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PEDIATRIC
EMERGENCY MEDICINE PRACTICE
AN EVIDENCE-BASED APPROACH TO PEDIATRIC EMERGENCY MEDICINE ▲ EMPRACTICE.NET
Urogenital Emergencies In
Boys: An Evidence-Based
Approach To Sensitive Issues
A 12-year-old male reports that his left testicle has been hurting for the last 3 hours.
He appears to be very uncomfortable and has vomited twice. He has no significant
history of trauma, although he wrestles around with his younger brothers quite
frequently. In another room, the anxious parents of a 1-year-old, uncircumcised boy
report that over the last 2 days his penile foreskin has become red and swollen. He is
afebrile, but a bit fussy.
B
Lance Brown, MD, MPH, FACEP, Chief,
Division of Pediatric Emergency
Medicine; Associate Professor
of Emergency Medicine and
Pediatrics; Loma Linda University
Medical Center and Children’s
Hospital, Loma Linda, CA.
Editorial Board
Jeffrey R. Avner, MD, FAAP, Professor
of Clinical Pediatrics, Albert Einstein
College of Medicine; Director,
Pediatric Emergency Service,
Children’s Hospital at Montefiore,
Bronx, NY.
Beverly Bauman, MD, FAAP,
FACEP, Assistant Chief, Pediatric
Emergency Services, Oregon Health
& Sciences University, Portland, OR.
T. Kent Denmark, MD, FAAP,
FACEP, Residency Director,
Pediatric Emergency Medicine;
Assistant Professor, Departments
of Emergency Medicine and
Pediatrics; Loma Linda University
Medical Center and Children’s
Hospital, Loma Linda, CA.
Michael J. Gerardi, MD, FAAP,
FACEP, Clinical Assistant Professor,
Medicine, University of Medicine
and Dentistry of New Jersey;
Director, Pediatric Emergency
Medicine, Children’s Medical
Center, Atlantic Health System;
Department of Emergency
Medicine, Morristown
Memorial Hospital.
Ran D. Goldman, MD, Associate
Professor, Department of Pediatrics,
University of Toronto; Division of
Pediatric Emergency Medicine
and Clinical Pharmacology and
Toxicology, The Hospital for Sick
Children, Toronto.
Martin I. Herman, MD, FAAP,
FACEP, Associate Professor,
Pediatrics, Division Critical Care
and Emergency Services, UT Health
Sciences, School of Medicine;
Assistant Director Emergency
Services, Lebonheur Children’s
Medical Center, Memphis TN.
Marilyn P. Hicks, MD, FACEP,
Director, Pediatric Emergency
Medicine Education, Department
of Emergency Medicine, WakeMed,
Raleigh, NC; Adjunct Assistant
Professor, Department of
Emergency Medicine, University of
North Carolina, Chapel Hill, Chapel
Hill, NC.
Mark A. Hostetler, MD, MPH,
Assistant Professor, Department
of Pediatrics; Chief, Section of
Emergency Medicine; Medical
Volume 1, Number 4
Authors
Floyd S. Ota, MD
Fellow of Pediatric Emergency Medicine, University of
Texas Southwestern Medical Center, Dallas, TX.
Robert A. Wiebe, MD
Professor and Director, Division of Emergency
Medicine, Department of Pediatrics, Sarah M. and
Charles E. Seay Distinguished Chair in Pediatric
Medicine, University of Texas Southwestern Medical
Center, Dallas, TX.
Peer Reviewers
OYS frequently present to the ED with a wide variety of complaints
about their external genitalia. These cases can be quite challenging.
Given cultural sensitivities and general discomfort with talking about genitals, new parents may have difficulty discussing their questions or concerns
with a physician. This may lead to a delay in seeking care. In some cases,
families are simply unable to talk about genitals and use euphemisms to
describe “down there.” Older, school-aged children may notice problems
and be too embarrassed to bring the problem to the attention of their parents.
Sexually active adolescents may want to conceal their sexual activity from
their parents and avoid asking to see a doctor. All of these issues can lead to
delays in care and miscommunication among boys, parents, teachers, and
health care providers. Although many physical conditions associated with
the penis and scrotal contents in boys are quite benign and require little more
than reassurance, some of these conditions require emergency intervention.
The emergency physician must not add further delays to those already inherent in patient presentation. If not addressed properly and expeditiously, these
clinical problems may have serious sequelae involving future reproductive
potential and sexual function. Social and litigious ramifications of a missed
diagnosis require the emergency physician to be vigilant in the care of these
patients. However, it can be difficult to determine which patients require
simple reassurance and which require a more extensive workup. IdentifyEditor-in-Chief
November 2004
Grace Kim, MD, FAAP
Assistant Professor of Emergency Medicine and
Pediatrics, Loma Linda University Medical Center and
Children’s Hospital, Loma Linda, CA.
Daniel M. Cohen, MD, FAAP, FACEP
Medical Director, Urgent Care Associate Director,
Emergency Medicine Children’s Hospital of Columbus,
Associate Professor of Pediatrics, Ohio State University,
Columbus, OH.
CME Objectives
Upon completing this article, you should be able to:
1. discuss the role of ultrasound in the diagnosis of
testicular torsion;
2. describe the diagnostic approach to the boy with a
swollen penis;
3. discuss the limitations of the physical examination
in evaluating acute scrotal pain; and
4. list male genitourinary conditions that require
prompt treatment to avoid serious sequelae.
Date of original release: November 30, 2004.
Date of most recent review: November 19, 2004.
See “Physician CME Information” on back page.
Director, Pediatric Emergency
Department, The University
of Chicago, Pritzker School of
Medicine, Chicago, IL.
Alson S. Inaba, MD, FAAP, PALS-NF,
Pediatric Emergency Medicine
Attending Physician, Kapiolani
Medical Center for Women &
Children; Associate Professor of
Pediatrics, University of Hawaii
John A. Burns School of Medicine,
Honolulu, HI; Pediatric Advanced
Life Support National Faculty
Representative, American Heart
Association, Hawaii & Pacific
Island Region.
Andy Jagoda, MD, FACEP, Vice-Chair
of Academic Affairs, Department
of Emergency Medicine; Residency
Program Director; Director,
International Studies Program,
Mount Sinai School of Medicine,
New York, NY.
Brent R. King, MD, FACEP, FAAP,
FAAEM, Professor of Emergency
Medicine and Pediatrics; Chairman,
Department of Emergency
Medicine, The University of Texas
Houston Medical School,
Houston, TX.
Robert Luten, MD, Professor,
Pediatrics and Emergency
Medicine, University of Florida,
Jacksonville, Jacksonville, FL.
Ghazala Q. Sharieff, MD, FAAP,
FACEP, FAAEM, Associate
Clinical Professor, Children’s
Hospital and Health Center/
University of California, San
Diego; Director of Pediatric
Emergency Medicine, California
Emergency Physicians.
Gary R. Strange, MD, MA, FACEP,
Professor and Head, Department of
Emergency Medicine, University of
Illinois, Chicago, IL.
COPYRIGHTED MATERIAL—DO NOT PHOTOCOPY OR DISTRIBUTE ELECTRONICALLY WITHOUT WRITTEN CONSENT OF EB PRACTICE, LLC
ing those children who require immediate and definitive
care is perhaps the most important role of the emergency
physician in the care of these children. In this issue of
Pediatric Emergency Medicine PRACTICE, we will examine
the evidence pertaining to complaints involving the male
genitalia.
hormonally regulated and may be terminated at any point,
resulting in an undescended testicle. Pillai et al noted
that the location of an abnormally positioned testicle was;
inguinal (63%), prescrotal (24%), ectopic (12%), and intraabdominal (8%).3
A capsule of fibrous tissue called the tunica albuginea
surrounds each testicle. This is covered by the visceral and
parietal layers of the tunica vaginalis, a sac formed from
the process vaginalis, a bulge of peritoneum that extends
into the inguinal canal during testicular decent. In their
final resting place, the testes, epididymis, and distal spermatic cord lie with the posterior aspect of the epidydimis
attached to the inner wall of the scrotum by a bare area not
covered by peritoneum. The arterial supply to the scrotal
sac arises from three sources: the testicular artery, the
cremasteric artery, and the artery to the ductus deferens.
Venous blood leaves the scrotum via the pampiniform
plexus to drain into the testicular veins. Finally, these
blood vessels, along with the nerves, lymphatic vessels,
and ductus deferens, are housed by a structure of loose
connective tissue called the spermatic cord.
Testicular torsion occurs when the spermatic cord
becomes twisted, obstructing venous and arterial blood
flow to the testicle. Testicular torsion is divided into two
categories; intra-vaginal torsion and extra-vaginal torsion.
Extra-vaginal torsion is seen mainly at birth and within
the first year of life, and occurs when the entire testes
and tunica vaginalis twists on the spermatic cord in a
vertical axis resulting from an incomplete fixation of the
gubernaculum to the scrotal wall during testicular decent.
Intra-vaginal torsion is more commonly found during
adolescence and is often associated with the “bell-clapper
anomaly.” In children who have the bell-clapper anomaly,
the testes, epididymis, testicular artery, and spermatic
cord can “twist” on its axis completely within the confines
of the tunica vaginalis. This anomaly was found in 12% of
patients upon general autopsy in one series.4 It is postulated that the bell-clapper anomaly may predispose a child
to torsion; however, torsion of the testicle is seen in much
less than 12% of the population. Thus, additional factors
must be contributing to its occurrence, and an anatomic
abnormality alone does not completely explain why testicular torsion occurs in some children and not others. Other
contributing factors to testicular torsion noted in previous
review articles are cold temperatures and scrotal trauma.5,6
Another group of authors found results to suggest a link
between low ambient temperature and testicular torsion,
postulating that low temperature may incite cremasteric
muscle spasm.7 However, other investigators found no
difference in the incidence during different temperate
seasons, and a clear connection remains unproven.8,9
Testicular torsion is a recognized entity in the setting of
acute scrotal trauma.10,11 Among one retrospective series of
138 children who presented with an acute scrotum, 5% of
the patients demonstrated testicular torsion, and 10% of
those with torsion of the appendix testis had a history of
trauma.10
Critical Appraisal Of The Literature
The Acute Scrotum
The critical issue addressed by the literature on the acute
scrotum is early recognition and treatment of testicular
torsion and differentiating this entity from other, less
emergent causes of testicular pain. The current literature
is largely based on evidence from retrospective cohort
studies and case reports. The most recent observational
studies appear to be moving away from routine scrotal
exploration when there is low suspicion of testicular torsion, to more conservative management with the addition of various imaging modalities. There are currently
no randomized, prospective studies, nor are there any
published guidelines from any national or international
medical groups.
