What are the differential diagnoses and management plan for penile pain in an 11‑year‑old boy, including how to treat paraphimosis?

Penile Pain in an 11-Year-Old Boy: Differential Diagnosis and Management

In an 11-year-old boy presenting with penile pain, testicular torsion must be excluded first as a surgical emergency requiring intervention within 6-8 hours, followed by systematic evaluation for paraphimosis, trauma, infection, and inflammatory conditions. 1

Immediate Life-Threatening Conditions to Rule Out

Testicular Torsion

• Although the pain is penile, testicular torsion can present with referred penile pain and must be excluded immediately because testicular viability is compromised after 6-8 hours 1, 2
• Testicular torsion has a bimodal distribution with peaks in neonates and postpubertal boys, making an 11-year-old at significant risk 1, 2
• Key examination findings include high-riding testicle, absent cremasteric reflex, scrotal swelling, and a negative Prehn sign (pain not relieved with testicular elevation) 1, 2
• If clinical suspicion is high, proceed directly to immediate urological consultation without waiting for imaging 1, 2

Priapism (in Sickle Cell Disease)

• If the child has sickle cell disease and presents with prolonged painful erection lasting more than 4 hours, this requires urgent treatment with penile aspiration, saline irrigation, and potential alpha-adrenergic injection to prevent irreversible tissue damage 1

Differential Diagnoses for Penile Pain

Paraphimosis (Urologic Emergency)

• Paraphimosis occurs when the foreskin becomes trapped behind the corona, forming a tight constricting band 3, 4
• This condition is more common in infants and toddlers with underlying phimosis but can occur at any age 3
• Examination reveals a swollen, edematous foreskin trapped behind the glans with visible constriction 4
• This is a urologic emergency requiring immediate reduction to prevent vascular compromise and tissue necrosis 4

Trauma/Corpus Cavernosum Rupture

• Although rare in prepubertal children, penile fracture can occur from blunt trauma (falling onto objects, bicycle injuries) 5
• Examination shows ecchymosis, swelling of the penile shaft, and acute-onset severe pain 5
• Ultrasound may reveal discontinuity of the corpus cavernosum 5
• This requires urgent surgical repair to prevent erectile dysfunction, fibrosis, and persistent deformity 5

Balanoposthitis (Infection/Inflammation)

• Common inflammation occurring in 4-11% of uncircumcised boys 6
• Presents with gradual onset of penile pain, erythema, swelling, and possible discharge 1
• May be associated with poor hygiene or underlying phimosis 6

Torsion of Testicular Appendage

• Most common cause of testicular/scrotal pain in prepubertal boys 1, 2
• Can present with referred penile pain 1
• Usually self-limiting, resolving within 3-10 days with conservative management 1

Urinary Tract Infection

• Children may experience penile or scrotal discomfort secondary to UTI 1
• Urinalysis shows pyuria and bacteriuria 1
• Dysuria and urinary frequency are common associated symptoms 1

Lichen Sclerosus

• Can cause penile pain, particularly with tightening of the foreskin (phimosis) leading to painful erections 7
• May present with difficulty retracting foreskin or paraphimosis as a complication 7
• Examination shows porcelain-white plaques, areas of ecchymosis, and possible fissuring 7

Sexual Abuse (Important Consideration)

• All U.S. states require reporting of suspected child abuse 7
• Consider STD screening if there is evidence of penetration, genital trauma, or other signs of abuse 7
• Lichen sclerosus with striking ecchymosis can be mistaken for abuse, but the two are not mutually exclusive 7
• Factors warranting STD evaluation include genital trauma, signs of STDs, or disclosure of abuse 7

Diagnostic Approach

History

• Onset and duration: Sudden onset suggests torsion or trauma; gradual onset suggests infection 1
• Mechanism of injury: Direct trauma, manipulation, catheterization, or spontaneous 5, 4
• Associated symptoms: Urinary symptoms, fever, discharge, scrotal pain 1
• Past medical history: Sickle cell disease (priapism risk), previous episodes, foreskin retraction history 1
• Social history: Screen sensitively for possibility of abuse using age-appropriate questions 7

