Balanitis/balanoposthitis - Usual causes are poor hygiene, chemical irritation (eg bubble bath), local trauma, contact dermatitis, candidal or bacterial infection. Culture urethral discharge if a concern for STDs. Consider sexual abuse. Parental involvement is needed for supervision of gentle cleaning under the foreskin, sitz baths, and application of 0.5% hydrocortisone cream. Topical antifugals can be effective. If a fiery-red erythema and a moist exudate are present then streptococcal etiology should be considered (Fournier’s gangrene is possible in the immunocompromised). Treat bacterial infections with oral antibiotics (eg 1st gen cephalosporin).
Phimosis – the foreskin gradually becomes retractile as a result of erections, manipulation and keratinization of the inner epithelium. At 3 years of age 90% of foreskin can be retracted and all by late adolescence. Causes include local trauma, infection (see above), chemical irritation, and poor hygiene. Forceful retraction causes future adhesions and strictures. Give a 2-6 week course of corticosteroid cream (eg, 0.1% triamcinolone or 0.05% to 0.1% betamethasone). In cases of urinary retention dorsal slit or circumcision may be needed.
Paraphimosis – leads to venous congestion and swelling and potential for ischemic injury to the glans. The foreskin may be retracted because of infection, trauma, masturbation, a hair tourniquet, a urethral foreign body or iatrogenic after inspection or foley placement. Reduction can be accomplished with gentle circumferential pressure and manipulation. Adjuncts include compressive wraps, needle puncture, ice/compression and use of babcocks. Don’t forget local anesthesia (dorsal penile block) if needed. If manual reduction is not accomplished then dorsal slit or circumcision is needed.
McGrath NA, Howell JM, Davis JE. Pediatric genitourinary emergencies. Emerg Med Clin North Am. 2011 Aug;29(3):655-66.
Leslie JA, Cain MP. Pediatric urologic emergencies and urgencies. Pediatr Clin North Am. 2006 Jun;53(3):513-27, viii.
Roberts and Hedges 5th ed., ch 55