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Balanoposthitis in a Toddler.

Balanitis is inflammation of the glans penis that results in swelling and infection. It is a common condition affecting an estimated 3% to 11% of males, with the majority being uncircumcised adults (Leber & Tirumani, 2017). The infection is termed balanitis when only the glans penis is involved and balanoposthitis when the prepuce is also affected. Symptoms of balanoposthitis include erythema and edema of glans penis and prepuce, foul odor, discharge, ulceration and/or plaques, lymphadenopathy, and rarely phimosis and/or urinary obstruction.

The general initiating factor in the inflammatory process of balanoposthitis is the lack of aeration in an uncircumcised male, with resulting irritation and inflammation (Porche, 2007). Causes of balanoposthitis include infection, irritation, trauma, premalignancy, or malignancy, or the cause can be idiopathic (Morris & Krieger, 2017). The most common causative agents are yeast, especially Candida albicans (Morris & Krieger, 2017; Porche, 2007). The genital area and prepuce provide an optimal medium for overgrowth of normal organisms found on the glans penis (Morris & Krieger, 2017). Other causative microbial agents include Group B and Group A beta-hemolytic streptococci, Neisseria gonorrhoeae, Chlamydia species, human papilloma virus, Gardnerella vaginalis, Treponema pallidum, Trichomoniasis, and the Borrelia species (Leber & Tirumani, 2017). Irritant causes include poor hygiene, retained soap or accumulation of smegma under the foreskin, or inadequate aeration and drying (Porche, 2007). Balanoposthitis may also be associated with contact dermatitis and/or obesity (Morris & Krieger, 2017).

Clinical History and Presentation

A 2-year-old Latino male presented to the primary care office with a one-day complaint of irritability and penile swelling. A Spanish translator was obtained for the parent interview. The patient had no recent illness, changes in appetite, or recent fevers. There was no known trauma to the abdomen or genitals.

The child's medical history was unremarkable, with an uncomplicated term pregnancy and no history of chronic illness, previous surgeries, or hospitalizations. The child lived at home with his parents and two school-aged sisters. His parents were poor historians and were unable to provide a family history. The child's immunizations were up to date. He had no known allergies and was on no routine medications. The review of systems was negative except as noted above. His growth and development were normal for age. His height was 34.25 inches, weight was 26.9 pounds (12.2 kg), and body mass index (BMI) was 16.1 kg/m2 (37th percentile). His vital signs were within normal for age: temperature 36.8[degrees] Celsius axillary, blood pressure 84/58, pulse 120 beats per minute, and respirations 24 breaths per minute.

On examination, the child appeared in no acute distress. He had no skin rash or lymphadenopathy. His abdomen was soft, non-tender, and non-distended with no hepatosplenomegaly. There was no ecchymosis noted to the abdomen or the genitals. The child was uncircumcised, with both testicles descended. The foreskin was semi-mobile with moderate erythema and swelling (ballooning) of the prepuce; the meatus was barely visible. The glans penis was moderately erythematous and edematous with the appearance of phimosis. Upon gentle palpation of the penile shaft, a large amount of mucopurulent discharge was easily expressed from the urethra and from under the foreskin. The child did not complain of pain with palpation of the penis or expression of discharge. The remainder of the physical exam was unremarkable.

Clinical Evaluation and Intervention

Based on the history and the physical examination, the differential diagnoses included balanoposthitis, balanitis, urinary tract infection (UTI), sexually transmitted infection (STI) secondary to possible abuse, hair tourniquet, and foreign body. A sample of the discharge was sent for bacterial culture and sensitivity. According to a review of current guidelines for diagnosing UTIs, non-toilet trained children should have a urine specimen collected by collection bag, catheterization, or suprapubic aspirate to help establish a UTI diagnosis (Okarska-Napierala, Wasilewska, & Kuchar, 2017). The primary care office did not have urine collection bags for obtaining a clean-catch urine specimen, or the capability of performing straight catheterization or suprapubic aspirate. Pelvic X-rays ruled out a foreign body in the urethra and bladder. Foreign bodies can travel into the bladder through migration from adjacent organs, through the urethra, or due to trauma (Bansal et al., 2016).

