A 3-year-old male came to clinic with swelling of the penile shaft that was noted after awakening. He complained that his penis “felt funny” but had no distinct pain, burning, itching. He had a full diaper in the morning and had urinated since the edema was noticed. The family denied trauma including potential abuse, bug bites, or being around allergic plants or fevers. The day before he had been playing outside without incident, had been bathed at night and went to bed. The past medical history was positive for eczema and getting welts easily with bug bites.
The pertinent physical exam showed a well-appearing male with normal vital signs and growth parameters in the 25-75%. His testes were easily palpable and retractile and no hernias were present. He was circumcised and had generalized swelling and erythema of the shaft of his penis and glans which ended at the lower abdomen. There was not excessive warmth or tenderness. During the examination he had an erection which then subsided and still left the shaft somewhat erect. The bodies of the corpus cavernosum and spongiosum did not feel distinctly taut, but the entire shaft seemed edematous. There was no external blood vessel engorgement,meatal discharge, localized skin changes or areas of trauma noted on the genitals, perineum, lower abdomen and upper legs. The rest of his physical examination was normal.
The physicians examining the patient were not sure what was causing the penile edema and weren’t sure what to call it. This extended farther down the shaft than infectious balanitis and although they did not think this was priapism, they were still worried that perhaps it was a variant that may need urological treatment. The resident urologist was uncertain of the cause also, but the attending urologist immediately recognized the diagnosis of a localized histamine reaction. He confirmed that this was not priapism as the corpora were not engorged and that the edema was generalized. He said that this was a variation of a localized angioedema reaction and because the patient had no other systemic symptoms, that it could be treated with antihistamines like other exaggerated histamine reactions and monitored closely. The urologist thought that maybe this was caused by a bug bite but probably not as he also did not see any trauma.
Because histamine reactions such as urticaria or angioedema are usually thought of as systemic problems, localized involvement of many different body parts is often not considered in the differential diagnosis. The location and often unusual presentation may cause the clinician to consider more worrisome causes and therefore appropriately begin more evaluation and workup. Additional information about localized angioedema can be found here. Penile edema can also be caused by frequent or vigorous intercourse, insect bites, generalized edema or vasculitis such as Henoch Schonlein Purpura, in addition to some of the other problems listed below.
Clinicians may often confuse the terminology of common penile problems.
Phimosis is a normal or abnormal condition where the distal foreskin cannot be retracted over the glans penis. Physiologic phimosis is normal at birth and the foreskin separates from the glans over time. Around 90% of boys have this occur by age 3 and 98-99% by adolescence. Acquired phimosis often occurs because of inadequate hygiene, chronic balanitis or forceful retraction of the foreskin, and occurs only in uncircumcised males. Phimosis itself should not cause urinary retention or obstruction of the urinary stream. But proper hygiene is necessary to decrease the risk of balanitis, posthitis, and skin infections. Forceful foreskin retraction can cause fibrosis of the foreskin or paraphimosis. Phimosis is not a surgical emergency. It is usually treated with improved hygiene, but topical steroids are also used in certain patients.
Paraphimosis is an abnormal condition where a retracted foreskin cannot be replaced to its normal position over the glans penis. It occurs only in uncircumcised males including those who have undergone circumcision but still retain some foreskin tissue. It is a surgical emergency. The retained retracted foreskin acts like a tourniquet, with potential venous engorgement which may over time, cause edema of the glans and foreskin. The increased pressure can then increase to cause arterial occlusion, with risk of loss of parts or the entire glans because of ischemia. It is usually treated by manual reduction, but surgical interventions may be necessary. Paraphimosis usually is an indication for circumcision in the future.
Balanitis is inflammation of the glans penis, often caused by infection. This can occur in uncircumcised or circumcised males. Posthitis is inflammation of the foreskin, also often caused by infection. This occurs only in uncircumcised males. Balanoposthitis is inflammation of the glans penis and the foreskin, often caused by infection. This occurs only in uncircumcised males. The affected area is usually warm, erythematous, edematous and tender. A thin exudate may be seen that is seropurulent. Infectious causes may be mixed flora (usually young children), candida and trichomonas (usually in sexually active males). Topical and oral antibiotics along with warm soaks, and pain control are the usual treatment.
Priapism a persistent, prolonged, penile erection lasting more that 4 hours, that is not associated with sexual stimulation or interest.
Questions for Further Discussion
1. What causes priapism in children?
2. What are indication for urology consultation?
3. What are possible indications for non-elective circumcision?
- Symptom/Presentation: Mass or Swelling
- Specialty: Nephrology / Urology
- Age: Preschooler
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at MedlinePlus for this topic: Penis Disorders
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Kim YC, Davies MG, Lee TH, Hagen PO, Carson CC 3rd. Characterization and function of histamine receptors in corpus cavernosum. J Urol. 1995 Feb;153(2):506-10.
Neveus A, von Gontard A, Hoebeke, et.al., The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children’s Continence Society, J Urol. 2006;176:314.
Angel CA, Santos C Jr., Circumcision. eMedicine. Available from the Internet at: http://emedicine.medscape.com/article/1015820-overview (rev. 1/25/2010, cited 2/22/2011).
Levey H, Bivilacquq T. Priapsism. ePocrates.
Available from the Internet at https://online.epocrates.com/u/2921505/Priapism/Basics/Definition (rev. 8/2/2010, cited 2/22/2011).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
16. Learning of students and other health care professionals is facilitated.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital