A 5-year-old healthy circumcised male presents to the emergency department in July complaining of swelling to the penile shaft just proximal to the glans. The swelling was noticed when he awoke this morning. There is moderate pruritus, no trauma, and the pain is minimal. The patient is able to void without any difficulty. The family reveals they had been sitting in the grass for several hours watching fireworks the previous evening, but no other pertinent history is provided. Examination findings are seen in the photograph. Several erythematous papules are seen throughout the genitourinary area.
A 13-year-old healthy uncircumcised male presents to the emergency department in the morning, complaining of severe pain to the shaft of his penis, just proximal to the glands. There is no history of trauma. The patient did retract his foreskin last night during a shower to clean his glans. He cannot recall if he replaced his foreskin after his hygienic maneuver. He is able to void, but with some difficulty. There is no pruritus or fever. Examination findings are seen in the photograph.
[hr gap=””] THE DIAGNOSIS
The patient has summer penile syndrome. Summer penile syndrome (SPS) is a seasonal acute hypersensitivity reaction of the penis due to chigger bites. Clinical findings include pruritus, dysuria, chigger mite exposure, swelling, erythema, and excoriations of the penile shaft. Duration of symptoms with treatment is typically 3-5 days, but may last up to 2 weeks. Treatment includes systemic antihistamines and cool compresses. Be sure the patient is able to void. Severe local reactions may appear similar to cellulitis and may be difficult to differentiate from infection. Other diagnoses to consider include paraphimosis, balanitis, balanoposthitis, and phimosis.
Similar in appearance to SPS, but very different, this patient is presenting with paraphimosis. A paraphimosis occurs when the retracted foreskin of an uncircumcised male becomes edematous due to lymphatic and venous congestion, which does not allow it to return to its normal position. Ongoing edema may cause progressive constriction of the penile shaft and restrict blood flow to the glans, resulting in ischemia and permanent damage. This is in contradistinction to phimosis, a condition where the foreskin cannot be fully retracted over the glans. Immediate reduction of the paraphimosis is necessary once identified.
The decision on who should perform the initial attempt at reduction depends on the degree of ischemia to the glans. If blue or black, urology should be called immediately to perform the reduction, otherwise the emergency physician should attempt it as soon as possible.
Reduction of a paraphimosis typically requires intravenous narcotics and/or sedation during the procedure. Manual circumferential compression for 5-10 minutes followed by manual reduction is the preferred initial ED method. Ice, compression bandages, osmotic agents (topical granulated sugar, 50% dextrose soaked gauze) are adjuncts to decrease the swelling, but may take several hours to work. If the emergency physician is unable to reduce the paraphimosis, urology should be consulted for potential surgical release.