The primary care provider consulted with pediatric urology because of the amount of penile swelling, discharge, and age of the patient. The urologist provided direction for diagnosis, treatment, and recommended follow up. As results of testing became available, the urologist recommended placing the child on both a systemic and a topical antibiotic due the amount of discharge and swelling of the penis. The child was placed on amoxicillin and clavulanate (Augmentin ES-600) 42.9 mg/5 mL suspension 90 mg/kg orally for seven days and topical bacitracin ointment twice a day.

First generation cephalosporin antibiotics are an alternate choice when penicillin allergy is present. Simple balanitis, without swelling or cellulitis, can often be treated topically with an antibacterial, antifungal, or mild steroidal cream or ointment. In this case, there was too much edema and erythema of the prepuce for topical monotherapy treatment only.

Patient Follow Up

Tests for sexually transmitted infections, chlamydia and gonorrhea, were negative. The bacterial culture was positive for Escherichia coli, indicating a bacterial infection and probable concomitant UTI, with sensitivity to Augmentin. The parents were notified of the lab results.

Although the child was afebrile, the urologist recommended a follow-up renal/bladder ultrasound due to unknown family history of any renal or urologic problems and because of the child's young age. A renal/bladder ultrasound might be recommended for children 2 years of age or younger with a first febrile UTI; children with recurrent febrile UTIs; children with a UTI who have a family history of renal or urologic disease, poor growth, or hypertension; and children who do not respond as expected to appropriate antibiotics (Shaikh et al., 2014). However, a recent investigation found children with vesicoureteral reflux may have been missed if current guidelines for management of UTIs were followed (Narchi, Marah, Khan, AlAmir, & Al-Shibli, 2015).

The clinic nurse informed the parents of the need for a renal/ bladder ultrasound. The parents stated the child was doing much better, and his "penis looked normal." The family did not return for follow up due to lack of transportation, making it difficult for the family to obtain medical services. Transportation challenges, along with other barriers to health services, such as poverty and lack of health insurance, are more common in Latino families (Velasco-Mondragon, Jimenez, Palladino-Davis, Davis, & Escamilla-Cejudo, 2016).

Nursing Considerations

The nurse spent extra time during the encounter teaching the mother about bathing and hygiene. Parents of uncircumcised infants should be instructed to never forcibly retract the foreskin, but to bathe and wash the genitals daily. As long as the foreskin does not easily retract, only the outside of the glans penis needs to be cleaned. If the foreskin retracts a little, the parents can be taught to clean the exposed area of the glans with gentle soap and warm water, or water alone. The foreskin should never be forcibly retracted. Forcing the foreskin back may harm the penis and cause pain, bleeding, and possible adhesions (American Academy of Pediatrics [AAP], 1999).

Smegma that collects under the foreskin, however, can be left alone. The AAP (1999) recommends not removing smegma because in its natural state, smegma serves as a lubricant. Smegma can become stale, unhealthy, and malodorous if allowed to accumulate in the foreskin cavity without bathing and caring for the uncircumcised penis as reviewed above. As the child gets older and foreskin retraction occurs naturally, parents should educate their son to retract the foreskin while bathing and to replace it in its normal position after cleansing (AAP, 1999).

Other Cultural Considerations

Therapeutic reasons for circumcision remain controversial. Although there are several medical reasons that influence parental decision-making, religious, ethical, and cultural reasons are among the strongest factors that influence most parents' decisions for circumcision or no circumcision of newborns (Sardi & Livingston, 2015). Hispanics living in the United States have the lowest rates of circumcision of all ethnic groups (Morris, Bailis, & Wiswell, 2014). This may be due to cultural factors, fear, lack of education regarding circumcision, or gaps in insurance coverage (Morris et al., 2014).

Practice Improvement

We have a large pediatric Latino population in our public health practice. These families are often seen by nurses at both the health center and on home visits prenatally. Nurses can instruct families on proper care and hygiene of the uncircumcised penis, as well as bathing and skin care of the newborn. Other potential social and cultural barriers to care should also be addressed, including transportation, insurance coverage, and language barriers.