Physical Examination Priorities

• Inspect for: Swelling, erythema, ecchymosis, discharge, foreskin position (retracted/trapped), lesions, and any signs of trauma 1
• Palpate: Both testicles for position (high-riding suggests torsion), tenderness, masses, and cremasteric reflex 1
• Assess: Ability to retract and replace foreskin, meatal patency, and presence of blood at meatus 1
• Transillumination: Can help differentiate hydrocele from solid masses, though reactive hydrocele can occur with torsion 2

Diagnostic Testing

• Urgent scrotal ultrasound with Doppler if testicular torsion cannot be clinically excluded, showing decreased/absent testicular blood flow and the "whirlpool sign" of twisted spermatic cord 1, 2
• Urinalysis to evaluate for infection (pyuria, bacteriuria) or hematuria suggesting trauma 1
• STD testing if abuse is suspected, using only highly specific tests to avoid false-positive results with serious legal consequences 7

Management Plan

For Testicular Torsion (if identified)

• Immediate urological consultation and surgical exploration within 6-8 hours 1, 2
• Do not delay for imaging if clinical suspicion is high 1, 2

For Paraphimosis

Manual reduction is the first-line treatment: 4

1. Reduce edema first: Apply firm, steady compression to the glans and edematous foreskin for 5-10 minutes to reduce swelling 4
2. Pharmacologic adjuncts: Apply topical anesthetic, ice, or hypertonic solutions (granulated sugar, hyaluronidase) to reduce edema 4
3. Manual reduction technique: With both thumbs on the glans, apply steady pressure while simultaneously pulling the foreskin forward over the glans with the fingers 4
4. If manual reduction fails: Emergency urological consultation for dorsal slit procedure, which involves incising the constricting band dorsally 3, 4
5. Definitive management: Elective circumcision is typically recommended after the acute episode resolves to prevent recurrence 6, 3

Common pitfall: Paraphimosis is often iatrogenically induced by healthcare providers who retract the foreskin for examination or catheterization and fail to return it to its normal position 4. Always ensure the foreskin is returned over the glans after any penile manipulation.

For Infectious Causes (Balanoposthitis)

• Warm water soaks and gentle hygiene 1
• Topical antibiotic ointment for mild cases 1
• Oral antibiotics (cephalexin 25-50 mg/kg/day divided q6-8h for 10 days) for more severe infections or if epididymitis is suspected 1

For Trauma/Corpus Cavernosum Rupture

• Urgent urological consultation for surgical repair 5
• Flexible cystoscopy to rule out urethral injury 5
• Timely surgical correction prevents long-term complications including erectile dysfunction and fibrosis 5

For Torsion of Testicular Appendage

• Conservative outpatient management with scrotal support 1
• Follow-up within 24-48 hours to confirm improvement 1
• Condition typically resolves within 3-10 days 1

For Priapism (in Sickle Cell Disease)

• Episodes <4 hours: Hydration and analgesia 1
• Episodes ≥4 hours: Emergency intervention with penile aspiration, saline irrigation, and potential alpha-adrenergic injection 1

Non-Pharmacologic Pain Management

• Distraction techniques (videos, games, conversation) 1
• Parental presence during examination 1
• Application of cooling sprays or ice 1
• Comfortable positioning with scrotal support 1

Key Clinical Pitfalls to Avoid

1. Never assume penile pain excludes testicular pathology—always examine and assess the testicles for torsion 1, 2
2. Always return the foreskin to its normal position after any examination or catheterization to prevent iatrogenic paraphimosis 4
3. Do not delay surgical exploration for imaging when clinical suspicion for torsion is high, as false-negative Doppler occurs in up to 30% of cases 2
4. Consider sexual abuse sensitively but systematically, as mandatory reporting laws exist in all U.S. states 7
5. Recognize that lichen sclerosus with ecchymosis can mimic abuse, but both conditions can coexist 7