OSCE #1

Case Scenario:

Theo O. is a 5 year old male who presents to the pediatric emergency department with a complaint of penile pain x 1 day. 

History Elements:

  • Onset: last night around 10pm
  • Location: penis, no radiation
  • Duration: constant pain, worse with urination
  • Character: pressure
  • Pain is worse with urination
  • No alleviating factors
  • No history of trauma to the area
  • No testicular pain
  • Some scant yellow discharge 
  • Normal quantity and frequency of urine – patient is able to void
  • Patient is uncircumcised 
  • ROS Pertinent positives: pain on palpation, dysuria described as a pressure, erythema, swelling of the penis, scant yellow discharge
  • ROS Pertinent negatives: urinary retention, fever, nausea, vomiting, diarrhea, chills, back/abdominal pain, changes in urinary color or frequency, testicular pain, radiating pain, lesions
  • No past medical, surgical history
  • No known allergies

Physical Exam:

Vitals:

BP: 93/53, right arm, sitting

HR: 80 beats/minute, regular

RR: 16 breaths/minute, unlabored

Temperature: 37.1℃, oral

SpO2 Sat: 97%, Room air

Height: 121.2cm

Weight 30.8kg

BMI: 22.5 kg/m2

General appearance: TO is a 5 year-old male who appears his stated age. He is alert and oriented, sitting calmly with his mom. Well-groomed with good hygiene. Patient is well-developed with good build.  Dressed appropriately. In no acute distress.

Skin: Warm and moist, good turgor. Nonicteric, no lesions or scars noted. Capillary refill < 2 seconds throughout. 

HEENT:   Normocephalic, atraumatic. Non tender to palpation throughout. No signs of alopecia, seborrhea, or lice. EOM intact, auditory acuity intact to whispered voice. Conjunctiva and cornea clear, non-icteric. PERRL. No epistaxis. Moist mucous membranes without erythema or exudate. Trachea midline, no lymphadenopathy. 

Chest: Symmetrical. No gross deformities of chest, no evidence of trauma.  No paradoxical respiration or use of accessory muscles noted.  Non-tender to palpation.

Lungs:  Breath sounds equal bilaterally. No adventitious sounds present.

Heart: Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4.  No splitting of S2 or friction rubs appreciated. 

Abdomen: Soft, symmetrical, non-distended abdomen. Non-tender to palpation throughout and normoactive bowel sounds present in all four quadrants. No evidence of guarding or rebound noted. No CVA tenderness.

Genitourinary:

  • Patient is uncircumcised
  • Shaft and head of penis are erythematous and swollen
  • Tenderness to palpation of the penis
  • When foreskin is retracted, patient has extreme pain
  • Urethra is unable to be appropriately visualized with foreskin retraction
  • Scant yellow discharge noted with retraction
  • No swelling, erythema, or tenderness to palpation of the testicles

Differential Diagnosis:

  1. Phimosis 
    1. Patient is uncircumcised. Penis is erythematous with a swollen foreskin and there is severe pain with retraction. The phimosis could be secondary to balanitis/balanoposthitis and is common in pediatric children especially younger than 7 years. 
  2. Balanitis/ balanoposthitis
    1. Patient has yellow urethral discharge, erythema, and penile pain with swelling. This could be a cause of phimosis. 
  3. Paraphimosis
    1. Patient has penile swelling and redness. However, as the patient is still able to retract the foreskin, this is not the likely current diagnosis.
  4. Urinary tract infection
    1. In young children, UTI is possible if part of the urinary tract is blocked. Uncircumcised boys have a higher risk of UTIs than circumcised, and if there is overlying phimosis it’s possible this could be the cause.
  5. Testicular torsion 
    1. Prior to physical exam findings, this diagnosis should always be considered in young children. Even though it is described as penile pain, sometimes children will unable to adequately describe where the pain is.

Tests:

  1. Urinalysis – negative
  2. Urine culture – no growth 
  3. CBC (not necessary but can help r/o bacterial etiology) – within normal limits

Treatment:

  • Empirical treatment with topical antibiotic — Polysporin, Bacitracin, mupirocin
  • Topical corticosteroids –  Betamethasone cream (0.05%) or Hydrocortisone 1%
    • Applied sparingly 2x daily for 1 week 
  • Gentle retraction as tolerated
  • Twice daily bathing with saline solution, maintain good hygiene, Sitz baths
  • Consider using a Q-tip to clean between foreskin and glans, irrigate with clean water regularly
  • Consider urological consult if symptoms worsen/ don’t improve
    • If recurrent issues – surgical circumcision as the last resort
  • Tylenol PRN for the pain

Pt Counseling/Education:

  • Routine washing of the penis and foreskin is necessary
    • Avoid forcible retraction but attempt to retract in order to clean and dry the area
  • Always return foreskin to normal position after retraction 
  • Pay attention to the child’s urinary habits to make sure there is no pain with voiding or urinary retention in the future
  • Avoid irritants – soap should not be used to clean under foreskin
  • This may occur again, but hopefully will be prevented with the above measures
  • If worsening, if urinary retention, or if foreskin becomes fixed and unable to retract, return to emergency room immediately 

References:

Tews, M. & Singer, J. (2021). Balanitis and balanoposthitis in children and adolescents: Management. UpToDate. Retrieved June 12, 2021 from https://www.uptodate.com/contents/balanitis-and-balanoposthitis-in-children-and-adolescents-management?search=balanitis%20in%20children&source=search_result&selectedTitle=1~59&usage_type=default&display_rank=1 

Tews, M. & Singer, J. (2021). Balanitis and balanoposthitis in children and adolescents: Clinical manifestations, evaluation, and diagnosis. UpToDate. Retrieved June 12, 2021 from https://www.uptodate.com/contents/balanitis-and-balanoposthitis-in-children-and-adolescents-clinical-manifestations-evaluation-and-diagnosis?search=balanitis%20treatment%20children&source=search_result&selectedTitle=2~59&usage_type=default&display_rank=2 

Wilcox, D. (2021). Care of the uncircumcised penis in infants and children. UpToDate.  Retrieved 6/12/2021 from https://www.uptodate.com/contents/care-of-the-uncircumcised-penis-in-infants-and-children?search=phimosis%20in%20children&source=search_result&selectedTitle=1~27&usage_type=default&display_rank=1