture 1, 3

For Infectious Causes (Balanitis/Balanoposthitis)

• Warm water soaks 2-3 times daily
• Topical antibiotic ointment if bacterial infection suspected
• Oral antibiotics if cellulitis or systemic symptoms present
• Antifungal cream if candidal infection (white plaques, satellite lesions)

For Paraphimosis

• Manual reduction: Apply firm compression to glans for 5-10 minutes to reduce edema, then gently reduce foreskin over glans
• If unsuccessful after 30 minutes, requires emergency urological consultation for dorsal slit procedure

For Priapism (in sickle cell patients)

• Hydration and analgesia for episodes <4 hours 2
• Episodes ≥4 hours require emergency intervention with exchange transfusion or leukapheresis, plus penile aspiration and irrigation 2

Critical Pitfalls to Avoid

• Do not assume all penile pain is benign infection—always exclude torsion and trauma, as delayed treatment causes irreversible damage 1, 3
• Do not forcibly retract foreskin in young boys with physiologic phimosis, as this can cause paraphimosis or scarring
• Do not delay surgical consultation for high suspicion of torsion based on negative ultrasound alone, as false negatives occur with partial torsion 1
• Normal urinalysis does not exclude testicular torsion 1
• In children with known sickle cell disease, maintain high suspicion for priapism and treat aggressively if duration exceeds 4 hours 2