Penile Complaints
The current literature pertaining to problems dealing
with penile swelling and pain is limited. The evidence is
mostly based on small cohort studies and case reports that
describe how the authors have managed the varied clinical
problems “in their experience.” There are currently no randomized, prospective studies, nor are there any published
guidelines from any national or international medical
committees. There are, however, a few prospective studies
pertaining to the medical treatment of phimosis that indicate the high efficacy of topical steroids for the resolution
of this condition. The bulk of the literature pertaining to
this topic has been observational.
Epidemiology, Etiology, And Pathophysiology
The Scrotum
Of the causes of acute scrotal complaints, testicular torsion
is the most serious, as testicular viability is dependent
on prompt diagnosis and surgical treatment. Testicular
torsion occurs at an annual incidence of 1 in 4000 males
under the age of 25 years.1 There is a bimodal distribution
with the first peak during infancy and a second, larger
peak around puberty (13 years old).2
Knowledge of testicular anatomy and embryology
is useful in understanding the causes of the acute painful
scrotum. The testicles must descend from an intra-abdominal existence into the scrotum during fetal development.
This process occurs in two distinct phases. The first phase
initiates at around 6 weeks gestation, allowing the testes to
migrate from within the abdominal cavity to the internal
inguinal ring. The second phase begins around the 28th
week of gestation, and the testes complete their descent
into the scrotum. Most commonly, the left testicle will
descend prior to the right. This process is thought to be
Pediatric Emergency Medicine Practice
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The newborn foreskin cannot be retracted over the glans
penis. This “physiologic phimosis” occurs as a natural
adherent to the surface of the penis. Smegma, a collection consisting of glandular secretions and epithelial cell
debris, forms between the prepuce and the glans penis.
Sometimes the smegma can collect at the tip of the penis
and easily be mistaken for pus. As time progresses the
physiologic adherence of the foreskin resolves spontaneously due to intermittent erections and normal movement.
Usually physiologic phimosis will resolve by the age of 3
to 5 years.12 In younger children retraction of the foreskin
is not required for basic hygiene. Forced retraction of the
foreskin can result in tearing, which may lead to scarring
and true phimosis. By the time a boy reaches puberty the
foreskin should be easily retracted and replaced over the
glans. The genital area should be cleaned like any other
area of the body.
The Acute Scrotum
The differential diagnosis for the acute scrotum in childhood is relatively short. (See Table 1.) The 3 most common
causes of a scrotum that has become acutely swollen, painful, or both, are testicular torsion, torsion of the appendix
testis, and epididymitis. Of these diagnoses, testicular
torsion is the most important to identify, due to the timesensitive and invasive nature of the treatment. Multiple
retrospective cohort studies of children who present
with an acute scrotum have attempted to document the
incidence of these common etiologies. The results are quite
variable. However, testicular torsion was consistently
reported in about 12-25% of all children presenting with
an acute scrotum. (13-20) Other causes, such as a hydrocele, varicocele, idiopathic scrotal edema, Henoch-Schönlein purpura, Kawasaki’s disease, minor blunt testicular
Table 1. The Differential Diagnosis Of The Acute Scrotum
Diagnosis
Symptoms
Physical Exam
Testicular torsion
•
•
•
•
Acute onset of pain
Nausea
Vomiting
Teenager or infant
•
•
•
•
Testicular tenderness
Absent cremasteric reflex
Hide-riding testicle
Bell-clapper anomaly
Epididymitis
•
•
•
•
•
Gradual onset of pain
Fever
Recent viral infection
Dysuria
Late childhood
•
Swollen and tender spermatic cord
Torsion of a testicular appendage
•
•
•
Gradual onset of pain
No fever
Middle to late childhood
•
•
Tenderness often localized to superior
pole of testicle
Blue dot sign
Testicular rupture
•
•
Clear history of trauma
Severe pain
•
•
•
Full scrotal sac
Ecchymosis
Irregular testicle
Hydrocele
•
Nonpainful
•
•
Transillumination
May change with position
Varicocele
•
•
Heavy feeling to scrotum
Teenager
•
“Bag of worms”
Henoch-Schönlein Purpura
•
•
•
•
Abdominal pain
Scrotal pain
Joint pain
Hematuria
•
•
Joint swelling
Palpable purpura
Kawasaki's Disease
•
•
Prolonged fever (> 5 days)
Irritability
•
•
•
•
•
•
•
Fever
Non-purulent conjunctivitis
Oral lesions
Cervical lymphadenopathy
Swollen/red extremities
Cutaneous rash
Urethral meatitis
Idiopathic scrotal edema
•
Unclear onset
•
Swollen scrotum
Testicular tumor
Signs of early puberty
•
•
•
Gynecomastia
Precocious puberty
Hard, nontender scrotal mass
Systemic vasculitis
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Differential Diagnosis
The Penis
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trauma, and testicular tumors, are also important sources
of scrotal complaints, but rarely need to be managed
within hours of the onset of symptoms and typically don’t
require surgery.
from testicular torsion. However, children who present
late often have symptoms that make the etiologies clinically indistinguishable.
Testicular Torsion
Epididymitis has an annual incidence of about 1.2 per 1000
boys, according to one study from Israel.25 The condition
appears to be rare in early childhood and more frequent in
late childhood and adolescence. Children will often present with fever and symptoms of an acute scrotum. The
literature is varied in citing the incidence of epididymitis,
as it was previously thought to be rare in the pediatric
population. Previous retrospective studies found a low
incidence, about 5-7% of children who presented with
an acute scrotum.18,20 However, one retrospective review
reported that the incidence of acute epididymitis may be
increasing, as they found 65% of children with an acute
scrotum to have epididymitis.26 A similarly high percentage of patients (71%) were also found by Kadish and Bolte
in their review.16 In multiple cohort studies, torsion of a
testicular appendage and epididymitis, which were once
thought to be less common causes than testicular torsion,
was found in variable incidences: 14%-53% for testicular
appendage, and 6%-71% for epididymitis.13-20 The variability may be due to the retrospective study design, as well
as the difficulty in clearly defining the diagnosis of each
entity. Often it is not easy to differentiate retrospectively
between the two conditions.
The cause of epididymitis in childhood is different
from the cause in sexually active adolescents and adults.
Epididymitis in adolescents who are sexually active is
most commonly caused by Chlamydia trachomatis and
Neisseria gonorrhoeae. In childhood, epididymitis is thought
by some investigators to be linked with urogenital tract
abnormalities. One review of 47 children with epididymitis found abnormalities of the urogenital tract in 47%
of prepubertal children. There were 4 children less than 1
year old in this population, and 3 of the 4 had urogenital
anomalies.27 It was hypothesized that abnormalities of
the urogenital tract, such as retrograde voiding, ectopic
ureter, or posterior urethral valves may cause inflammation of the epididymitis due to reflux of urine and resulting ascending infection. However, results of other studies
conflict with those findings, suggesting a low incidence of
structural abnormalities in children with epididymitis.1,19,28
One report cited that children without a circumcision
may be at higher risk for epididymitis, and another cited
dysfunctional voiding.29,30 Most recently, it appears that
nonspecific epididymitis in childhood is postulated to be a
postinfectious inflammatory phenomenon. A prospective
study in 44 non-sexually active children with epididymitis found elevated titers to mycoplasma, enterovirus,
and adenovirus when compared to a group of same-aged
controls.25
Epididymitis
Patients with testicular torsion often present with an acute
onset of scrotal pain, abdominal pain, nausea, and vomiting. Classical teaching states that testicular torsion more
commonly occurs in the left testes. One retrospective
study confirmed this clinical finding; however, other retrospective studies found no difference.2,21 Nausea and vomiting may be helpful in distinguishing testicular torsion
from other diagnoses. One retrospective study of patients
with scrotal pain found that nausea and vomiting had,
respectively, a 96% and a 98% positive, predictive value
for recognizing children with testicular torsion. However,
the overall sensitivity for nausea (69%) and vomiting
(60%) was low, and thus absence of these findings cannot
rule out the diagnosis.22 Another retrospective study of 100
children found vomiting in 45% of children with testicular torsion, while no patients with torsion of a testicular
appendage and only 6% of children with epididymitis had
vomiting.15 The duration of time from the onset of symptoms may also be helpful in making the diagnosis of testicular torsion. Children with testicular torsion may present
on average within a shorter time period than those with
nonsurgical etiologies. Mushtaq et al found a mean time
for presentation of testicular torsion to be 9.5 hours (range
3.5 hours-72 hours) versus 48 hours (range 14 hours-72
hours) for torsion of a testicular appendage, and 22 hours
(range 11hours-48 hours) for epididymitis.20 Clearly, time
of presentation alone cannot distinguish between etiologies. However, those children with a shorter onset of
symptoms should be identified and taken seriously, as
shorter time periods do directly increase the prognosis for
testicular salvage.1,18,20 A prompt and expeditious evaluation with a high suspicion for testicular torsion should
be initiated for any child with a painful scrotum who
presents with nausea and/or vomiting.
