Penile Swelling in a 6-year-old Boy

A previously healthy 6-year-old boy presents to the emergency department (ED) in late July for penile swelling. The mother reports that there is 1 day of penile pain, swelling, and itchiness. Both the parents and the patient deny trauma or any known injuries to the area. He does not have fevers, chills, hematuria, vomiting, abdominal pain, dysuria, or difficulty urinating. The parents note that he has been playing outside and swimming frequently during the past several weeks. He was circumcised at 6 months of age. Before evaluation in the ED, he saw his primary care provider, who felt that it was consistent with a Candida infection and prescribed topical nystatin. Due to progressively worsening swelling, the patient presents to the ED later that evening. The physical examination is remarkable for a circumcised phallus with erythema and circumferential swelling of the inner preputial skin. There is additional swelling of the base of the shaft, as well as a small erythematous papule near the base of the shaft (Figs 1–3). There is no visible hair tourniquet or necrosis. The scrotum appears normal, and the testicles are descended bilaterally. Clinical examination confirms the diagnosis.The differential diagnosis for penile swelling in a child is broad and includes traumatic, infectious, and inflammatory etiologies such as paraphimosis/phimosis, penile tourniquet syndrome, balanitis/balanoposthitis, priapism, sexual abuse, and hypersensitivity reactions.Pediatric urology was consulted in the ED and felt that his presentation was most consistent with summer penile syndrome based on the clinical features, time of year, and recent history of time spent outside. He was prescribed a combination antifungal/corticosteroid ointment and was recommended to use acetaminophen or ibuprofen for supportive care. The patient was discharged home with close follow-up with his primary care provider.Penile swelling may be a primary (localized to the penis) or secondary (systemic) process. Secondary causes include nephrotic syndrome or heart failure, which can cause generalized edema or anasarca. Another possible secondary cause is priapism due to vaso-occlusive crisis in sickle cell disease. (1) Primary causes present more acutely and are usually a result of an infectious, inflammatory, or traumatic process. Phimosis is the constriction of the foreskin resulting in an inability to expose the glans, which is physiologic in most cases, especially in infants and toddlers. (2)(3) Paraphimosis occurs when a retracted foreskin is unable to be reduced to its normal position and is often extremely painful. (2)(3) Penile tourniquet syndrome is caused by venous congestion and reduced lymphatic flow from a foreign body (such as a strand of hair or thread of clothing) that becomes wrapped around the penis. (4) Balanitis and balanoposthitis are inflammatory conditions that cause itching, burning, and irritation with associated inflammation of the glans penis and foreskin, usually caused by an underlying infection. (3) In the pediatric population, this is often seen in conjunction with diaper dermatitis, particularly Candida. Although the patient in this case had penile itching, pain, and swelling, given the circumferential nature of his swelling, sparing of the glans, and lack of urethral discharge, balanitis was thought to be less likely."Summer penile syndrome," also known as "lion's mane penis" or "seasonal acute hypersensitivity reaction of the penis," is a benign, self-limited hypersensitivity reaction of the skin of the penile shaft. Most boys are between 3 and 7 years old and present with notable edema to the skin of the shaft of the penis, most often just proximal to the glans. (4) It is thought to be due to outdoor exposure to insect bites (particularly chiggers) or plants and as a result, erythematous papules or bite marks can also be seen on physical examination, (4)(5)(6)(7) as was seen on the patient in this case. In summer penile syndrome, most patients report pruritus, but unlike paraphimosis, it is rarely painful and does not typically cause urinary symptoms. (4)(5)(6) Most patients with summer penile syndrome have symptom improvement in 4 to 5 days, but it can last up to 2 to 3 weeks. (4) The condition is self-limited, and treatment is focused on symptomatic relief with oral antihistamines, topical corticosteroids, and cool compresses. (6)(7) Systemic corticosteroids should be reserved for those who are in significant pain or are having difficulty urinating. (4) Urology consultation and follow-up is usually unnecessary. Topical antibiotics or antifungals are not needed unless there is uncertainty regarding the diagnosis; this patient previously received nystatin from his pediatrician due to concern for infectious etiology, so this was continued after his ED visit with a combination antifungal/corticosteroid ointment for symptomatic relief.The patient had a health supervision examination several months later with no further genitourinary concerns noted.