In this blog, we’re going to dive into the topic of pediatric urologic emergencies. We’re going to focus on some of the more uncommon emergencies such as: phimosis, paraphimosis, priapism, entrapment injuries, testicular torsion, epididymitis, varicocele, and hydrocele. It’s important to note that UTI’s and Kidney stones are also common in peds, and often require additional work-up as often indicate abnormal anatomy or disease processes.
Balanoposthitis
Bananitis equals inflammation of the glans penis, while posthitis equals inflammation of the foreskin. Balanoposthitis equals the inflammation of both. It is primarily caused by inadequate hygiene leading to external irritation. This irritation can subsequently lead to colonization with Candida species, Staph species, and Strep species (less commonly caused by Mycoplasma genialium). Treatment is often conservative with improved hygiene of area. (typically recommend saline with adequate drying afterwards). Some recommend against soap as may increase inflammation of area. If superimposed infection, then treat with associated antimicrobial (nystatin cream for Candida; keflex/clindamycin for bacterial).
Phimosis
Phimosis is defined as inability to retract foreskin over the glans penis. Important to note that this can be normal up 3-4 yoa. In fact, only 4% at birth fave fully retractable foreskin.
The main complication to look for is signs of ischemia (discoloration), which indicates need for emergent Dorsal Slit procedure.
More often phimosis presents without ischemia and can be managed on a non-emergent basis. Often treated non-surgically with topical steroids (betamethasone 0.05% to 0.1% bid for 1-2 months) with daily preputial retraction or surgically with circumcision
Paraphimosis
Unlike phimosis, paraphimosis always indicates a urologic emergency (“Paraphimosis requires the paramedics”). Paraphimosis indicates inability to reduce the foreskin distally over the glans penis into its natural position. This can result in glans edema and venous engorgement that can progress to arterial compromise and gangrene. It can be preceded by infection, trauma, or hair tourniquet.
Like all penile injuries, it is important to first adequately treat the pain (penile nerve block). Then attempt to reduce the foreskin back into its natural position. Most commonly used technique is to pour sugar into water to make a hyperosmotic solution. Dunk gauze into this solution, and wrap around penis. Then use an ACE bandage to wrap around tightly. If manual retraction is not successful, then can cut superficial dorsal incision of band to allow foreskin retraction. Urology follow-up for definitive treatment with circumcision.
Priapism
Priapism is defined as an erection lasting >4 hours. While most cases in adults are caused by drugs (e.g. Papaverine injections, prostaglandin E1 injection, Sildenafil, HTN meds, and neuroleptic medications (e.g. trazodone, thorazine), cases in kids are largely associated with hematologic disorders like Sickle Cell Disease. Prolonged erections without treatment can lead to complications such as anatomical changes and impotence (35% of untreated cases).
There are 2 types of priapism: Low-Flow and High-Flow Priapisms. Low-Flow Priapism is much more common (95% of call cases) and is caused by above disorders. High-Flow priapism is typically a result of trauma or urologic surgeries that lead to high-flow AV fistulas.
Treatment is often with drainage of blood (first perform penile block). Drainage can be done by inserting 18-gage needle at either 10 o’clock or 2 o’clock position of penis (to avoid nerve and vascular structures). Only 1 side needs to be aspirated as there is a communication between both sides (see video below, it is not safe for work). Have multiple syringes nearby to continually aspirate blood from the area. If aspiration is not successful, then can inject phenylephrine (concentration 100-500 mcg/mL) 1 mL into same position using 29 gage needle q5 minutes. To make this phenylephrine concentration, order normal phenylephrine and draw up 1mL and dilute into NS syringe with 9cc (this will make phenylephrine 100 mcg/mL). Again, only need to inject into 1 side as there is a cavernosum connection. Once detumescence is achieved, wrap in ACE bandage, and observe pt for 2 hours to ensure no reoccurrence.
Priapism Drainage and Phenylephrine Injection (NSFW)
Entrapment Injuries
Zipper Entrapment
First, ensure analgesia (perform nerve block if able). If the zipper head is involved, then can cut the median bar (see below) which will cause zipper to fall apart.
Penile Hair Tourniquet
These can be difficult diagnoses as the hair may not be visible within the edema. Can attempt to cut the hair. Can also apply Depilatory Cream (dissolves hair within 2-8 minutes) and wash away with cloth afterwards.
Scrotal Edema General
The most common cause of scrotal edema in pediatrics is contact dermatitis as well as idiopathic. Most episodes resolve in 1-4 days with scrotal elevation, NSAIDs, and rest. Other more serious causes are listed below.
Testicular Torsion
Often in adolescent period. Rarely preceded by trauma. Presents with nausea/emesis, severe testicular pain with radiation into lower abdomen. Physical exam often shows firm, tender testis in transverse lie. Often associated with absence of cremasteric reflex and Bell Clapper deformity.
Treatment consists of early analgesia and antiemetics. Ultrasound has great specificity (>98%) but note that it cannot always rule out torsion as sensitivity (83%). Therefore, still need to have high index of suspicion with consistent history and physical even if ultrasound negative. If urology is not available, then can attempt detorsion yourself with “Open Book” Method. 2/3 of cases twist in lateral to median fashion, therefore, opening book method should work in majority of cases. It typically involves 1.5 turns for pain relief. If not improved or worsened, then try the opposite direction.
Appendage Torsion
There are 4 testicular appendages: appendix testis, appendix epididymis, paradidymis (organ of Giraldes), and vas aberrans. Like all appendices, they serve no physiologic purpose. Appendix Testis is responsible for ~90% of appendageal torsions followed by Appendix Epididymis for 8%. Presents similar to testicular torsion (though often lacks nausea and vomiting) with pathognomonic “Blue Dot Sign.” Treatment is with scrotal elevation, reassurance, and NSAIDs. Typically resolves in 3-5 days
Hydrocele
Hydrocele is a fluid collection within the processus or tunica vaginalis (the peritoneal projection that follows the testis during its descent into the scrotum). Communicating hydrocele results when the upper processus vaginalis fails to obliterate leaving an open tract between the peritoneum and scrotum, while non-communicated hydrocele has a closed tract. Most hydroceles are right-sided, present at birth, painless, and worse with crying or exertion. Most hydroceles (both communicating and non-communicating) resolve by 12 months of age. Communicating hydroceles after 12 months of age should be surgically corrected as they can put the infant at higher risk of indirect inguinal hernias.
Varicocele
Varicocele is a collection of venous varicosities of spermatic veins in scrotum. It is caused by incomplete drainage of the pam-uniform plexus. 85-95% of varicocele are left-sided due to orientation of renal veins. It is rare in kids <10 yoa, often presents at onset of puberty. Physical exam often described as “bag of worms” and more prominent with standing or Valsalva. It does not transilluminate. Usually not painful, but described as uncomfortable with dullness/heaviness. Treatment is with scrotal support and urology follow-up. It is associated with increased risk of subfertility and may require surgical correction