Torsion of Testicular Appendices
Torsion of appendix testis occurs when this appendage
becomes twisted at its base, resulting in venous congestion, subsequent edema, and arterial obstruction. The
most commonly torsed appendage is the appendix testes,
or hydatid of Morgani, found at the superior pole of the
testicle, a remnant of the Mullerian duct. There is also
an appendix epididymis that is a remnant of the Wolffian duct and found at the head of the epididymis. This is
the second most commonly torsed testicular appendage.3
The peak incidence of torsion of a testicular appendage is
slightly earlier than that of testicular torsion, as it appears
to peak at about 7-12 years of age.23 A child with torsion of
a testicular appendage will usually present later than one
with testicular torsion, due to the lower severity and the
gradual onset of the pain.20,24 Children with early torsion
of a testicular appendage may have localizing findings on
physical exam, which helps to differentiate this condition
Pediatric Emergency Medicine Practice
Trauma
Direct, blunt trauma to the scrotum seldom requires
emergent management. However, there is an association
between testicular torsion and scrotal trauma. Although
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found on the left side, as the testicular vein enters the left
renal vein at a more acute angle than the right testicular
vein enters the inferior vena cava. On physical exam a
varicocele feels like “a bag of worms.” They are often
found in early adolescence, and they should be referred to
a urologist for follow-up, as they can decrease fertility and
may require surgical intervention.
Henoch-Schönlein Purpura
Henoch-Schönlein purpura (HSP) is a systemic vasculitis
of unknown etiology. This entity is common in children
and presents with a palpable purpuric rash — most often
on the buttocks and lower extremities — and concordant
arthralgia/arthritis, abdominal pain, and nephritis. Other
urogenital manifestations of HSP include: ureteritis with
hydronephrosis, calcified ureter, hematoma of the bladder
wall, and hemorrhagic spermatic cord.32 Scrotal involvement is fairly common, as one series found that 24% of
93 children with HSP had scrotal involvement.33 In this
retrospective review, no child had testicular torsion, and
the scrotal involvement was thought to be caused by the
vasculitis. In this series, 8 children eventually did undergo
scrotal explorations, due to the inability to clinically rule
out testicular torsion. Unfortunately, the simultaneous
involvement of testicular torsion within the context of HSP
has been reported in a single case report.34 Despite this
extremely rare coincidence, most authors do recommend
a conservative approach when presented with a child
with scrotal involvement and HSP.32,33,35,36 However, in the
setting of significant scrotal pain in a child with HSP, the
diagnosis of testicular torsion must be seriously considered. Since the presence of testicular torsion with HSP is
extremely rare, but can occur, scrotal exploration may be
indicated if the suspicion of its presence is high enough.
Of note, another systemic vasculitis of childhood, Kawasaki’s disease, can also rarely present with scrotal swelling.
This syndrome presents as a constellation of symptoms,
including prolonged fever, non-purulent conjunctivitis,
oral lesions, cervical lymphadenopathy, swelling and/or
erythema of the distal extremities, and cutaneous skin
rash.
Idiopathic Scrotal Edema
Idiopathic scrotal edema is a self-limiting condition that
usually resolves without sequelae. The exact etiology is
unclear, but it is thought to be due to a hypersensitivity response, perhaps a variant of angioedema.37 One retrospective study of 44 children found onset at an average age of
6.2 years, with an overall resolution of symptoms within
1-4 days. Interestingly, 8 patients had eosinophilia; otherwise, blood cell count and urine analysis were normal.37
Testicular Tumors
Testicular tumors are rare in childhood. They have a
bimodal age distribution and occur primarily before the
age of 5 years and during puberty. The most common
testicular tumors are germ cell tumor, yolk sac tumors,
and teratomas. They may be associated with systemic
findings, such as precocious puberty or gynecomastia. On
physical exam they are usually found as painless, scrotal
masses.
Penile Complaints
The differential diagnosis of the child with penile complaints is quite limited. (See Table 2 on page 6.) Often
children will seek medical attention for balanitis, balanoposthitis, paraphimosis, phimosis, and trauma, often due
to zipper entrapment or hair tourniquet. Of these, it is
important to identify paraphimosis, as this entity requires
expeditious reduction to avoid serious sequelae to the
glans penis and foreskin.
Paraphimosis
Paraphimosis is a true urological emergency that requires
prompt and definitive care. This condition is not due to
an infection, but it occurs when the foreskin is pulled over
the coronal sulcus of the glans penis and cannot return to
its previous position. When the foreskin is trapped, it may
form a tight, constricting band that may impede blood
flow to and from the glans and prepuce, resulting in ischemic injury and vascular engorgement.38 A paraphimosis
is often caused by the retraction of the foreskin to examine
the penis, but can also rarely occur due to an erection.
Hydroceles and Varicoceles
Hydroceles can be found in many pediatric patients. They
are usually painless, will transilluminate with light, and
will often resolve by 1 to 2 years of age. Hydroceles can
be divided into two types: communicating and non-communicating hydroceles. The non-communicating type is,
by definition, a collection of fluid around the testicle, but
within the process vaginalis that does not communicate
with the peritoneum. This will usually resolve as the boy
grows older. A communicating hydrocele, by definition,
has a communication with the peritoneal cavity via a patent process vaginalis. This communication allows for an
exchange of fluid and causes size variability, depending
on the position of the patient. Both types of hydroceles require close primary care follow-up; however, communicating hydroceles require a surgical referral, as the presence
of an indirect inguinal hernia is likely present.
Varicoceles are thought to be a defect in the valves of
the venous plexus of the testicle. They are more commonly
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Balanitis and Balanoposthitis
Balanitis — inflammation of the glans penis — or balanoposthitis — inflammation of the prepuce and glans penis
— can be caused by trauma, local irritation, or infection.39
Most commonly this problem affects males between the
ages of 2-5 years. The presence of a foreskin may have a
role in increasing the incidence of balanitis. In a retrospective survey of 545 boys aged 4 months to 12 years; 272
uncircumcised boys had balanitis diagnosed in 6% versus
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a minor testicular contusion may have occurred, this may
be the precipitating event for testicular torsion. Testicular
rupture is also seen and is a urologic emergency. The pain
and swelling will often be significant, and the scrotal sac
will be ecchymotic and tender.31
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3% of circumcised males; however, the difference in these
findings was not statistically significant.40 Penile irritation
may be accentuated by local colonization of Candida albicans, or gram-positive anaerobic and aerobic bacteria, such
as Group A Streptococcus.39,41,42 A single case report cited
acute balanitis in association with a child who developed
Staphylococcal toxic shock syndrome.43 In the sexually
active adolescent, Chlamydia trachomatis and Neisseria gonorrhoeae are more commonly the causative agents. Inflammation can also be caused by external irritation from soap,
laundry detergents, and antistatic sheets.39
In one retrospective study of 64 boys with penile trauma,
2% of the cases were due to zipper injuries, and 16% were
caused by hair tourniquets.48 These entities appear self
explanatory, but the literature is scant on these topics.
Zippers from the boys’ trousers often entrap the prepuce
or penile shaft when a child fastens or releases the zipper
without the protection of underwear. This will often cause
significant pain and discomfort for the child, and the parents eventually bring the child to the ED after the attempt
at release is unsuccessful at home.
Phimosis
Phimosis is a condition that occurs when the foreskin
cannot be retracted over the glans penis. This often is the
result of local irritation or inflammation. As described
previously, primary phimosis is physiologic and will
usually resolve by the age of 5 years. Secondary phimosis, or an inability to retract the prepuce over the glans,
when previously it was retractable, is due to chronic scar
tissue formation. The incidence has been reported to be
0.4 cases per 1000 boys per year, or 0.6% of all boys by the
15th birthday.44 This condition may be due to irritation,
infection, or possibly a chronic inflammatory condition
of unknown etiology called balanitis xerotica obliterans
(BXO), also known as lichen sclerosis et atrophicus. In a
prospective study in 100 prepubertal males undergoing
elective circumcision due to phimosis, balanitis, or recurrent balanitis, 14 were found to have histological evidence
of lichen sclerosis et atrophicus.45 Another prospective
study involving 23 cases of phimosis in boys aged 4-11
years, found that 20 out of 21 histological specimens had
evidence of lichen sclerosis et atrophicus.46
Human hair is very strong and, when wet, will stretch
in length. As it dries, it can form a tight, constricting
band around a penis. This is the same mechanism as that
described for toes. Sometimes a child may present with
inconsolable crying of unclear etiology when, upon examination of the genitals, a hair tourniquet may be found
constricting the penis. This “hair tourniquet syndrome” is
a rare entity that may be mistaken for balanitis, if a careful search for the offending agent is not performed. Since
properly circumcised children can’t sustain a paraphimosis, by definition, and are less likely to contract balanitis,
a hair tourniquet must be considered in the differential
diagnosis of a circumcised boy who presents to the ED
with a swollen penis.49 Urethral fistulas and auto-amputation of the glans have been described as serious sequelae
of prolonged hair tourniquets around the penis.47,49 The
origin of these injuries in children is unclear; however, one
review reported that playful experimentation, warding
off evil sprits, the prevention of nocturnal enuresis, and
child maltreatment were all causes previously stated in the
literature.47
Zipper Injuries
Prehospital Care
Hair Tourniquet
Finally, entrapment injury to the penis can occur. This is
commonly due to zipper injuries and hair tourniquets.47
There is little information on the role of paramedics in the
management of acute scrotal and penile complaints. Given
Table 2. The Differential Diagnosis Of Acute Penile Complaints
Diagnosis
Symptoms
Signs
Paraphimosis
•
•
History of retracting foreskin
Painless to painful
•
Constricting ring of edema around
coronal sulcus
Balanoposthitis/Balanitis
•
•
Painful
Pruritic
•
•
•
Red
Swollen
+/- purulent discharge
Phimosis
•
•
•
Pruritic
Dysuria
Abnormal voiding
•
•
•
Inability to retract the foreskin
Minimal swelling
Chronic skin changes
Zipper injury
•
Occurs with fastening or removal of
pants zipper without underwear
•
Zipper may entrap foreskin, penile
shaft, and/or glans
Hair tourniquet
•
History of circumcision
•
•
Red and swollen distal to hair
Hair may not be easily seen if inflammation is severe
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ED Evaluation
The Acute Scrotum
History
In the ED, the history should be directed toward identifying testicular torsion and increasing the probability of
testicular salvage.50,51 The time of the onset of symptoms
should be immediately determined. Was the onset of
pain gradual or acute? The pain of testicular torsion has
an acute onset, as if someone suddenly pressed the “on”
button. Are there any other accompanying symptoms,
such as abdominal pain, nausea, or vomiting? Was there
any antecedent trauma? A history of intermittent pain
with spontaneous resolution could suggest intermittent
testicular torsion.52 Even a previous history of orchiopexy does not rule out testicular torsion, as re-torsion has
been reported after testicular fixation.53 It is important to
quantify and characterize the child’s pain, as most often
nonemergent etiologies of the acute scrotum present with
modest or no pain. Symptoms such as dysuria, recent viral
symptoms, fever, or urethral discharge may be more suggestive of epididymitis. However, distinguishing between
etiologies by history alone may be difficult, and thus a
careful physical exam is well worth the effort.
