An inflamed prepuce and glans penis in a young uncircumcised boy can be induced by trauma, irritation or infection, including sexually transmitted diseases. Scant attention is paid to this problem in the emergency medicine literature1, 2 or in general pediatric textbooks3, 4 and journals.5, 6 Nelson's textbook of pediatrics fails to discuss this condition.3 Infection may be caused by Neisseria gonorrhoeae, Chlamydia trachomatis, Streptococcus pyogenes, Candida albicans and rarely other microbial agents. During a recent 16-month period, three uncircumcised young boys were diagnosed with balanoposthitis by a group of five pediatricians in a single private practice setting in northern Virginia. One of the three boys underwent extensive and expensive evaluations for sexually transmitted diseases; all laboratory results were negative. This paper underscores the similarities as well as the differences encountered in the diagnosis and management of these cases. The purpose of this article is to educate primary care physicians about balanoposthitis and to highlight diagnostic clues that might avoid the need for specific laboratory tests and reduce parental anxiety that results when the physician suggests that their child may have a sexually transmitted disease.
Case reports. Case 1. A 4-year-old boy was bought to his pediatrician's office because of a “sore penis” for a few days. He had no known sexual contact. Examination revealed an uncircumcised boy with a retractable foreskin and redness and irritation of the glans and the inner surface of the prepuce. Smegma had not accumulated in the preputial fold. Milking the length of the urethra produced no discharge at the meatal opening. The diagnosis was mild irritation-induced balanoposthitis. The condition improved quickly with gentle cleaning of the glans and application of 0.5% hydrocortisone cream to the irritated area.
Case 2. A 7-year-old uncircumcised boy presented at the pediatrician's office complaining of penile discomfort. Despite physician-recommended application of 1.0% hydrocortisone cream and mupirocin ointment, the prepuce became progressively more inflamed and swollen, and the pain worsened. Improvement was rapid after treatment with oral erythromycin ethylsuccinate (40 mg/kg/day). One year later, shortly after the boy had completed a 10-day course of penicillin treatment for streptococcal pharyngitis, signs and symptoms of acute balanoposthitis recurred. Although a culture of the inflamed area was not obtained, the presumptive diagnosis was streptococcal balanoposthitis. The child rapidly improved after treatment was initiated with cephalexin (20 mg/kg/day) for 10 days.
Case 3. A 4-year-old uncircumcised boy complained that “it hurt to touch my penis.” Symptoms had been present for 1 day. There was no dysuria, and the accompanying parent admitted to no knowledge of sexual molestation. Thick yellow material was visible in the preputial sulcus covering the preputial opening. Manual stripping of the length of the urethra produced no true urethral discharge. Because of the physician's concern about the possibility of an infectious etiology, specimens of the presumed “pus” were sent to the laboratory for tests for gonococcus, Chlamydia and S. pyogenes. The tests included a rapid streptococcal antigen detection test, DNA probes for N. gonorrhoeae and C. trachomatis, a Gram stain of the yellow material and a culture on chocolate agar. A urinalysis was also ordered. On the basis of a presumptive diagnosis of gonococcal or chlamydial urethritis, the child received an intramuscular injection of ceftriaxone (125 mg) and a prescription for erythromycin (40 mg/kg/day for 10 days). Local hygienic measures included gentle washing of the area and sitz baths. Laboratory results did not confirm the initial diagnosis of sexually transmitted disease.
Discussion. Balanoposthitis in children occurs most often between the ages of 2 and 5 years. In a survey of 272 uncircumcised boys balanitis was diagnosed in 6% and irritation of the glans or prepuce in 4%.6 Most cases represent nonspecific balanoposthitis, usually caused by inadequate hygiene of the preputial-glanular sulcus. In such cases inflammation of the glans and prepuce is accompanied by irritation and swelling of the inner moist fold of the prepuce. Colonization by C. albicans or anaerobic Gram-positive skin bacteria may be present and is usually associated with inability to retract an adherent foreskin and subsequent accumulation of smegma. Inflammation can also be caused by external irritation from soap, bubble bath, laundry detergent or antistatic sheets such as Bounce®.7
Physical examination of these patients reveals redness, soreness and slight swelling. In rare cases trauma secondary to compulsive masturbation (foreskin fiddling8) or zip-fastener injuries may precipitate the condition.9 The most common symptoms of 100 consecutive English boys diagnosed with balanitis were redness (100%), swelling (91%) and discharge (73%).8 In our own experiences discharge was far less frequent. When caused by benign irritation or streptococcal balanoposthitis, there should be no urethral drainage upon milking the length of the urethra starting at the base of the penis. Although commonly associated with partially or completely or nonretractable foreskin, true phimosis is usually not present.6-10 Most boys have a single episode.
