What are the differential diagnoses and symptomatic management for penile pain in a 6-year-old male child?

Penile Pain in a 6-Year-Old Boy: Differential Diagnosis and Management

Immediate Life-Threatening Conditions to Exclude First

The most critical diagnosis to rule out immediately is testicular torsion, which requires surgical intervention within 6-8 hours to prevent testicular loss, even though the child reports "penile" pain—young children often cannot accurately localize scrotal versus penile pain. 1, 2

Testicular Torsion

• Presents with abrupt onset of severe pain that may be referred to the penis or lower abdomen in young children 1
• Has a bimodal distribution with peaks in neonates and postpubertal boys, but can occur at age 6 1, 2
• Characterized by negative Prehn sign (pain not relieved with testicular elevation) 1
• Requires immediate urological consultation without delay for imaging if clinical suspicion is high 2
• Testicular viability is compromised after 6-8 hours, making this a true surgical emergency 1, 2

Priapism (in children with sickle cell disease)

• Presents as prolonged painful erection lasting more than 4 hours 2
• Requires urgent treatment to prevent irreversible tissue damage 3, 2
• Emergency intervention includes penile aspiration, saline irrigation, and potential alpha-adrenergic sympathomimetic injection 3, 2

Complete Differential Diagnosis by Likelihood in This Age Group

High Probability Diagnoses

Torsion of testicular appendage (most common cause of testicular/penile pain in prepubertal boys):

• Gradual onset compared to testicular torsion 1
• May present with localized tenderness at upper pole of testis 1
• "Blue dot sign" is pathognomonic but only seen in 21% of cases 1
• Normal testicular perfusion on Doppler with localized hyperemia near the appendage 4

Balanitis/Balanoposthitis (infection of glans or foreskin):

• Presents with erythema, swelling, and discharge from the glans or under foreskin 2
• Gradual onset of pain 2
• May have difficulty urinating or foul odor 2

Paraphimosis:

• Retracted foreskin that cannot be reduced, causing painful swelling of glans 2
• Visible constricting band of foreskin behind glans 2
• Requires urgent reduction to prevent vascular compromise 2

Moderate Probability Diagnoses

Trauma (zipper injury, straddle injury, direct blow):

• Clear history of injury, though young children may not report it accurately 2, 5
• Visible ecchymosis, swelling, or skin breaks 2
• Ultrasound can differentiate intracavernosal from extracavernosal hematomas 5

Urinary tract infection with referred pain:

• Dysuria, frequency, or fever may be present 2
• Urinalysis shows pyuria and bacteriuria 3

Epididymitis (less common in prepubertal children):

• Gradual onset of pain with scrotal swelling 3, 4
• Enlarged epididymis with increased blood flow on Doppler ultrasound 4
• May have abnormal urinalysis 4

Lower Probability but Important Diagnoses

Acute idiopathic scrotal edema:

• Painless or minimally painful marked scrotal wall thickening 1, 4
• Self-limiting condition, diagnosis of exclusion 1

Incarcerated inguinal hernia:

• Palpable mass in groin or scrotum that cannot be reduced 2
• May present with pain, vomiting, or signs of bowel obstruction 2

Diagnostic Approach Algorithm

Step 1: Rapid Clinical Assessment (within minutes)

• Determine exact pain location: Have child point with one finger; young children often cannot distinguish penile from scrotal pain 2
• Assess onset and duration: Sudden onset suggests torsion or trauma; gradual suggests infection 2
• Check for systemic signs: Fever suggests infection; vomiting suggests torsion or incarcerated hernia 1, 2

Step 2: Focused Physical Examination

• Inspect penis: Look for swelling, erythema, discharge, ecchymosis, foreskin position (paraphimosis), and any visible trauma 2
• Palpate both testicles: Assess position (horizontal lie suggests torsion), tenderness, masses, and cremasteric reflex (absent in torsion) 1, 2
• Transilluminate scrotum: Helps differentiate hydrocele from solid masses or hematomas 2
• Examine abdomen and groin: Check for inguinal hernia or referred pain from other sources 2

Step 3: Risk Stratification for Torsion

If ANY of the following are present, proceed directly to urological consultation without imaging:

• Sudden onset severe pain 1, 4
• Absent cremasteric reflex 4
• High-riding or horizontally positioned testis 1
• Nausea/vomiting 4
• TWIST score 6-7 (high risk) 4

Step 4: Imaging When Indicated

For intermediate clinical suspicion (TWIST score 1-5), obtain urgent Duplex Doppler ultrasound of scrotum: 1, 4