Physical Examination
The physical exam of the child with an acute scrotum can
be difficult at times. Consoling an irritable child can be trying, but all attempts should be made to comfort the child.
Start with observation of the child in the room. How
much pain is he actually experiencing? It is important to
examine the testes of young boys with abdominal pain,
as embarrassed or nonverbal children may express this
as their chief complaint, rather than complain of pain in
their scrotum. Palpation of the scrotum should begin with
evaluation of the uninvolved side, taking care to notice
the testicular position and the level of where the testicles
lie. A horizontal lie indicates a bell-clapper deformity, and
high-riding testicles on the involved side are red flags for
testicular torsion. The testicles should be examined for the
exact area of tenderness, swelling, and redness. A tender,
swollen spermatic cord is suggestive of epididymitis.
Classical signs such as relief of scrotal pain with elevation
of the involved side may suggest, but is not diagnostic for,
epididymitis (Prehn’s sign), and a blue dot on the scrotum
with localized tenderness at the superior pole of the testicle suggests the diagnosis of torsion of a testicular appendage (blue dot sign). However, these findings may not be
present, or are difficult to determine in younger children.
It is important to observe the child’s genitals in both the
supine and upright positions, if possible. This may reveal
a previously hidden inguinal hernia or hydrocele. Sometimes having the child blow into a glove or party balloon
will increase intra-abdominal pressure enough to produce
the needed clinical findings. A varicocele may feel like a
“bag of worms” and have a bluish appearance through the
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Penile Complaints
History
The most important aspect of the history is to determine
if the child has been circumcised. A boy who has not
undergone circumcision is more likely to have an emergent condition, such as paraphimosis. The history should
then focus on the onset of the symptoms. Did the swelling occur after retraction of the prepuce? Are there any
symptoms, such as discomfort with voiding, an inability
to void, fever, sore throat, or urethral discharge? Was there
a clear history of trauma? Is the boy sexually active?
Physical Examination
School-aged children may be apprehensive or embarrassed about their swollen penis, so make all attempts to
make the child comfortable. Examine the foreskin and
glans for redness and swelling, the hallmark of balanitis
7
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skin of the scrotum. The presence of “palpable” purpura
in the lower extremities and/or buttocks suggests a diagnosis of HSP. A child with a ruptured testicle will have a
full scrotum, with tenderness and ecchymosis. The testicle
itself may be irregular, however this may be difficult to
assess due to the swelling.31
The most clinically useful physical finding is the
cremasteric reflex.55 This reflex is produced by stroking the
inner aspect of the thigh, causing a reflex loop involving
the spinal nerve segments L1-L2, inciting the cremasteric
muscle contraction, pulling the ipsilateral testicle closer
to the body. Many experienced practitioners feel that the
lack of this finding is diagnostic for testicular torsion in
the setting of an acute scrotum. This is a very reliable
clinical finding, as the cremasteric reflex is consistently
present in older children. In one study of 225 children
who presented for non-urogenital problems, all children
(100%) older than 30 months (54 children) had an intact
cremasteric reflex. However, as the population decreased
in age, the presence of the reflex was less consistent, as
48% of newborn children and 45% of children less than 30
months old had a cremasteric reflex on physical exam.54
Three retrospective studies that included a total of 444
boys with an acute scrotum found testicular torsion in 91
boys. In these studies all children (100%) with testicular
torsion had an absent cremasteric reflex.2,14,16 In a single
case report, testicular torsion was present in a child with
an intact cremasteric reflex.56 Van Glabeke et al reported 3
infants with testicular torsion who had intact cremateric
reflexes. In these cases the testes were not found to be ischemic, and the cord was twisted only once. In this series an
absent cremasteric reflex had a 60% sensitivity and a 93%
negative predictive value in determining testicular torsion. One problem with these values is that not all of the
patients are accounted for, as some data are missing, due
to the retrospective nature of the study.17 Despite these few
cases, it appears that the presence of testicular torsion with
an intact cremasteric reflex is extremely rare, and in its
absence emergent scrotal exploration should be seriously
considered.
that most of these boys can walk, it is relatively unusual
for EMS to be dispatched for these problems.
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and balanoposthitis. With these conditions the foreskin
may be swollen, but not retracted. In sexually active
adolescents, milk the penis for urethral discharge that
would suggest a sexually transmitted disease. Paraphimosis presents with a swollen prepuce that forms a tight
ring around the coronal sulcus proximal to the glans
penis. If the entrapment is recent, minimal redness will
be present, and the glans should appear viable. Delays in
seeking treatment or in making the diagnosis may result
in necrosis of the glans penis and prepuce. Phimosis will
present with an inability to retract the prepuce over the
glans, and erections may incite pain. There should be little
to no swelling, but there may be signs of chronic irritation
and scarring at the distal end of the prepuce. In infants
and young children, look for a hair tourniquet that may
be the cause of the swelling. This may not be immediately
apparent if the degree of swelling is great. However, if a
hair tourniquet is there, careful examination may prevent
serious sequelae from a missed diagnosis. If a zipper has
entrapped the child’s penis, look to see what structures are
involved, and minimize the amount of movement until the
child can receive adequate analgesia.
This finding can be misleading, despite the presence of
pyuria; if the child clinically has testicular torsion, it must
be ruled out surgically. If hematuria is present, it may suggest nephritis associated with Henoch-Schönlein purpura.
If Henoch-Schönlein purpura is suspected, further clinical
correlation may prevent unnecessary scrotal explorations.
Urine culture should be done on all children with an
acute scrotum. A urine culture may be of help in children
diagnosed with epididymitis. All children with epididymitis should receive antibiotic therapy if their cultures grow
significant quantities of a single organism. However, it
should be up to the consulting pediatric surgeon or urologist to pursue further studies to rule out an underlying
urogenital abnormality.
Imaging Studies (Scintigraphy and Ultrasound)
The use of nuclear scintigraphy and color Doppler ultrasonography to identify testicular torsion is common
practice.60-62 These tests are very good screening modalities
for assessing the presence or absence of testicular blood
flow.60,63-65 They are able to show decreased testicular blood
flow in cases of testicular torsion, and find increased testicular blood flow in cases of epididymitis and torsion of
a testicular appendage. Some authors advocate using both
tests, if one test yields equivocal results.66 Anderson found
that scintigraphy could reliably differentiate between torsion from other acute scrotal problems.67 Another study
found nuclear scintigraphy to be even more accurate
than color Doppler ultrasound; however, the number of
cases was small.65 Currently in our center, color Doppler
ultrasound is the screening modality of choice, when the
clinical diagnosis is in doubt, for assessing the pediatric
acute scrotum. One study reviewed 65 cases of acute scrotal disease and found color Doppler ultrasound to have a
positive predictive value of 73%, sensitivity of 100%, and
a negative predictive value of 100% in diagnosing testicular torsion.68 Another study of 110 patients who did not
undergo immediate scrotal exploration found a sensitivity
of 88.9%, specificity of 98.8%, and a false positive of 1%
for testicular torsion.69 In the context of Henoch-Schönlein
purpura, in one study of 93 boys with HSP, color Doppler
ultrasonography demonstrated normal testicular flow in
all 7 boys with scrotal involvement. All 7 of the boys did
well and had no complications.70 However, one study
cautioned the use of color Doppler ultrasonography as
the sole determiner of the presence of testicular torsion, as
it might yield false-positive results.71 This study population consisted of 50 normal boys. Blood flow was found
bilaterally in 58%, only unilaterally in 8%, and no flow
was detected in 34% of patients. However, the main issue
for these diagnostic modalities is the small number of
reported false-negative results, and the resulting concern
for missing the diagnosis of a testicular torsion.72-75 Falsenegative sonograms may be the result of torsion without
arterial compromise, such as happens early on in the process, or with a mild (180-degree) twist of the cord. A study
comparing color Doppler to nuclear scintigraphy found
an equal incidence of false-negative results. Prospectively
Diagnostic Studies
The Acute Scrotum
Serum Studies
There are currently no serum studies that clearly help
in the workup of the pediatric acute scrotum. Acutephase reactants, such as white blood cell count (WBC)
and C-reactive protein, have been found to be elevated
in epididymitis, as compared to other causes of the acute
scrotum. One study of children with epididymitis found
an elevated WBC (>10,000) in 44 % of children; however,
another study found an elevation in only 7% of patients.28,37 Other studies have looked at WBC in the acute
scrotum; however, since most studies are retrospective,
often this test was not ordered on all of the patients, and it
is difficult to draw a clear conclusion.
