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, anti-fungal, 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, Al-Amir, & 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).
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).
Urol Nurs. 2018;38(5):237-239. © 2018 Society of Urologic Nurses and Associates