• Grayscale examination to assess testicular homogeneity and identify "whirlpool sign" 1, 4
• Color/Power Doppler to assess testicular perfusion compared to contralateral side 1, 4
• Power Doppler is particularly useful in prepubertal boys with normally slow flow 1

Critical pitfall: Normal Doppler does not exclude partial torsion or early torsion—false-negative rate up to 30% 1, 4

Symptomatic Treatment by Diagnosis

For Testicular Torsion (Confirmed or Highly Suspected)

• Immediate urological consultation for surgical exploration and bilateral orchiopexy 1, 2
• NPO status pending surgery 2
• Intravenous access and analgesia (intravenous opioids for severe pain) 6
• Do NOT delay surgery for pain control 1, 2

For Torsion of Testicular Appendage

• Oral ibuprofen 10 mg/kg every 6-8 hours for mild-moderate pain 6
• Scrotal support and rest 3
• Reassurance that condition is self-limiting (typically resolves in 3-10 days) 1
• Follow-up in 24-48 hours to ensure improvement 3

For Balanitis/Balanoposthitis

• Warm water soaks 3-4 times daily 2
• Topical antibiotic ointment (mupirocin or bacitracin) if mild 2
• Oral antibiotics (cephalexin 25-50 mg/kg/day divided every 6-8 hours) if moderate-severe with cellulitis 2
• Gentle retraction and cleaning of foreskin (if not causing pain) 2
• Oral ibuprofen 10 mg/kg every 6-8 hours for pain 6

For Paraphimosis

• Manual reduction is first-line treatment (apply firm pressure to glans for 3-5 minutes to reduce edema, then reduce foreskin) 2
• Topical lidocaine gel or penile block for pain control during reduction 2
• Ice application to reduce edema before reduction attempt 2
• Emergency urological consultation if manual reduction unsuccessful 2
• Post-reduction: oral ibuprofen and warm soaks 6

For Trauma

• Ice application for first 24 hours to reduce swelling 2
• Scrotal support 2
• Oral ibuprofen 10 mg/kg every 6-8 hours or acetaminophen 15 mg/kg every 4-6 hours 6
• Urological consultation if suspicion for penile fracture (rupture of tunica albuginea) or significant hematoma 5
• Ultrasound can differentiate intracavernosal from extracavernosal hematomas 5

For Epididymitis (Rare in Prepubertal Boys)

• Scrotal elevation and support 3
• Oral ibuprofen 10 mg/kg every 6-8 hours 6
• Antibiotics based on likely etiology (in prepubertal boys, usually enteric organisms): 3
  • Cephalexin 25-50 mg/kg/day divided every 6-8 hours for 10 days 3
• Bed rest until fever and inflammation subside 3
• Re-evaluate in 3 days if no improvement 3

For Priapism (in Sickle Cell Patients)

For episodes <4 hours: 2

• Aggressive hydration (oral or intravenous) 2
• Oral analgesia (ibuprofen or acetaminophen) 2, 6

For episodes ≥4 hours (emergency): 2

• Intravenous hydration 2
• Intravenous opioids for pain 6
• Exchange transfusion or leukapheresis 2
• Penile aspiration and irrigation with saline 2
• Alpha-adrenergic sympathomimetic injection if detumescence not achieved 3, 2

General Pain Management Principles for All Diagnoses

Pharmacological options by pain severity: 6

• Mild pain: Oral ibuprofen 10 mg/kg (max 400 mg) every 6-8 hours 6
• Moderate pain: Ibuprofen plus acetaminophen 15 mg/kg (max 1000 mg) every 4-6 hours 6
• Severe pain: Intranasal fentanyl 1.5 mcg/kg (faster onset than oral opioids) or intravenous morphine 0.1 mg/kg 6

Non-pharmacological adjuncts (effective in reducing pain and anxiety): 7, 6

• Distraction techniques (videos, games, conversation about interests) 7
• Parental presence and involvement 7
• Cooling sprays or ice application for trauma 7
• Comfortable positioning and scrotal support 3

Critical Pitfalls to Avoid

1. Assuming "penile pain" excludes testicular pathology—young children cannot accurately localize pain and testicular torsion often presents as penile or lower abdominal pain 1, 2

2. Delaying surgical consultation for imaging when clinical suspicion for torsion is high—testicular salvage rates decline dramatically after 6-8 hours 1, 4, 2

3. Relying solely on Doppler ultrasound to exclude torsion—false-negative rate up to 30%, especially with partial torsion 1, 4

4. Undertreating pain in children—use validated pain scales and aggressive multimodal analgesia 7, 6

5. Missing paraphimosis—always check foreskin position after catheterization or examination in uncircumcised boys 2

6. Failing to consider underlying conditions—ask about sickle cell disease (priapism risk) and previous episodes of similar pain 2