A study in adults found that there was a 4-fold elevation of C-reactive protein in patients with epididymitis,
compared with conditions such as testicular tumor or
testicular torsion.57 These results have not been validated
in the pediatric population, and the causes of epididymitis
in the adult and pediatric populations differ. It is not routinely recommended that serum studies be sent for a child
with an acute scrotum, and precious time may be wasted
waiting for results.
Urinanalysis and Urine Culture
Urine analysis has been the cornerstone of the workup of a
child with an acute scrotum. However, the clinical yield is
often low, and actually may add to the confusion. Finding
pyuria is often linked to the diagnosis of epididymitis;
however, studies of children with epididymitis found
pyuria in only 7-24% of the patients.25,58 Furthermore,
children with testicular torsion can also have pyuria, but
the incidence of this is much less than in epididymitis.59
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Penile Complaints
There are currently no laboratory or imaging studies that
aid in the evaluation of a boy with a penile complaint,
except in sexually active adolescents. Urethral culture in
sexually active adolescents may help to determine an exact
etiology, but should not change the acute management. In
most cases of the acutely swollen penis, no ancillary studies are needed to provide appropriate care in the ED.
Treatment
The Acute Scrotum
Surgical Exploration
Emergent scrotal exploration is the current gold standard
to diagnose and treat acute testicular torsion. Surgical
treatment serves two purposes. The first purpose is to
re-establish circulation to the ischemic testicle, and the second purpose is to perform an orchiopexy to both testicles
to prevent further episodes. It has been clearly documented that expeditious scrotal exploration increases chances
of testicular salvage.1,18,20 In these retrospective reviews,
children who presented within 12 hours of the onset of
scrotal pain had salvage rates ranging from 88-100%.
These studies also found that, after 12 hours, testicular
salvage rates dropped dramatically — to 22%-36%. In
Closed Manual Detorsion
Manual, manipulative detorsion is not recommended for
the emergency physician, as torsion can often recur, and
scrotal exploration is still required.78 One study suggests
that the classic teaching of torsion occurring medially may
be misleading, as lateral rotation of the cord occurred in
33% of their cases.21 Attempts at manual detorsion in these
Continued on page 12
Cost- And Time-Effective Strategies
For Eurogenital Emergencies In Boys
1. Diagnostic imaging for the assessment of a painful and
swollen scrotum can be costly and does not ensure 100%
accuracy.
Doppler ultrasonography, should be reserved for equivocal
cases where the diagnosis is in question and unnecessary
surgery can be avoided by further imaging studies.
2. A carefully performed physical examination followed
by timely exploratory surgery and the avoidance of
unnecessary studies is the prudent approach to take
whenever there is a high suspicion for testicular torsion.
4. Delays in obtaining definitive surgical correction carry a
high morbidity.
5. The value in obtaining imaging studies should always be
weighed against the risks caused by time delays. ▲
3. Diagnostic studies, such as scintigraphy and color
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another study, even if the testicle was salvaged, on longterm follow-up, the presence of testicular atrophy directly
correlated with the duration of symptoms before surgical
intervention.76 Not only does duration of symptoms play
a role in saving the testicle, it may also play a role in its
long-term viability.
Only one study has prospectively looked at using
a set protocol for determining scrotal exploration. This
protocol called for emergent exploration for any child
presenting within 24 hours of onset of scrotal pain, unless
there was a palpable, tender nodule to suggest torsion of
a testicular appendage. Using these criteria, 20 boys were
prospectively studied, with 10 out of 20 boys presenting
within 24 hours of symptoms. Of the early group, 8 of the
10 children were surgically explored, and testicular torsion
diagnosed in 6, with torsion of the testicular appendage
in 2. The other 2 children in the early group had palpable,
tender nodules and were conservatively managed, as were
the 10 children who presented after 24 hours of symptoms.
None of the conservatively managed children had testicular atrophy on follow-up at 4-6 weeks, with complete
resolution of symptoms.24 How the power of this study
was determined was not mentioned in the article, so the
significance of the results is not clear. This protocol needs
to be carried out on a larger scale; however, it does give us
something to think about.
It is possible that some testicles may be salvageable
beyond 24 hours of the onset of symptoms, and a single
case report showed a viable testicle even after 7 days of
symptoms.77 This case report, however, only illustrated
intra-operative re-perfusion of the testicle and did not
comment on its long-term viability.
in 46 children, the investigators found flow in 3 out of 14
children in each group who had testicular torsion, finding
sensitivity 78.6 and 78.6 and specificity 96.9 and 90.6 for
color Doppler ultrasonography and scintigraphy, respectively.74 It appears that both modalities are similar in accuracy and are not infallible. Color Doppler ultrasonography
is quicker, less invasive, and requires no radiation when
compared to nuclear scintigraphy. The downside to both
modalities is that they require skilled personal to complete
and interpret the procedures. These resources may not be
readily available to the general emergency practitioner,
and the time it takes to carry them out may be the difference between testicular salvage and the need for orchiectomy. For equivocal cases, these imaging modalities may
decrease the incidence of unnecessary scrotal explorations
of the pediatric acute scrotum.64,65,68
Acute onset of painful scrotum
YES
➤
Absent cremasteric reflex,
abnormal testicular
orientation within the
scrotum, and acute onset?
➤
YES
Emergent Surgical Exploration
(Class I)
NO
1.
➤
➤
Onset < 24 hours?
YES
➤
2.
Emergent Surgical Exploration
(Class II)
Imaging with ultrasound or
scintigraphy (Class II)
NO
➤
•
•
Doppler Ultrasound (US)
Nuclear Scintigraphy (NS)
Decreased blood flow to testicle?
➤
YES
Surgical Exploration
(Class II)
NO
➤
Localized tenderness to the superior pole of the testes
YES
for torsion of appendix
➤ Treat
testes (Class II)
NO
➤
Fever/tender spermatic cord
YES
➤
Treat for epididymitis
(Class II)
NO
➤
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Clinical Pathway: The Acute Scrotum
Consider alternative diagnoses and treat based on the most likely diagnosis.
(See Table 1.)
The evidence for recommendations is graded using the following scale. For complete definitions, see back page. Class I: Definitely
recommended. Definitive, excellent evidence provides support. Class II: Acceptable and useful. Good evidence provides support. Class III:
May be acceptable, possibly useful. Fair-to-good evidence provides support. Indeterminate: Continuing area of research.
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending
upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright ©2004 EB Practice, LLC. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Practice, LLC.
Pediatric Emergency Medicine Practice
10
EBMedPractice.net •November 2004
Swollen or Painful Penis
YES
➤
Circumcised?
➤
YES
Look for hair tourniquet and
treat if found (Class II)
NO
➤
Constricting band around coronal sulcus?
➤
YES
Paraphymosis
•
Analgesia (Class II)
•
Reduction (Class II)
•
Circumcision (Class II)
NO
➤
Zipper present?
YES
➤
NO
Zipper Injury
•
Analgesia (Class II)
•
Mineral oil (Class II)
Cut median bar of zipper (Class II)
•
•
Circumcision (Class II)
➤
Erythema to foreskin with or
without purulent discharge?
YES
NO
➤
Balanitis/Balanoposthitis
•
Topical steroids (Class II)
•
Oral antibiotics (if discharge present)
(Class II)
•
Antihistamines (Class II)
➤
Chronic inflammation and
non-retractable foreskin?
YES
➤
Phimosis
•
Topical steroids (Class I)
•
Urology follow-up
NO
➤
Consider alternative diagnoses and treat based on the most likely diagnosis.
(See Table 1.)
The evidence for recommendations is graded using the following scale. For complete definitions, see back page. Class I: Definitely
recommended. Definitive, excellent evidence provides support. Class II: Acceptable and useful. Good evidence provides support. Class III:
May be acceptable, possibly useful. Fair-to-good evidence provides support. Indeterminate: Continuing area of research.
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending
upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright ©2004 EB Practice, LLC. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Practice, LLC.
November 2004 • EBMedPractice.net
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Clinical Pathway: Penile Complaints
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Continued from page 9
penile block with 1% plain lidocaine is a good addition
for pain reduction. Once adequate analgesia is attained,
simple manual reduction is usually successful for correcting paraphimosis. Manual reduction involves holding the
distal foreskin and penile shaft with constant pressure
down on the head of the glans penis. Ice and compression
can often be helpful in reducing edema and facilitating
manual reduction. The inverted finger of a large surgical glove placed over the penis for compression and the
glove filled with ice can be a helpful edema-reducing
technique. Additional substances, such as injection of 1 cc
haluronidase (150 Units/cc) into the edematous prepuce,
have been reported to help with reduction. Haluronidase
acts by breaking down ground substance in connective
tissue, enhancing the diffusion of the liquid between tissue
planes.80 Holding the edematous prepuce in granulated
sugar for 2 hours to osmotically decrease edema has also
been found to be a helpful adjunct to manual reduction.81
Other, more invasive measures have been described, such
as the puncture technique. This technique involves making a series of small punctures around the swollen prepuce
with a, 21G needle, followed by gentle compression of the
swollen foreskin to express the edematous fluid. Manual
reduction is then attempted.82-84 A technique using only a
single needle puncture has been described, as well.85 As
a last resort, dorsal slit or complete circumcision may be
completed by a pediatric surgeon, if these other measures
fail to reduce the entrapped foreskin.
cases may actually worsen the ischemia. We recommend
that all children who present within 24 hours of acute
scrotal pain with a high suspicion of testicular torsion
(ie, nausea, vomiting, and no cremasteric reflex) receive
rapid pediatric surgical consultation or be transported to a
children’s hospital where such consultation is available for
scrotal exploration. Imaging modalities such as ultrasonography and scintigraphy have no role in assessing these
patients, as they will only delay care and increase bad
outcomes.
