What is the next step in managing a 9-year-old male with persistent penile itching, inflammation, and testicular pain despite initial treatment with Fluconazole (fluconazole) and Clotrimazole (clotrimazole) Cream?

Urgent Testicular Ultrasound is Mandatory Before Any Further Treatment

This 9-year-old requires immediate completion of the testicular ultrasound to rule out testicular torsion or epididymitis before any additional antifungal therapy is considered. The combination of persistent symptoms despite appropriate antifungal treatment, plus testicular pain that began after the penile symptoms, raises serious concern for a surgical emergency or bacterial infection rather than simple treatment-resistant candidiasis 1.

Immediate Priority: Complete the Ultrasound

• The ultrasound must be performed urgently because testicular torsion can occur in prepubertal boys (this is the most common cause of testicular pain in this age group), and testicular viability is compromised after 6-8 hours from symptom onset 1.
• Even though 3 days have passed since testicular pain began, partial torsion can present with less severe symptoms and still requires surgical intervention 1.
• The American College of Radiology recommends Duplex Doppler ultrasound for intermediate clinical suspicion, which should include grayscale examination to identify the "whirlpool sign" of twisted spermatic cord (96% sensitivity) and color Doppler assessment of testicular perfusion (96-100% sensitivity) 1.

Critical Differential Diagnoses to Exclude

Testicular Torsion

• Torsion of testicular appendage is the most common cause of testicular pain in prepubertal boys like this 9-year-old 1.
• Key features include abrupt onset of scrotal pain, though the gradual onset over days doesn't completely exclude partial torsion 1.
• The "blue dot sign" is pathognomonic for appendage torsion but only seen in 21% of cases 1.
• If torsion is confirmed, immediate urological consultation and surgical exploration are required 1.

Epididymitis

• Gradual onset of pain over days to weeks is characteristic, which fits this patient's 3-day timeline 2.
• May present with testicular tenderness and can have normal urinalysis (normal urinalysis does not exclude epididymitis) 2.
• Ultrasound findings would show enlarged epididymis with increased blood flow on Doppler 1.
• If confirmed, empiric antibiotic therapy should be initiated immediately, along with scrotal elevation, NSAIDs, and bed rest 2.

Why the Antifungal Treatment May Have Failed

• The penile inflammation persisting despite fluconazole and clotrimazole suggests either:
  • Fluconazole-resistant Candida albicans (documented in penile infections, though rare) 3
  • Secondary bacterial infection from scratching and local trauma
  • The testicular pain is unrelated to the candidal balanitis and represents a separate acute process

Management Algorithm After Ultrasound Results

If Ultrasound Shows Torsion:

• Immediate urological consultation for surgical exploration 1
• Surgical detorsion and orchiopexy within 6-8 hours of symptom onset prevents permanent ischemic damage 1

If Ultrasound Shows Epididymitis:

• Initiate empiric antibiotic therapy immediately while awaiting culture results 2
• Supportive measures: scrotal elevation, NSAIDs for pain, bed rest until inflammation subsides 2
• Reassess within 48-72 hours; if no improvement, reconsider diagnosis 2

If Ultrasound is Normal but Penile Inflammation Persists:

• Consider fluconazole-resistant Candida albicans and switch to oral itraconazole (documented effective for fluconazole-resistant penile candidiasis) 3
• Alternative: voriconazole or amphotericin B if itraconazole unavailable, as these show sensitivity against resistant strains 3
• Obtain fungal culture with antifungal susceptibility testing to guide therapy 3
• Consider bacterial superinfection requiring topical or systemic antibiotics if signs of secondary infection present

Critical Pitfalls to Avoid

• Never delay imaging when testicular pain is present - there is significant overlap in clinical presentation between different causes of scrotal pain, and false-negative Doppler can occur with partial torsion or spontaneous detorsion 1, 4.
• Do not assume the testicular pain is related to the candidal infection - the temporal sequence (penile symptoms first, then testicular pain 1 day later) suggests two separate processes 1.
• Do not continue the same antifungal regimen without ultrasound completion - persistent symptoms after 4 days of appropriate therapy warrant investigation for resistance or alternative diagnosis 3.
• Any patient with acute scrotal complaint and negative scan should receive daily follow-up until symptoms subside 4.