What is the appropriate management for a 5-year-old male child presenting with acute penile swelling of 1 day duration?

Management of Acute Penile Swelling in a 5-Year-Old Child

Immediately assess for paraphimosis, hair tourniquet, balanitis, trauma, and signs of abuse—these are the most common urgent causes of penile swelling in young boys and require prompt identification to prevent tissue necrosis or identify safeguarding concerns. 1, 2

Immediate Life-Threatening Conditions to Rule Out

Paraphimosis (Urologic Emergency)

• Look for a retracted foreskin trapped behind the glans penis that cannot be reduced 1
• This creates a constricting band causing venous congestion, progressive swelling, and potential tissue necrosis 1
• Attempt immediate manual reduction: apply firm pressure to the glans while simultaneously pulling the foreskin forward over the glans 2
• If manual reduction fails within minutes, obtain urgent urologic consultation to prevent irreversible ischemic damage 2

Hair Tourniquet Syndrome

• Carefully examine the entire penile shaft, particularly the coronal sulcus, for wrapped hair or thread 1
• This can cause circumferential constriction with distal swelling and potential vascular compromise 1
• Requires immediate removal, sometimes necessitating careful incision under magnification 1

Trauma or Abuse

• Inspect for bruising, lacerations, bite marks, or patterned injuries 1
• Look for behavioral changes, inappropriate sexual knowledge, or inconsistent history 1
• Immediately report to child protective services if sexual abuse is suspected based on examination findings 1
• Document all findings with photographs when appropriate and available 1

Common Non-Emergent Causes

Balanitis (Inflammation/Infection of Glans)

• Characterized by redness, swelling, and possible discharge from the glans and foreskin 1
• Often associated with poor hygiene, retained smegma, or irritants 1
• Treatment consists of gentle warm water soaks 2-3 times daily and topical antifungal or antibiotic cream depending on suspected etiology 1
• Oral antibiotics reserved for severe cases with systemic signs 2

Physiologic Phimosis

• Normal non-retractile foreskin in young boys that may cause ballooning during urination 1
• Most cases resolve spontaneously by age 5-7 years 1
• Management is gentle hygiene education and watchful waiting unless complications develop 1
• Only forceful retraction attempts (which should never be done) cause acute swelling 1

Allergic or Contact Dermatitis

• History of new soaps, detergents, or topical products 1
• Diffuse erythema and edema without focal findings 1
• Remove offending agent and consider topical corticosteroids for symptomatic relief 1

Diagnostic Approach

History Elements to Obtain

• Duration and progression of swelling (sudden vs. gradual) 1, 2
• Associated pain, urinary symptoms, or discharge 1, 2
• Recent trauma, including falls or straddle injuries 1, 2
• New products, medications, or exposures 1
• Fever or systemic symptoms suggesting infection 2
• Previous episodes or chronic foreskin issues 1

Physical Examination Priorities

• Assess foreskin position and retractability (do not force retraction if not already retractable) 1
• Examine entire penile shaft circumferentially for constricting bands 1
• Palpate for fluctuance suggesting abscess 2
• Check for inguinal lymphadenopathy 2
• Evaluate for signs of systemic illness or sepsis 2

Red Flags Requiring Urgent Action

• Paraphimosis with inability to reduce the foreskin → immediate urologic consultation 1, 2
• Hair tourniquet identified → immediate removal 1
• Signs of vascular compromise (dusky discoloration, coolness, severe pain) → emergency evaluation 1
• Suspected abuse → mandatory reporting to child protective services 1
• Severe systemic signs (high fever, lethargy, hypotension) → consider necrotizing infection and obtain emergency surgical consultation 2
• Acute urinary retention → requires catheterization and urgent evaluation 2

When to Refer to Pediatric Urology

• Paraphimosis that cannot be manually reduced 1, 2
• Pathologic phimosis with scarring (white, thickened foreskin suggesting lichen sclerosus) 1
• Recurrent balanitis (≥2-3 episodes) 1
• Urinary obstruction or significant ballooning during urination 1
• Suspected abscess requiring drainage 2
• Any case where diagnosis remains unclear after initial evaluation 1, 2

Common Pitfalls to Avoid

• Never forcibly retract a non-retractile foreskin in young boys—this can cause paraphimosis, scarring, and pathologic phimosis 1
• Do not dismiss genital complaints in children without thorough examination—abuse must always be considered 1
• Avoid attributing all penile swelling to infection without examining for mechanical causes like hair tourniquet 1
• Do not delay reduction attempts in paraphimosis—every minute counts for tissue viability 2
• Remember that in rare cases, penile swelling can be an extraintestinal manifestation of Crohn's disease, particularly if recurrent or associated with gastrointestinal symptoms 3