It is unclear if children who present late with testicular torsion constitute an “emergency,” as salvage rates
beyond 48 hours are already extremely poor. One caveat
to this is future viability and productivity of the remaining
uninvolved testicle. Anderson et al studied semen quality
in a group of 16 males who underwent scrotal exploration
— 9 males treated with detorsion and orchiopexy, and 7
with orchiectomy. The quality of the semen from the single
remaining testicle was significantly decreased from that
of age-appropriate controls when the patients required
an orchectomy. However, when scrotal exploration was
able to salvage the involved testicle, the quality of semen
showed no significant difference. They concluded that
early intervention produces better long-term outcomes
in terms of fertility that go beyond just simply saving the
involved testicle.79
Antibiotics and Analgesics
In children who are at low risk for torsion or who present
later than 24 hours after the onset of symptoms, imaging
modalities may be helpful. These children should have a
color Doppler ultrasound or nuclear scintigraphy to help
further rule out testicular torsion. Children with torsion of a testicular appendage should receive ibuprofen,
10 mg/kg every 6-8 hours until the pain subsides, and
they should wear supportive underwear. Children with
epididymitis should receive the same treatment as those
with a torsed appendage testis, and if pyuria is present,
then antibiotics to target gram-negative enteric organisms
should be prescribed. If the urine analysis is normal, no
antibiotics should be required.58
Topical and Oral Treatments
The treatment of acute balanitis and balanoposthitis is
dependent on the clinical findings. Local inflammation
and swelling without a purulent discharge suggest the
cause may be due to a local irritant, and a topical 1%
hydrocortisone cream may be applied 2-3 times daily for
7-10 days. In the younger child, if a purulent discharge is
present on exam, then treatment to target Group A Streptococcus and Staphylococcus aureus should also be initiated.
Oral antibiotics, such as cephalexin 25 mg/kg per dose 3
times per day, amoxicillin-clavulanate 25 mg/kg per dose
twice daily, or clindamycin 10 mg/kg per dose 3 times
per day may be given. Diphenhydramine 1.25 mg/kg per
dose every 6 hours as needed is often helpful to decrease
pruritus associated with the inflammation. In the sexually
active adolescent, testing for sexually transmitted diseases
(typically urethral cultures) should be performed, and
the most recently recommended treatments for Chlamydia
trachomatis and Neisseria gonorrhoeae should be initiated in
the ED (eg, azithromycin 1 gram orally once plus ceftriaxone 1 gram intramuscularly or intravenously). If there is
high fever and/or severe involvement of the penile shaft
and groin, hospital admission for intravenous antibiotics
and observation may be indicated. Fortunately, this clinical scenario is quite rare. Adolescent boys with balanitis
whose sexual partners have vaginal yeast infections may
have good clinical resolution of their symptoms when
given a single dose of fluconazole 150 mg given orally.
There is little to do for a child with secondary
Penile Complaints
Paraphimosis Reduction
The treatment of a child with paraphimosis involves
reduction of the edema and replacement of the foreskin
to its normal position. Preferably this process is completed expeditiously to prevent ischemic injury to the
glans and prepuce. There are currently no prospective,
blinded studies pertaining to this topic. However, multiple
case reports and a few cohort studies describe multiple
methods of foreskin reduction. Prior to reduction, oral or
IV analgesia should be provided to the patient. Morphine
sulfate, 0.1mg/kg IV, or Hydrocodone, 0.2 mg/kg PO
with acetaminophen, are good choices. The addition of
proper analgesia to the procedure is crucial to its success,
as a relaxed child will be more easily reduced. A dorsal
Pediatric Emergency Medicine Practice
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study, Huntley et al found an 81% success rate for topical steroids in 31 children initially treated medically for
phimosis.88 One limitation to these studies is the lack of a
control arm to compare the efficacy of therapy. However,
one small prospective, double-blinded study showed that
topical steroid was superior to placebo in the treatment
of phimosis. Two groups of 20 males (N=40) were treated
with 0.05% Betamethasone cream or placebo cream twice
daily for 4 weeks. In the treatment group 19 out of 20
boys had complete reduction of the foreskin at 4 weeks,
compared to 4 out of 20 in the control group (p<0.001).89
Clearly, topical steroids should be a first-line treatment for
secondary phimosis in pediatrics. Follow-up should be
arranged by the primary care physician, so that a surgical
specialist can ensure that no further complications arise.
Ten Pitfalls To Avoid
1. “I want this patient to get a color Doppler ultrasonography of the scrotum, because I am pretty sure this is
testicular torsion.”
An ultrasound is very helpful in working up cases of
moderate or low suspicion for testicular torsion. If the
diagnosis is certain or near certain, the best approach is to
contact the surgeon with the expectation of prompt surgical
exploration. If the suspicion for testicular torsion is high,
further imaging only decreases the chance of testicular
viability by possibly delaying definitive care.
testicular torsion, only to find epididymitis or torsion of
a testicular appendage, should not lead to legal action.
Aggressive treatment has been the rule for many years, and
it is still a good standard if the diagnosis is in question.
6. “I did not look in the genital area because the child’s chief
complaint was abdominal pain and vomiting.”
Children may not complain of their genitals hurting, but
rather complain of abdominal pain or nausea. It is good
practice to examine the scrotum on any boy with acute
abdominal pain to rule out scrotal etiologies.
2. “The ultrasound showed arterial flow, so this child cannot
have testicular torsion.”
Early testicular torsion and intermittent torsion may yield
a false-negative result on ultrasound. Studies report the
incidence of this finding to be about 1%. If time is a factor
and the suspicion is high for testicular torsion, emergent
scrotal exploration is indicated. The diagnosis should be
made at the bedside.
7. “I thought that the swelling from paraphimosis was due
to an infection.”
The 2 key questions are: “Is this child circumcised?” and
“How did it happen?” Both of these questions help to rule
in paraphimosis. Paraphimosis cannot occur in properly
circumcised individuals, and often the entrapment of the
foreskin can be blamed on a single incident of retracting it.
8. “I did not see the hair tourniquet.”
Hair tourniquets can easily be missed and mistaken
for balanitis, if a close examination of the penis is not
performed. Also, any male infant who presents with crying
or irritability should be examined for hair tourniquets of the
digits, including the penis.
3. “No follow-up is needed since the ultrasound does not
show testicular torsion.”
All children should be followed closely over the next few
days. It is easy to mistakenly discharge an intermittent or an
early testicular torsion. Prolonged monitoring in the ED is
indicated, or close follow-up with the pediatrician and good
instructions for when to return should be given.
9. “There’s no way this 13-year old could be sexually active.”
In any child in the teen years, a sexual history can be very
important to identify sexually transmitted diseases and the
etiology of epididymitis.
4. “The urinanalysis has leukocytes, so this child has
epididymitis.”
Boys with testicular torsion can also have leukocytes in
their urine. Although pyuria is seen more commonly in
epididymitis, the overlap with testicular torsion can be
misleading.
10. “I thought he probably had gastroenteritis. He was
vomiting. How could he have had testicular torsion?”
Presumably, due to the abrupt onset of substantial pain,
testicular torsion commonly presents with vomiting. Due
to embarrassment or lack of insight, boys may be reluctant
to offer a history of testicular pain, if the questions are not
asked directly or if the genitals are not examined. ▲
5. “An unnecessary scrotal exploration could result in
medical litigation.”
Going to the operating room to definitively rule out
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phimosis in the ED. However, medical treatment may
be implemented while awaiting outpatient urological
follow-up. Numerous studies have shown that topical
application of steroids is efficacious in the resolution of
secondary phimosis. Medium-strength topical steroids,
such as betamethasone or triamcinolone, have been
proven to be efficacious in the resolution of phimosis
when used consistently for 4-6 weeks. In a retrospective
review of 69 boys aged 3-13 years, Webster et al found that
82% had complete resolution of phimosis with the application of triamcinolone cream twice daily for 6 weeks.86 In
a prospective study on 194 males under 16 years old with
phimosis, Ashfield et al successfully avoided circumcision in 87% by using topical 0.1% betamethasone ointment applied twice daily.87 Most recently, in a prospective
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Controversies / Cutting Edge
Zipper Injury Treatment
When a foreskin is entrapped by a zipper, further manipulation is often painful. By the time the patient presents to
the ED, the parents have most likely attempted removal
on their own without success. The least invasive maneuver described in the literature is to apply mineral oil to the
area in the hopes of helping to lubricate the skin, so that
moderate traction is now enough to free the penis from
the zipper.90 The use of bone cutters or a small hacksaw to
cut the medial bar of the zipper has also been described
with good success.91-93 This measure breaks the zipper
into 2 parts releasing the trapped prepuce. Lastly, surgical
consult for complete circumcision of the entrapped area is
an alternative, if these other measures fail.
Two articles specifically explored the use of bedside color
Doppler ultrasonography by the emergency physician
to rapidly make the correct diagnosis in patients with an
acute scrotum.95,96 One small retrospective review found a
95% sensitivity and a 94% specificity for making the correct diagnosis in 36 cases of an acute scrotum, when compared to the official radiology reading or surgical exploration.96 However, a large prospective study is lacking at this
time. As bedside ultrasonography becomes more readily
available, and emergency practitioners become more comfortable and skilled in its use, this screening modality may
provide the most timely and effective tool for diagnosis of
testicular torsion.
Hair Tourniquet Treatment
Disposition
There are no studies that describe the best way to remove
a hair tourniquet from a swollen penis. Often, if the swelling is not severe, the hair may simply be untangled or
cut from the penile shaft. Soaking the area in 8% calcium
thioglycollate (Nair) for 15 minutes has been suggested.94
However, this is contraindicated if the tourniquet is not
made of human hair. Timely treatment is important, since
inflammation and skin breakdown will occur. If the swelling is marked or there is evidence of gangrene, emergent
urological consult should be considered prior to any
attempts at removal. The removal might be performed in
the operating room, if there is any suspicion that a repair
to the glans or urethra may be necessary. Often, surgeons
may need to make a lateral incision perpendicular to the
tourniquet, at the level of the lateral-inferior depressed
area that lies between the corpus cavernosum and corpus
spongiosum. This allows avoidance of the urethra and
dorsal neurovascular bundle.47
Most children who do not have testicular torsion are
discharged home. All children with acute scrotal pain who
do not receive surgical intervention should have close follow-up with either their pediatrician or a urologist experienced in the care of children within 1-2 days. The child’s
pediatrician should be contacted to assure follow-up on all
urine cultures, as children with epididymitis and positive
urine cultures may require urology follow-up and further
studies to rule out underlying urogenital abnormalities.
