A 5-year-old boy is brought to the emergency department by his mother due to redness and white discharge around his penis. His mother reports frequent episodes of nocturnal bed wetting in the past few weeks after months of being dry overnight. The patient has no chronic medical conditions, and his vaccinations are up to date. Temperature is 36.7 C (98.1 F), blood pressure is 104/62 mm Hg, pulse is 86/min, and respirations are 16/min. The abdomen is soft and nontender, and the bladder is not palpable. The penis is uncircumcised, and the glans penis is erythematous with thick, white discharge around the glans when the foreskin is retracted. There is no urethral discharge. There is no phimosis or paraphimosis. In addition to teaching the proper foreskin hygiene, which of the following is the best next step in management of this patient?

Question

A 5-year-old boy is brought to the emergency department by his mother due to redness and white discharge around his penis.  His mother reports frequent episodes of nocturnal bed wetting in the past few weeks after months of being dry overnight.  The patient has no chronic medical conditions, and his vaccinations are up to date.  Temperature is 36.7 C (98.1 F), blood pressure is 104/62 mm Hg, pulse is 86/min, and respirations are 16/min.  The abdomen is soft and nontender, and the bladder is not palpable.  The penis is uncircumcised, and the glans penis is erythematous with thick, white discharge around the glans when the foreskin is retracted.  There is no urethral discharge.  There is no phimosis or paraphimosis.  In addition to teaching the proper foreskin hygiene, which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c180_63c6_8f63_8b6d66bc409b_MD0005_00 This patient has signs of inflammation (ie, erythema, discharge) around the glans penis consistent with balanitis. Balanoposthitis is a similar condition in which inflammation also extends to the foreskin. Balanitis and balanoposthitis are common in uncircumcised boys age 2-5 and are typically due to irritation from poor genital hygiene (eg, accumulation of smegma beneath the foreskin). Excessive smegma and the moist environment under the prepuce can also predispose the area to secondary infection. Candida albicans is the most common fungal pathogen that causes balanitis and should be suspected when thick, white discharge is present around the glans (as seen in this child). Some patients with Candida infection may also have distinct satellite lesions in addition to the typical penile erythema, swelling, and tenderness seen with balanitis. Diagnosis is confirmed by the presence of budding yeast on potassium hydroxide (KOH) microscopy, and treatment is with a topical antifungal (eg, nystatin). In addition to treating the infection, a prepubertal child with no risk factors for C albicans (eg, diaper dermatitis, recent antibiotic therapy) should be evaluated with a blood glucose level because balanitis can be the first presenting sign of diabetes mellitus. This patient's secondary nocturnal enuresis (ie, new-onset bed wetting after establishing a period of nighttime urinary continence) could also be suggestive of polyuria due to diabetes and further supports the need for screening. (Choices A and B) Topical mupirocin and topical terbinafine are used to treat balanitis due to bacteria and tinea, respectively. Bacterial balanitis may cause purulent discharge, and tinea corporis is characterized by an annular rash; neither condition is associated with thick, white discharge. (Choice D) Balanitis is not a typical indication for circumcision unless it is severe, recurrent, or refractory to treatment. (Choice E) An enuresis alarm is used in children with primary enuresis who have never established nocturnal continence to train the brain to awaken after bed wetting. Training devices are not typically required for secondary enuresis, and evaluation for an underlying condition contributing to balanitis and enuresis is the priority in this patient. Educational objective: Balanitis refers to inflammation of the glans penis, and Candida albicans should be suspected as the causative organism when thick, white discharge is present. Budding yeast on potassium hydroxide microscopy confirms the diagnosis, and treatment includes proper hygiene and a topical antifungal. Evaluation with a blood glucose level for underlying diabetes mellitus should be performed, particularly if other signs of diabetes (eg, nocturnal enuresis) are present. References: Candida balanitis: risk factors (http://www.ncbi.nlm.nih.gov/pubmed/20002652) Diabetes and balanoposthitis (http://www.ncbi.nlm.nih.gov/pubmed/27524547)

A 5-Year-Old Boy Is Brought to the Emergency Department by His