White Penile Discharge in a 5-Year-Old Male
This child requires immediate STI screening with cultures for N. gonorrhoeae, C. trachomatis, and T. vaginalis, followed by mandatory reporting to child protective services if any sexually transmitted infection is confirmed, as any STI in a prepubertal child is highly suspicious for sexual abuse. 1, 2
Immediate Evaluation Protocol
Visual Inspection
Examine the genital, perianal, and oral areas specifically looking for:
- Discharge characteristics (color, consistency, odor)
- Bleeding or erythema
- Hypopigmentation (suggests lichen sclerosus)
- Warts or ulcerative lesions
- Signs of trauma 1, 2
Mandatory STI Screening
All prepubertal children with penile discharge require cultures for sexually transmitted infections due to legal implications and possibility of sexual abuse. 2
Obtain the following specimens:
- N. gonorrhoeae culture from pharynx, anus, and urethra (meatal specimen if discharge present) using only standard culture procedures—Gram stains are inadequate and should not be used 1, 2
- C. trachomatis culture from urethra and anus using standard culture systems with fluorescein-conjugated monoclonal antibody confirmation 1, 2
- T. vaginalis culture and wet mount from urethral specimen 1, 2
- HSV culture or PCR if any vesicular or ulcerative lesions are present 1, 2
Critical caveat: Only culture-based methods should be used—NAATs lack FDA approval in children and have insufficient specificity for medical-legal purposes. 2 All presumptive N. gonorrhoeae isolates must be confirmed by at least two different testing methods (biochemical, enzyme substrate, or serologic), and isolates should be preserved for additional testing. 1
Differential Diagnosis Beyond STIs
Balanitis Xerotica Obliterans (Lichen Sclerosus)
- Presents with white plaques on the glans or foreskin, often with discharge 3, 4
- Average age of presentation is 8 years but can occur from ages 1-16 4
- May cause phimosis and white discharge-like appearance 4, 5
- Treatment: Topical corticosteroids as first-line therapy 2, 4
Candida Balanitis
- Less common in prepubertal children without diabetes 6
- Treatment: Topical clotrimazole 1% cream applied twice daily for up to 7 days (only if confirmed by culture) 2
- Important: Oral fluconazole should not be prescribed to children under 12 years 2
Poor Hygiene/Physiologic Smegma
- Begin with hygiene measures as first-line approach if STI screening is negative 2
- Reserve antimicrobial therapy only for confirmed infections 2
Treatment Algorithm
If STI confirmed:
- Gonococcal infection: Ceftriaxone 125 mg IM single dose (for children <45 kg) 2
- Do not use oral cephalosporins—pharmacokinetic data from adults cannot be extrapolated to children 2
- Follow-up cultures from infected sites are necessary to ensure treatment effectiveness 2
- Mandatory reporting to child protective services 7, 2
If lichen sclerosus suspected:
- Topical steroids as first-line treatment 2
- Close follow-up due to risk of meatal stenosis and recurrent phimosis 5
If candida confirmed:
- Topical clotrimazole 1% cream twice daily for up to 7 days 2
Follow-Up Schedule
- 2-week follow-up if initial exposure was recent, as organisms may not produce sufficient concentrations for positive testing initially 2
- 12-week follow-up for serologic testing to allow antibody development 2
- Schedule additional follow-up if symptoms persist or recur within 2 months 2
Critical Pitfalls to Avoid
- Never use NAATs for gonorrhea or chlamydia testing in prepubertal children—they lack FDA approval and specificity for medical-legal purposes 2
- Never delay STI screening while initiating empiric treatment, as this could interfere with diagnosis and have serious legal consequences 1
- Never assume benign etiology without completing full STI evaluation—the identification of an STI in a child may prompt investigation of possible abuse 7
- Never use Gram stains alone to diagnose or exclude gonorrhea in prepubertal children 1