All children with an acutely swollen penis should be
reexamined by their pediatrician or by a physician in the
ED within 48 hours of treatment. The patients with acute
balanitis and balanoposthitis require very close monitoring. Worsening of the swelling and pain may be indicative
of antibiotic-resistant organisms or a missed diagnosis.
Children who have a reduced paraphimosis, or who have
had a hair tourniquet or zipper entrapment removed, may
Key Points For Urogenital Emergencies In Boys
• The treating emergency practitioner must have a very
high suspicion for testicular torsion with any child who
presents with testicular pain.
coexist. The trauma patient with an absent cremasteric
reflex should have emergent surgical consultation.
• Children with HSP and scrotal involvement can usually
be managed conservatively. However, if testicular torsion
cannot be ruled out, then diagnostic imaging is of great
benefit.
• Children in whom there is a high suspicion of testicular
torsion that present within 24 hours of the onset of
symptoms should receive surgical consultation for a
possible emergent scrotal exploration.
• Children with epididymitis and torsion of a testicular
appendage can be managed with supportive care and
close follow-up.
• Children with equivocal findings for testicular torsion
should undergo an imaging modality, such as color
Doppler ultrasonography or nuclear scintigraphy, to
further help to rule out testicular torsion. For those cases
in which imaging is either unreliable or unavailable, and
the patient presents within 12-24 hours of the onset of
symptoms, scrotal exploration should be considered.
• Children with paraphimosis should be expeditiously
reduced to prevent serious sequelae.
• The emergency physician must have a high suspicion for
a hair tourniquet in a circumcised child with a swollen
penis. ▲
• Trauma to the testicle and torsion of the testicle may
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Toilet Seat Injury
Although it is certainly possible for toilet seats to accidentally fall down while young boys urinate, it is quite
unusual for injuries due to this phenomenon to require
an ED visit.102 If penile fracture is suspected, or if swelling
is sufficient to obstruct urinary outflow, prompt urologic
consultation is probably prudent.
Summary
Although most boys with urogenital complaints are
discharged home from the ED, prompt identification and
treatment for testicular torsion and paraphimosis are the
keys to a successful ED visit for these boys. Having confidence in the management of other urogenital complaints
allows the emergency physician to treat these boys appropriately and goes a long way toward reassuring anxious
parents. ▲
References
Evidence-based medicine requires a critical appraisal of
the literature based upon study methodology and number
of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial
should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the
type of study and the number of patients in the study, will
be included in bold type following the reference, where
available.
Special Circumstances
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Willams CR, Heaven KJ, Joseph DB. Testicular Torsion:
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Elsaharty S, Pranikkoff K, Suprin G, et al. Traumatic Torsion
Priapism In Sickle Cell Disease
Priapism is a well-described complication of sickle cell
disease. In one survey, 35% of men with sickle cell disease
had experienced priapism at some point in their lives,
and the mean age of onset was 15 years.98 Recommendations for treatment of prolonged erections in boys with
sickle cell disease range from conservative fluid and pain
management at home, to intravenous hydration in the ED,
to intracavernosal aspiration.99 There is no evidence-based
management plan that is widely accepted. Consultation
with the patient’s hematologist is probably prudent.
Foreign Bodies And Piercings
Sexual exploration in adolescence is well recognized.
Although we were not able to identify any specifically
pediatric literature describing urethral foreign bodies
and genital piercings in adolescent boys, these have been
described in relatively young adults.100,101 If encountered in
the ED, each instance will need to be managed on a caseby-case basis, due to the paucity of information on these
topics.
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require oral analgesia. Further, supportive local wound
care with topical antibiotic ointments and warm sitz baths
may also be of help. Lastly, children diagnosed with phimosis with initiation of topical steroid treatment should be
seen by their pediatrician in 1-2 weeks to monitor progress
and make the proper surgical referral.
Unfortunately, the acute pediatric scrotum poses a
difficult clinical problem for the emergency physician,
as a missed testicular torsion can result in legal action.
Misdiagnosis of testicular torsion is an active area of
litigation for many reasons: the problem requires emergent
diagnosis and treatment, there is occasionally diagnostic
uncertainty, there is a relatively high rate of poor outcomes
(orchiectomy), and the psychological impact of a lost
testicle can be significant.97 Matteson et al retrospectively
reviewed 39 closed cases of 58 individual claims made
against individual physicians regarding missed testicular
torsion between the years 1979-1997. In this series, 26 out
of 39 (67%) resulted in indemnity payments, and 9 out
of 39 were concluded with no payment on the behalf of
the physician. The remaining 4 claims went to trial with
findings in favor of the defendant. The mean defense cost
was $10,785 per case, and the physician most often sued
was the urologist. The most common reasons for litigation
payments against non-surgeons were improper referral or
not ordering imaging studies. Interestingly, there was no
difference in the rate of payment between those patients
who presented within 8 hours of symptoms, those that
presented later than 8 hours, and those whose time of presentation could not be determined. Apparently, the welldocumented fact that a delayed presentation decreases the
rate of testicular salvage did not affect legal outcomes in
this study population.97
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Baker LA, Sigman D, Docimo SG. An Analysis of Clinical
Outcomes Using Color Doppler Testicular Ultrasound for
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September2004
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Pediatric Emergency Medicine Practice
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50.
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88.
of the tunica vaginalis, leading to this anomaly.
Huntley JS, Bourne MC, Wilson-Storey D, et al, Troubles
with the foreskin: one hundred consecutive referrals to pediatric surgeons. J R Soc Med. 2003;96:449-451. (Prospective;
100 patients)
89.
Golubovic Z, Milanovic D, Perovic S, et al. The Conservative
Treatment of Phimosis in Boys. Br J Urol. 1996;78:786-788.
(Prospective, randomized, double blinded, placebo controlled; 40 patients)
90.
Kanegaye JT, Schonfeld N. Penile Zipper Entrapment: a
simple and less threatening approach to using mineral oil.
Pediatr Emerg Care. 1993;9:90-91. (Case report)
91.
Saraf P, Rabinowitz R. Zipper Injuries to the Foreskin. Am J
Dis Child. 1982;136:557-558. (Case report)
92.
Strait RT. A Novel Method for Removal of Penile Zipper Entrapment. Pediatr Emerg Care. 1999;15:412-413. (Case report)
93.
Nolan JF, Stillwell TJ, Sands JP. Acute Management of the
Zipper Entrapped Penis. J Emerg Med. 1990;8:305-307. (Case
report)
94.
Douglas DD. Dissolving hair wrapped around an infant’s
digit. J Pediatr. 1977;91:162. (Case report)
95.
Blaivas M, Batts M, Lambert M. Ultrasonographic Diagnosis
of Testicular Torsion by Emergency Physicians. Am J Emerg
Med. 2000;18:196-200. (Case reports)
96.
Blaivas M, Sierzenski P, Lambert M. Emergency Evaluation
of Patients Presenting with Acute Scrotum Using Bedside
Ultrasonography. Acad Emerg Med. 2001;8:90-93. (Retrospective; 36 patients)
97.
Matterson JR, Stock JA, Nagler HM, et al. Medicolegal
Aspects of Testicular Torsion. Urology. 2001;57:783-786. (Retrospective; 39 cases)
98.
Adeyoju AB, Olujohungbe AB, Morris J, et al. Priapism in
sickle-cell disease; incidence, risk factors and complications
- an international multicentre study. BJU Int. 2002;90:898-902.
(Questionnaire/Survey; 130 patients)
99.
Maples BL, Hagemann TM. Treatment of priapism in pediatric patients with sickle cell disease. Am J Health Syst Pharm
2004;61:355-363. (Review)
epididymitis
A condition characterized by fever and symptoms of an
acute scrotum. Believed to be caused by urogenital anomalies.
hair tourniquet
occurs when a hair forms a tight, constricting band around
a penis
Henoch-Schönlein purpura
a systemic vasculitis of unknown etiology; presents with a
palpable purpuric rash — most often on the buttocks and
lower extremities — and concordant arthralgia/arthritis,
abdominal pain, and nephritis
hydrocele
a collection of fluid around the testicle
Kawasaki’s disease
a systemic vasculitis of unknown etiology; presents with
prolonged fever, non-purulent conjunctivitis, oral lesions,
cervical lymphadenopathy, swollen/red extremities, cutaneous rash, urethral meatitis
paraphimosis
Occurs when the foreskin is pulled over the coronal sulcus
of the glans penis and cannot return to its previous position. When the foreskin is trapped, it may form a tight,
constricting band that may impede blood flow to and from
the glans and prepuce, resulting in ischemic injury and
vascular engorgement. A true urological emergency.
testicular torsion
a condition caused when the spermatic cord becomes
twisted, obstructing venous and arterial blood flow to a
testicle (most common in the left testes)
100. Jones SA, Flynn RJ. An unusual (and somewhat piercing)
cause of paraphimosis. Br J Urol 1996;78:803-804. (Case
report)
toilet seat injury
any trauma to the genitalia due to a falling toilet seat
101. MacLeod TM, Adeniran S. An unusual complication of
penile piercing: a report and literature review. Br J Plast Surg
2004;57:462-464. (Case report)
varicocele
a defect in the valves of the venus plexus of the testicle;
may feel like “a bag of worms”
102. Gazi MA, Ankem MK, Pantuck AJ, et al. Management of
penile toilet seat injury - report of two cases. Can J Urol.