Conclusion

In summary, balanprosthitis occurs more frequently in uncircumcised males. When parents opt not to circumcise their child, it is imperative for healthcare providers to teach parents proper care and hygiene of the uncircumcised penis to prevent infection or complications. Additionally, healthcare providers can assist older male patients in other ways to prevent balanprosthitis, such as weight reduction for males who are obese. It is also important for healthcare providers to discuss the pros and cons of circumcision with parents prenatally, if possible, while considering the family's cultural and religious beliefs.

doi: 10.7257/1053-816X.2018.38.5.237

References

American Academy of Pediatrics (AAP). (1999). Care of the uncircumcised penis, Elk Grove Village, IL: American Academy of Pediatrics. Retrieved from http://www.cirp.org/ library/normal/aap 1999/

Bansal, A., Yadav, P., Kumar, M., Sankhwar, S., Purkait, B., Jhanwar, A., & Singh, S. (2016). Foreign bodies in the urinary bladder and their management: A single-centre experience from North India. International Neurourology Journal, 20(3), 260-269. doi:10.5213/inj.1632524.262

Leber, M.J., & Tirumani, A. (2017). Balanitis. Retrieved from https://emedicine.medscape.com/article/777026-overview

Morris, B.J., Bailis, S.A., & Wiswell, T.E. (2014). Circumcision rates in the United States: Rising or falling? What effect might the new affirmative pediatric policy statement have? Mayo Clinic Proceedings, 89(5), 677-686. doi:10.1016/j.mayocp.2014. 01.001

Morris, B.J., & Krieger, J.N. (2017). Penile inflammatory skin disorders and the preventive role of circumcision. International Journal of Preventive Medicine, 8, 32. doi:10.4103/ijpvm. IJPVM_377_16

Narchi, H., Marah, M., Khan, A.A., AlAmir, A., & Al-Shibli, A. (2015). Renal tract abnormalities missed in a historical cohort of your children with UTI if the NICE and AAP imaging guidelines were applied. Journal of Pediatric Urology, 11(5), 252.e1-252.e7. doi:10.1016/j.jpurol.2015. 03.010

Okarska-Napierala, M., Wasilewska, A., & Kuchar, E. (2017). Urinary tract infection in children: Diagnosis, treatment, imaging--Comparison of current guidelines. Journal of Pediatric Urology, 13(6), 567-573. doi:10.1016/j.jpurol.2017.07.018

Porche, D.J. (2007). Balanitis. The Journal for Nurse Practitioners, 3(5), 310-311. doi:10.1016/j.nurpra.2007.03. 016

Sardi, L., & Livingston, K. (2015). Parental decision making in male circumcision. MCN: The American Journal of Maternal/Child Nursing, 40(2), 110-115. doi:10.1097/NMC.0000000000 000112

Shaikh, N., Craig, J.C., Rovers, M.M., Da Dalt, L., Gardikis, S., Hoberman, A., ... Shope, T. (2014). Identification of children and adolescents at risk for renal scarring after a first urinary tract infection: A meta-analysis with individual patient data. JAMA Pediatrics, 168(10), 893-900. doi:10.1001/jamapediatrics.2014.637

Velasco-Mondragon, E., Jimenez, A., Palladino-Davis, A.G., Davis, D., & Escamilla-Cejudo, J.A. (2016). Hispanic health in the USA: A scoping review of the literature. Public Health Review, 37(31), 1-27. doi:10.1186/s40985-016-0043-2

Kimberly P. Toole, DNP, APRN, CNP, is an Assistant Professor and Nurse Practitioner, Xavier University, Cincinnati, OH.

Catherine Frank, DNP, AGACNP-BC, APRN, is an Assistant Professor and Nurse Practitioner. Xavier University, Cincinnati, OH.
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Title Annotation:Case Study
Author:Toole, Kimberly P.; Frank, Catherine
Publication:Urologic Nursing
Article Type:Report
Date:Sep 1, 2018
Words:1942
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