Rosen & Barkin's 5-Minute Emergency Medicine Consult (545 page)

• Dysuria, hematuria
  
• Poor urinary stream
  
• Whitish, narrowed preputial opening of the foreskin
  
• Edema, erythema, and tenderness of prepuce
  
• Balanoposthitis
  (inflammation of the glans and foreskin)
  
• Ballooning of foreskin on urination in severe cases
  

Exam should include an evaluation for potential complications:

• Obstruction and vascular compromise of glans
  
• Occur only in the most extreme cases
  

• In the majority of cases, no workup is necessary.
  
• In patients with severe stenosis, the complication of an
  obstructive uropathy
  may occur. This should be investigated by:
  
  • Evaluation of kidney function:
    
    • BUN and creatinine
      
  • Renal sonogram
    
• Phimosis secondary to recurrent balanoposthitis should prompt a workup for
  diabetes mellitus
  :
  
  • Urinalysis, serum glucose, or glycosylated hemoglobin (Hgb A1C)
    

• Preputial adhesions are normal in young children.
  
• Balanoposthitis without phimosis
  

TREATMENT

• Pre-hospital personnel and family members should be instructed not to attempt retraction of the foreskin prior to medical evaluation.
  
• Unwarranted attempts may traumatize a normal, nonretractable prepuce or convert the situation to a more emergent
  paraphimosis
  .
  

None required in most cases

• Relieve obstructive uropathy, if present, with urethral catheterization or suprapubic aspiration.
  
• If vascular flow to the glans is compromised, a dorsal slit must be made in the foreskin:
  
  • Performed after achieving adequate penile block (see Paraphimosis for more detailed description of procedure)
    
  • This is rarely necessary in phimosis.
    
• Potent topical steroids for a multiweek course have been reported to successfully reduce phimosis:
  
  • Betamethasone dipropionate 0.05–0.1%: Apply to preputial orifice twice daily for 4–6 wk.
    

For foreskin incision, procedural sedation will likely be needed in place of penile block.

Pain control as required

FOLLOW-UP

• Obstructive uropathy
  
• Severe balanoposthitis with ischemia or necrosis
  

• Ability to urinate
  
• Adequate urologic follow-up
  

Urologic follow-up for response to steroid therapy, dilation of the preputial opening, operative repair, or elective circumcision as necessary

Physiologic phimosis requires waiting for age-appropriate development and continued preputial hygiene.

• Foreskin is normally nonretractable from the neonatal period to age 3 yr.
  
• Do not forcibly retract foreskin especially in children 3–17 yr, as phimosis may still be physiologically normal.
  
• Vascular compromise of the glans penis requires a dorsal slit to the foreskin to prevent necrosis.
  

• Donohoe JM, Burnette JO, Brown JA. Paraphimosis treatment.
  eMedicine
  . Available at
  http://www.emedicine.medscape.com/article/442883
  . Updated October 7, 2009.
  
• Ghory HZ, Sharma R. Phimosis and paraphimosis.
  eMedicine
  . Available at
  http://www.emedicine.medscape.com/article/777539
  . Updated April 28, 2010.
  
• Huang CJ. Problems of the foreskin and glans penis.
  Clin Ped Emerg Med
  . 2009;10:56–59.
  
• Marx JA, Hockberger RS, Walls RM.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice
  . 7th ed. St. Louis, MO: Mosby; 2009:2201–2202.
  
• Ramos-Fernandez MR, Medero-Colon R, Mendez-Carreno L. Critical urologic skills and procedures in the emergency department.
  Emerg Med Clin North Am.
  2013;31(1):237–260.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Paraphimosis
  
• Priapism
  

CODES

605 Redundant prepuce and phimosis

BASICS

• A self-limited skin exanthem of unknown origin primarily affecting children and young adults
  
• Skin findings often begin with an isolated “herald patch,” an ovoid erythematous raised lesion seen along the trunk and extremities
  
• A secondary eruption usually follows, where multiple smaller exanthems appear along the Langer lines of the trunk and proximal extremities in a symmetric “Christmas tree pattern”
  
• Nearly 80% of symptoms resolve within 2 mo
  

• Unknown, although there is weak evidence for a viral etiology such as herpes 6 and 7
  
• Many medications have been associated with a pityriasis-like reaction:
  
  • Barbiturates
    
  • Captopril
    
  • Clonidine
    
  • Gold
    
  • Isotretinoin
    
  • Metronidazole
    
  • Bismuth
    
  • Hepatitis B vaccine
    
  • Gleevec
    
  • Interferon
    
• Eczema, asthma, and underlying malignancies may be weakly associated
  

DIAGNOSIS

Prodromal symptoms and characteristic skin findings are discussed below

Prodromal symptoms occur in 60–70% of patients:

• Malaise
  
• GI symptoms
  
• Respiratory symptoms
  

Dermatologic findings

• Herald patch:
  
  • Solitary, erythematous, slightly raised papule 2–10 cm in diameter
    
  • Seen in 50–90% of cases
    
• Secondary eruption:
  
  • Widespread salmon-colored, elliptic, finely scaling papules
    
  • Usually appear symmetrically along Langer lines in a “Christmas tree” pattern
    
  • Generally follows herald patch by 7–14 days
    
  • Lesions are concentrated on the trunk and proximal extremities
    
  • Pruritus is common
    
• Lesions concentrated on the face and distal extremities with minimal trunk involvement characterize
  inverse pityriasis
  

• Inverse pityriasis, lesions on the face and distal extremities characterize
  inverse pityriasis
  and may be seen more often in pediatric populations
  
• Rarely, pediatric presentations may have oral lesions, usually punctate hemorrhage and ulceration
  

Exclude other diagnoses, especially when a herald patch is not seen:

• Secondary syphilis can have similar skin findings. Consider RPR in a patient with STI risk factors
  
• KOH prep may diagnose tinea
  

None required:

• KOH and RPR if other diagnoses are considered