2001;8:1293-1294. (Case series; 2 patients)
Physician CME Questions
Glossary
balanitis
Inflammation of the glans penis
49. Which of the following statements is true regarding
the “bell-clapper anomaly”?
a. All boys with a bell-clapper anomaly eventually
develop testicular torsion
b. Boys with a bell-clapper anomaly will be infertile
c. Boys with a bell-clapper anomaly make a ringing
sound when they walk
d. Boys with a bell-clapper anomaly have a propensity to develop intra-vaginal torsion
balanoposthitis
Inflammation of the prepuce and glans penis
bell-clapper deformity
The testes, epididymis, testicular artery, and spermatic
cord can “twist” on its axis completely within the confines
Pediatric Emergency Medicine Practice
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EBMedPractice.net •November 2004
56. Balanitis refers to:
a. injury to the testicles
b. inflammation of the glans
c. parasitic scrotal infection
d. abrasion from zipper injury
e. precocious puberty
57. Which of the following typically requires the most
prompt treatment?
a. neonatal phimosis
b. paraphimosis
c. balanoposthitis
d. bell-clapper anomaly
e. torsion of appendix testis
51. Which of the following is most consistent with testicular torsion?
a. Absence of the cremasteric reflex
b. Frequent dysuria
c. Poor urinary flow at night
d. Foul penile discharge
e. Testicles low in the scrotum
58. Which of the following is usually the most important historical feature when evaluating boys with a
penile complaint?
a. travel history
b. family history
c. social history
d. circumcision history
e. type of underwear worn
52. Which of the following symptoms is most helpful in
differentiating testicular torsion from other causes
of acute scrotal pain?
a. chills
b. headache
c. myalgias
d. paresthesias
e. vomiting
59. Which of the following is considered the most helpful in the evaluation of penile complaints?
a. physical examination
b. nuclear scintigraphy
c. Doppler ultrasound
d. penile specific antigen
53. Which of the following organisms is most commonly
identified in cases of epididymitis in older adolescents?
a. Haemophilus influenzae
b. Methicillin Resistant Staphylococcus aureus
(MRSA)
c. Chlamydia trachomatis
d. Rickettsia rickettsiae
e. Streptococcus epididymitidae
60. Which of the following is a recommended treatment
for balanitis?
a. intracavernosal injection of alpha blocker
b. cephalexin
c. Doppler ultrasound
d. immediate manual reduction
61. Which of the following is true regarding litigation for
cases of testicular torsion?
a. testicular torsion rarely results in litigation because boys have two testicles
b. cases generally are won or lost based on the time
from symptom onset to treatment
c. emergency physicians and the physicians most
commonly named in the lawsuit
d. legal outcomes do not appear to be related to
duration of symptoms before presentation
54. Which of the following most likely explains the scrotal findings in cases of Henoch-Schönlein purpura?
a. testicular torsion
b. torsion of the appendix testis
c. vasculitis
d. Müllerian degeneration
e. epididymitis
55. Which of the following is most commonly associated
with testicular tumors?
a. severe pain on palpation
b. a painless testicular mass
c. recurrent epididymitis
d. inguinal hernia
e. bewildering fever
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62. Which of the following conditions is most strongly
associated with sickle cell anemia?
a. balanitis
b. priapism
c. zipper injury
d. paraphimosis
e. testicular torsion
19
Pediatric Emergency Medicine Practice
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50. Which of the following is true regarding the development of the foreskin?
a. It is normal for the foreskin to be easily retractable at birth
b. The presence of smegma is pathognomonic for
sexual abuse
c. If the foreskin cannot be retracted easily at birth,
prompt circumcision is indicated
d. Most boys should be able to retract their foreskin
by the time they enter school
e. Circumcised boys cannot contract balanitis
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Physician CME Information
63. Which of the following is an accepted treatment for
phimosis?
a. surgical exploration
b. 1% hydrocortisone cream
c. sitz baths
d. manual detorsion
This CME enduring material is sponsored by Mount Sinai School of Medicine
and has been planned and implemented in accordance with the Essentials
and Standards of the Accreditation Council for Continuing Medical Education.
Credit may be obtained by reading each issue and completing the printed
post-tests administered in December and June or online single-issue post-tests
administered at EBMedPractice.net.
Target Audience: This enduring material is designed for emergency medicine
physicians.
64. Which of the following is the most serious sequela of
paraphimosis?
a. ischemic injury to the glans penis
b. sickle cell anemia
c. testicular torsion
d. gynecomastia
e. sepsis
Needs Assessment: The need for this educational activity was determined by
a survey of medical staff, including the editorial board of this publication;
review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP;
and evaluation of prior activities for emergency physicians.
Date of Original Release: This issue of Pediatric Emergency Medicine Practice
was published November 30, 2004. This activity is eligible for CME credit
through November 1, 2007. The latest review of this material was November
19, 2004.
Discussion of Investigational Information: As part of the newsletter, faculty
may be presenting investigational information about pharmaceutical
products that is outside Food and Drug Administration approved labeling.
Information presented as part of this activity is intended solely as continuing
medical education and is not intended to promote off-label use of any
pharmaceutical product. Disclosure of Off-Label Usage: This issue of Emergency
Medicine Practice discusses no off-label use of any pharmaceutical product.
Coming in Future Issues:
Accidental Poisoning • Vomiting And Diarrhea
Faculty Disclosure: In compliance with all ACCME Essentials, Standards, and
Guidelines, all faculty for this CME activity were asked to complete a full
disclosure statement. The information received is as follows: Dr. Ota, Dr.
Wiebe, Dr. Kim, and Dr. Cohen report no significant financial interest or other
relationship with the manufacturer(s) of any commercial product(s) discussed
in this educational presentation.
Class Of Evidence Definitions
Each action in the clinical pathways section of Pediatric Emergency Medicine
Practice receives a score based on the following definitions.
Class I
• Always acceptable, safe
• Definitely useful
• Proven in both efficacy and effectiveness
Level of Evidence:
• One or more large prospective studies are present (with rare exceptions)
• High-quality meta-analyses
• Study results consistently positive
and compelling
Class II
• Safe, acceptable
• Probably useful
Level of Evidence:
• Generally higher levels of evidence
• Non-randomized or retrospective
studies: historic, cohort, or case• control studies
• Less robust RCTs
• Results consistently positive
Class III
• May be acceptable
• Possibly useful
• Considered optional or alternative
treatments
Level of Evidence:
• Generally lower or intermediate
levels of evidence
• Case series, animal studies, consensus panels
• Occasionally positive results
Accreditation: Mount Sinai School of Medicine is accredited by the
Accreditation Council for Continuing Medical Education to sponsor
continuing medical education for physicians.
Indeterminate
• Continuing area of research
• No recommendations until further
research
Credit Designation: Mount Sinai School of Medicine designates this
educational activity for up to 4 hours of Category 1 credit toward the AMA
Physician’s Recognition Award. Each physician should claim only those
hours of credit actually spent in the educational activity. Pediatric Emergency
Medicine Practice is approved by the American College of Emergency
Physicians for 48 hours of ACEP Category 1 credit (per annual subscription).
Pediatric Emergency Medicine Practice has been approved by the American
Academy of Family Physicians as having educational content acceptable for
Prescribed credit. Term of approval covers issues published within one year
from the distribution date of July 1, 2004. This issue has been reviewed and
is acceptable for up to 4 Prescribed credits. Credit may be claimed for one
year from the date of this issue. Pediatric Emergency Medicine Practice has
been approved for 48 Category 2-B credit hours by the American Osteopathic
Association.
Level of Evidence:
• Evidence not available
• Higher studies in progress
• Results inconsistent, contradictory
• Results not compelling
Significantly modified from: The
Emergency Cardiovascular Care
Committees of the American Heart Association and representatives from the
resuscitation councils of ILCOR: How
to Develop Evidence-Based Guidelines
for Emergency Cardiac Care: Quality of
Evidence and Classes of Recommendations; also: Anonymous. Guidelines for
cardiopulmonary resuscitation and
emergency cardiac care. Emergency
Cardiac Care Committee and Subcommittees, American Heart Association.
Part IX. Ensuring effectiveness of community-wide emergency cardiac care.
JAMA 1992;268(16):2289-2295.
Earning Credit: Two Convenient Methods
• Print Subscription Semester Program: Paid subscribers with current and
valid licenses in the United States who read all CME articles during each
Pediatric Emergency Medicine Practice six-month testing period, complete the
post-test and the CME Evaluation Form distributed with the December and
June issues, and return it according to the published instructions are eligible
for up to 4 hours of Category 1 credit toward the AMA Physician’s Recognition Award (PRA) for each issue. You must complete both the post-test and
CME Evaluation Form to receive credit. Results will be kept confidential. CME
certificates will be delivered to each participant scoring higher than 70%.
• Online Single-Issue Program: Paid subscribers with current and valid
licenses in the United States who read this Pediatric Emergency Medicine
Practice CME article and complete the online post-test and CME Evaluation
Form at EMPractice.net are eligible for up to 4 hours of Category 1 credit
toward the AMA Physician’s Recognition Award (PRA). You must complete
both the post-test and CME Evaluation Form to receive credit. Results will be
kept confidential. CME certificates may be printed directly from the Web site
to each participant scoring higher than 70%.
Pediatric Emergency Medicine Practice is not affiliated with any pharmaceutical firm or medical device manufacturer.
Publisher: Robert Williford. Executive Editor: Cheryl Strauss.
Direct all editorial or subscription-related questions to EB Practice, LLC: 1-800-249-5770 • Fax: 1-770-500-1316 • Non-U.S. subscribers, call: 1-678-366-7933
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Pediatric Emergency Medicine Practice (ISSN 1549-9650) is published monthly (12 times per year) by EB Practice, LLC, 305 Windlake Court, Alpharetta, GA 30022. Opinions expressed are not necessarily
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