Harwood-Nuss’ Clinical Practice of Emergency Medicine
4th Edition

Balanitis describes inflammation of the glans penis. Posthitis describes inflammation of the prepuce of the penis. Because balanitis and posthitis usually occur together, balanoposthitis correctly describes a male with inflammation of the glans and prepuce. Balanitis is more common in uncircumcised men who exercise poor hygiene, but it may affect young boys. Patients with balanoposthitis have an edematous, erythematous, fissured, and painful prepuce and glans. A variety of skin changes are possible based on the etiology.

When the foreskin is not retractable behind the glans penis, the condition is termed phimosis. Physiologic phimosis is present until normal adhesions between the foreskin and glans have separated. Although most young boys are able to retract the foreskin by puberty, retraction is usually possible at an earlier age (4,6). As normal secretions accumulate and epithelial sloughing occurs, smegma is formed. Smegma assists in the separation of the foreskin from the glans and is normal. Parents may confuse smegma with infectious penile discharge if expressed from the penis. Pathologic phimosis, or simply phimosis, occurs when retraction of the foreskin is not possible after puberty or when the foreskin was previously retractable.

Paraphimosis occurs when the retracted foreskin is not replaced, usually after cleansing or catheter insertion. After foreskin retraction, the constricting phimotic ring causes progressive edema and impairs venous return, threatening the viability of the glans. Most patients complain of pain and usually provide a history of foreskin retraction; however, debilitated, uncircumcised patients may not provide this history. Do not confuse paraphimosis with balanitis in these patients.

The differential diagnosis may be divided into infectious and noninfectious causes. Fungal infections resulting from Candida albicans cause itching and burning of the penis and are accompanied by white discharge, discrete ulcerated papules, and white and cheesy plaques. Group B streptococci, Gardnerella vaginalis, and mixed anaerobes have been isolated from men with balanoposthitis. Secondary syphilis and condyloma latum may infect the glans. Protozoal infections with Trichomonas vaginalis and amoebiasis have been reported. Genital herpes may cause necrotizing balanoposthitis, and human papillomavirus (HPV) can induce genital warts on the glans or foreskin.

Noninfectious causes of balanoposthitis include trauma, latex allergy, and various dermatoses. Dermatologic lesions include psoriasis, lichen planus, erythema multiforme, and a variety of premalignant and malignant lesions. When balanoposthitis is severe, phimosis may occur and precipitate urinary retention.

The emergency department evaluation is usually limited to the history and physical examination. Test the patient’s blood glucose when infection caused by C. albicans is suspected, and perform serologic testing for syphilis when this organism is suspected. Acetic acid whitens the superficial epithelial skin layer when applied to lesions infected with HPV.

Meticulous hygiene, including retraction of the foreskin and cleansing of the glans penis and prepuce, is the mainstay of treatment. Direct the treatment of infectious balanoposthitis toward the offending organism. Treat fungal infections of the glans with topical antifungal agents. Use metronidazole to treat Gardnerella, anaerobic infection, and Trichomonas infections. Treat secondary syphilis according to established guidelines.

Asymptomatic phimosis does not require emergent treatment. Reassure concerned parents when physiologic phimosis is present and discourage them from attempting forceful retraction. Several recent studies have demonstrated that topical steroids applied to the foreskin for a month are 90% effective in young boys with childhood phimosis when retraction is desired (1,15,17,24). When severe phimosis causes urinary retention or interferes with placement of a urinary catheter, a slit made in the dorsal aspect of the foreskin facilitates access to the urethral meatus (12,20). After achieving adequate local anesthesia of the penis with a dorsal nerve block or ring block placed at the base of the penis, gently separate adhesions between the foreskin and glans with a hemostat. Place one jaw of the hemostat inside the dorsal foreskin, taking care not to include the urethral meatus or glans. Crush the foreskin for 3 to 5 minutes by closing the hemostat and incise the crushed foreskin with straight scissors. The crushed edges rarely bleed but may require absorbable suture for hemostasis if they separate. Although some patients are satisfied with the cosmetic appearance of the foreskin after the dorsal slit procedure, the urologist may perform elective circumcision.

Paraphimosis requires definitive treatment in the emergency department. After adequate sedation or penile anesthesia, attempt manual reduction. Place the fingers of both hands behind the phimotic ring and foreskin and apply gentle, steady pressure on the glans with the thumbs (4,2,20). Gauze placed under the fingers may improve traction on the foreskin while bringing it over the glans, but lubricants are rarely helpful. Several other techniques are described to treat paraphimosis; application of these techniques should be guided by the physician’s skill and training in the maneuvers. Use a 21-gauge needle to puncture the edematous foreskin; manual compression after puncture may allow the escape of enough edema fluid to facilitate reduction (2,12). Repeated punctures or blood aspirated from the engorged glans after a tourniquet is placed at the base of the penis may allow reduction (10,19). Subdermal hyaluronidase injected into the edematous foreskin facilitates dispersion of edema fluid and may make reduction possible (5). Granulated sugar has been applied to the edematous glans and foreskin to extract tissue water and ease reduction (11). When less aggressive methods fail, the phimotic ring is incised with a scalpel to facilitate foreskin reduction (20). Prevention is key; emergency department personnel must replace the foreskin after urinary catheter placement.