In cases of nonspecific balanoposthitis, we suggest use of local hygienic measures including sitz baths, gentle cleaning of the preputial sulcus and glans and application of 0.5% hydrocortisone cream. If nonfixed phimosis secondary to swelling has developed, saline solution may be injected by means of a butterfly device with the needle cut off and the cut end of the tubing gently inserted into the preputial sulcus. C. albicans may be cultured from the glans; however, it probably is an innocent saprophyte and instillation of specific anti-Candida cream is usually unnecessary once local hygienic measures are initiated. Recalcitrant irritation balanoposthitis may require a short course of erythromycin or one of the penicillins which should kill the anaerobic bacteria that may produce irritant enzymes. Circumcision or performance of a dorsal slit procedure is indicated only for recalcitrant or recurrent balanoposthitis (more than two acute episodes), unless the initial acute episode results in pathologic phimosis.10-12 Wiswell et al.13 reviewed the reasons for circumcision in 476 boys beyond the neonatal period, 23% of whom underwent the procedure for recurrent balanoposthitis.
The presence of a thin purulent discharge within the preputial-glanular sulcus in the absence of a true urethral discharge may signal a streptococcal infection. The primary signs of streptococcal balanoposthitis are pain in the area, intense fiery redness and a moist glistening transudate or exudate under the prepuce and over the glans. Streptococcal balanoposthitis has been reported in young boys, even without complaints of sore throat.5 Consideration of streptococcal etiology should prompt the physician to order a rapid antigen detection test, culture or both from a sample of secretions from the preputial sulcus or moist surface of the prepuce or glans. Treatment for this condition is standard 10-day administration of an anti-streptococcal antibiotic such as penicillin V suspension, given by mouth.
When urethral discharge is present and the rapid antigen detection test is negative, a smear of the discharge should be made and sent to the laboratory for Gram stain. The presence of polymorphonuclear leukocytes on Gram stain preparation with a negative test for S. pyogenes should prompt consideration of sexually transmitted disease. The presence of urethral discharge after stripping the length of the urethra is an important diagnostic clue in the detection of sexually transmitted diseases. In preschool children gonorrhea or chlamydial urethritis unaccompanied by frank urethral discharge is unusual.14 After puberty, N. gonorrhoeae may be isolated in the absence of urethral discharge. Clinical or historical suspicion of sexual abuse also mandates evaluation for N. gonorrhoeae and C. trachomatis with Gram stain, cultures, DNA probes or other rapid antigen tests for Chlamydia. If the cultures are positive, recommended treatment would include ceftriaxone, 125 mg im for N. gonorrhoeae, followed by a suspension of a macrolide antibiotic by mouth.
In summary three boys with balanoposthitis, with and without discharge, were diagnosed and treated at a private pediatric office in a recent 16-month period. The experiences of these and other patients enabled the authors to draw several conclusions concerning effective diagnosis of this condition. Attention to these clues can usually identify boys in whom the diagnosis of sexually transmitted disease is highly unlikely and avoid the necessity of unneeded laboratory tests. However, it is advisable to perform a test for S. pyogenes, because streptococcal balanoposthitis may be indistinguishable from the more common condition caused by inadequate local hygiene. Streptococcal balanoposthitis need not produce a discharge. Other than cases of streptococcal etiology or sexually transmitted diseases, most boys with this condition can be managed by attention to local hygiene and, in some cases, use of a mild hydrocortisone cream.
Richard H. Schwartz, M.D.; H. Gil Rushton, M.D.
Departments of Pediatrics (RHS) and Urology (HGR)
Children's National Medical Center
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