Treatment for 13-Year-Old Boy with Penile Pain During Urination and Negative Urinalysis (No STI Concern)
In a 13-year-old boy with dysuria and negative urinalysis where STI is not a concern, the most likely diagnosis is non-infectious urethritis or early epididymitis, and symptomatic management with analgesics and observation is appropriate, with antibiotics reserved only if pyuria develops or symptoms worsen.
Diagnostic Reasoning
Age-Specific Considerations
- In adolescents under 18 years, acute epididymitis is most commonly idiopathic (96.1% of cases), unlike in adults where infectious causes predominate 1
- Testicular torsion must be excluded first, as it is more frequent in adolescents and represents a surgical emergency requiring intervention within 6-8 hours 2, 3
- The gradual onset of pain and absence of severe acute symptoms makes torsion less likely 3
Urinalysis Interpretation in Pediatric Patients
- In children with epididymitis, 96.1% (73 of 76 cases) showed negative pyuria on urinalysis 1
- A negative urinalysis in this age group does not rule out epididymitis but suggests a non-infectious etiology 1
- Urinalysis is valuable to rule out UTI, but diagnosis requires both pyuria and positive urine culture 4, 5
Recommended Management Approach
Initial Assessment
- Confirm absence of testicular torsion by evaluating for sudden onset severe pain, negative Prehn sign (no pain relief with testicular elevation), and firm tender testicle 3
- If torsion cannot be excluded clinically, ultrasound with Doppler is first-line imaging 3
- Examine for urethral discharge, which would indicate urethritis requiring different management 2
Treatment Strategy
For negative urinalysis without pyuria:
- Routine antibiotics are NOT required in pediatric patients with epididymitis and negative pyuria 1
- Provide symptomatic management with analgesics 2
- Recommend scrotal support/elevation if testicular involvement is suspected 2
- Observation with close follow-up is appropriate 1
Antibiotics should be considered ONLY if:
- Urinalysis shows pyuria (with or without positive culture) 1
- Symptoms worsen or fail to improve within 3 days 2
- Follow-up urinalysis becomes positive 1
If Antibiotics Become Necessary
For non-STI related infection in this age group (enteric organisms or anatomic abnormalities):
- Ofloxacin 300 mg orally twice daily for 10 days (for patients >35 years or with enteric organisms) 2
- Alternative: Cephalexin may be appropriate if E. coli is suspected, as 92.6% of E. coli isolates are susceptible 6
Follow-Up Protocol
- Re-evaluate within 3 days if symptoms persist or worsen 2
- Repeat urinalysis if clinical picture changes 1
- If swelling and tenderness persist after any antimicrobial therapy, comprehensive evaluation is needed to exclude tumor, abscess, testicular cancer, or tuberculous/fungal epididymitis 2
Critical Pitfalls to Avoid
- Do not empirically treat with antibiotics based solely on dysuria without objective evidence of infection (pyuria or positive culture) in this age group 1
- Do not delay evaluation for testicular torsion if pain is severe, sudden onset, or clinical picture is unclear 3
- Do not assume STI pathogens are the cause in prepubertal or early adolescent boys without sexual activity history 2
- Do not use bagged urine specimens for culture due to high false-positive rates 4, 5