What is the management approach for a child with bleeding from the penis?

Management of Pediatric Penile Bleeding

For a child presenting with bleeding from the penis, immediately assess for life-threatening causes including priapism in chronic myeloid leukemia (CML), trauma, or coagulopathy, and initiate emergency hemostatic measures while simultaneously investigating the underlying etiology.

Initial Emergency Assessment and Stabilization

Critical Life-Threatening Causes to Rule Out

• Priapism in CML: This represents a true urologic emergency requiring intervention within 24-48 hours to prevent permanent erectile dysfunction 1

  • Occurs in 2.5-3.3% of boys at CML diagnosis 1
  • Requires immediate leukoreduction via exchange transfusion or leukapheresis alongside emergency urologic intervention 1
  • Emergency treatment includes penile puncture with blood aspiration from cavernous tissue, saline flushing, and epinephrine injection if detumescence fails 1
  • Dissociative sedation with low-dose ketamine may prompt detumescence 1

• Bleeding from CML-related coagulopathy: 20% of children with CML present with bleeding despite normal or elevated platelet counts 1

  • May be due to acquired von Willebrand syndrome (AVWS) even with high platelet counts 1
  • Treatment options include desmopressin for mild bleeding, or fresh frozen plasma (10-15 mL/kg), von Willebrand factor concentrates, intravenous immunoglobulin, or recombinant factor VIIa for severe bleeding 1, 2
  • TKI therapy resolves AVWS within 2-4 weeks 1

Immediate Hemostatic Measures for Active Bleeding

• If bleeding is severe or child is in shock: Administer fresh frozen plasma 10-20 mL/kg to provide immediate clotting factors 2

  • Response time of 2-4 hours is diagnostic for vitamin K deficiency bleeding 2
  • For neonates specifically, consider vitamin K deficiency bleeding in the differential 2

• Monitor for hypovolemia: Estimated blood volume is 70 mL/kg in children, up to 100 mL/kg in newborns 2

  • RBC transfusion of 10 mL/kg increases hemoglobin by approximately 20 g/L if needed 2

Trauma-Related Bleeding

Circumcision Complications

• Post-circumcision bleeding: The most common cause of penile trauma in pediatric populations, accounting for 67% of penile injuries requiring hospitalization 3

  • Minimal skin loss or meatal injury: Primary skin closure or meatoplasty 3
  • Post-Plastibell bleeding occurs in 0.5% of cases (48% of all Plastibell complications) 4
  • Mean device fall-off time is 6 days; complications are easily correctable with detailed attention to ligature placement 4

• Urethrocutaneous fistulae: Require surgical repair; account for 15% of functional disability in circumcision-related injuries 3

Other Traumatic Causes

• Zipper injuries: Account for 3% of penile trauma cases; typically require local management 3
• Strangulation injuries (hair-tie): Account for 16% of cases; none resulted in glans loss with timely intervention 3
• Animal attacks: Associated with highest rate of long-term functional disability (75% poor outcomes) 3

Non-Traumatic Medical Causes

Infectious/Inflammatory Etiologies

• Perineal streptococcal dermatitis: Can present with perianal and genital hemorrhage mimicking trauma 5
  • Requires microbiological testing and appropriate antibiotic therapy 5

Anatomic Abnormalities

• Hypospadias with bleeding: Detected in 0.7% of circumcision candidates; circumcision should be postponed until time of hypospadias repair 4
• Meatal stenosis: May present with bleeding; requires meatoplasty 3

Hematologic Disorders

• Immune thrombocytopenia (ITP): 20% of children present with bleeding manifestations despite normal platelet counts 1

  • First-line treatment options include:
    • IV immunoglobulin 0.8-1 g/kg single dose (raises platelets in >80% within hours) 1
    • Prednisone 4 mg/kg/day for 3-4 days (effective in 72-88% within 72 hours) 1
    • IV anti-D immunoglobulin for Rh(D)-positive children 1

• Homozygous protein C deficiency: Rare but critical differential presenting with purpura fulminans 2

  • Administer FFP 10-20 mL/kg every 12 hours or protein C concentrate 20-60 units/kg until lesions resolve 2

Diagnostic Workup

Essential Laboratory Studies

• Complete blood count with differential (assess for leukemia, thrombocytopenia) 1
• Coagulation studies (PT, PTT, fibrinogen) to identify coagulopathy 1
• von Willebrand factor studies if platelets elevated but bleeding present 1
• Blood type and screen if transfusion anticipated 2

Imaging Considerations

• Ultrasound of penis and perineum if structural abnormality or hematoma suspected 3
• Consider abdominal imaging if systemic illness present (splenomegaly in CML) 1

Common Pitfalls to Avoid

• Do not assume normal platelet counts exclude bleeding disorder: AVWS can occur with elevated platelets in CML 1
• Do not delay urologic consultation for priapism: Permanent dysfunction occurs after 24-48 hours 1
• Do not overlook infectious causes: Perianal streptococcal infection can mimic trauma 5
• Do not circumcise if hypospadias present: This compromises future surgical repair 4
• Do not use aspirin in children with thrombocytosis: Risk of Reye syndrome and platelet dysfunction 1

Follow-Up and Monitoring

• Reassess within 24-48 hours for resolution of bleeding and wound healing 3
• Monitor for complications including infection, fistula formation, or recurrent bleeding 3, 4
• Long-term follow-up for functional and cosmetic outcomes, particularly after significant trauma 3