Treat patients who have balanoposthitis as outpatients except when they have associated medical conditions, such as diabetes. This group of patients require hospital treatment if the diabetes is poorly controlled, complicating outpatient treatment. When phimosis is present and causes urinary retention, consultation in the emergency department with a urologist may be required to relieve the phimosis to allow free drainage of urine if the emergency physician cannot place a urinary catheter. All patients with balanoposthitis require followup with their primary physician and may benefit from urologic evaluation for circumcision. Refer patients with skin lesions suspicious for precancerous changes or malignancy to a dermatologist for evaluation.

Priapism is characterized by a prolonged, painful, unwanted penile erection, usually in the absence of sexual stimulation. The physiologic balance achieved between venous outflow and arterial dilation of the corpora cavernosa controls erectile function. Priapism occurs when normal physiologic blood flow is altered and this balance is disrupted. Today, medications used to treat erectile dysfunction in men (sildenafil, papaverine, prostaglandin E1, among others) cause most cases of priapism (3,8,21). It is uncommon in boys, unless sickle cell disease is present, and it is rare in neonates (22). Henoch-Schönlein purpura has caused priapism (13). Patients with priapism complain of penile pain and persistent erection, even after ejaculation. The mean time to presentation in one series of 34 patients was 30 hours (8). The penis is erect and painful to palpation. The corpora cavernosa are engorged, but in contrast to normal erections, the corpus spongiosum and glans penis are flaccid.

The differential diagnosis is divided into “low-flow” and “high-flow” priapism (8). Simply stated, low-flow priapism results from abnormally venous outflow; high-flow priapism results from abnormally increased arterial inflow.

Low-flow priapism is far more common than high-flow priapism and is often caused by vasoactive drugs that cause engorgement of the corpora cavernosa. Impaired venous outflow causes sludging, thrombosis, acidosis, and decreased oxygen tension within the corporal bodies. This pathophysiologic cascade causes the irreversible cellular damage and corporal fibrosis responsible for the long-term complications of low-flow priapism. Oral and intracavernosal agents used for erectile dysfunction, antihypertensive agents, psychotropic drugs, cocaine, and ethanol are among the drugs that have been implicated. Leukemia, sickle cell anemia, and a variety of neoplastic etiologies are also responsible for priapism (8,18).

High-flow priapism is uncommon and usually results from trauma to the penis or perineum (9). Arterial fistula formation between the cavernosal artery and the corporal bodies increases arterial flow into the penis that exceeds venous outflow.

The history usually suggests the etiology of the patient’s priapism. Careful attention to prescription or illicit drug use may help determine whether these agents are responsible. Suspect sickle cell disease among patients at risk when the history of sickle cell disease is unknown. Record the onset of erection and elicit the history of prior episodes of priapism. The penis is painful to palpation and the corporal bodies are engorged, but the glans and the corpus spongiosum are soft. Some authors recommend blood gas analysis of blood aspirated from the corporal bodies to assist in differentiating between low and high flow states (8,20). Low pH, low oxygen tension, and high carbon dioxide levels suggest low-flow, venous obstruction. Blood gas parameters similar to arterial blood suggest high-flow priapism, a condition usually seen after trauma. Order Doppler flow ultrasonography of the penis and perineum to document arteriovenous fistulas when high-flow priapism is suspected (9).

Most cases of priapism encountered in the emergency department treatment will be low-flow priapism. There is conflicting literature describing the efficacy of terbutaline in priapism. The results of some small clinical trials demonstrate that oral terbutaline is more effective than placebo in achieving detumescence (14); others have shown no benefit (7). Because of its relative safety in patients without hypertension or coronary artery disease, a trial of subcutaneous terbutaline (0.25 to 0.5 mL injected subcutaneously, repeated in 20 minutes if needed), or 5 mg of oral terbutaline, repeated in 15 minutes, may be attempted (20). When sedation, analgesia, or terbutaline do not result in detumescence, corporal aspiration and irrigation are indicated (8,20). Anesthetize the penis and aspirate 30 to 60 mL of blood from a single corporal body at the 10 o’clock or 2 o’clock positions. Do not puncture the glans; anastomoses between the corporal bodies obviate the need for bilateral aspiration. When the erection persists after aspiration, carefully inject phenylephrine into the punctured corpus cavernosum. Dilute 1 mg of phenylephrine in 9 mL of sterile saline to achieve a concentration of 100 μg/mL. Inject 200-μg aliquots of phenylephrine up to 3 times to achieve detumescence. Monitor the blood pressure and cardiac rhythm when repeated injections are required.

Sickle cell patients with priapism require analgesia, hydration, and supplemental oxygen. Although one study challenged its efficacy, red blood cell exchange transfusion may be employed when traditional anti-sickling measures fail (16,18). Emergent therapy in the emergency department is not required for high-flow priapism because it does not cause the ischemic injury seen in low-flow priapism.

When detumescence is accomplished in the emergency department, the patient is usually discharged and instructed to followup with the urologist. When emergency department
treatment fails to relieve the erection or when high flow priapism is suspected, a urologic evaluation is indicated. If the urologist is unavailable, transfer the patient to definitive care.