Paraphimosis and Phimosis

What is it?

Paraphimosis: the penile foreskin becomes retracted around the coronal sulcus (= the circumference at the base of the glans penis), leading to vascular congestion and glans edema

Phimosis: the foreskin is retracted over the glans

This is only an emergency if it is causing acute urinary retentionKeep in mind most uncircumcised infants have normal phimosis

Why do we care?

 If left untreated, paraphimosis can lead to some awful complications, such as necrosis or gangrene of the glans penis which can then necessitate a partial amputation of the penis 

For phimosis causing urinary retention, can cause infections and renal failure

When to suspect it?

The main risk factor is lack of circumcision.

Crying infants (the S=Strangulation in ITCRIES for those who love mnemonics)

Adolescents may present later due to embarassment - can be caused by genital piercings or sexual intercourse 

Another risk factor is prolonged erotic dancing, ie wining - a gyrating motion that alongside others causes prolonged erection and friction on the penis (multiple case reports)

How do we manage it? 

Don't miss other injuries - look at their scrotum for a concomitant torsion or Fournier's 

Paraphimosis

Call urology urgently if you note signs of ischemia or the patient has had symptoms for >12 hours.

If there are no signs of ischemia, consider non-manipulative methods, which entail a combination of compression and osmotic agents as well as patience:

1. "Iced Glove" - place ice and water in a glove and invaginate the thumb portion to place the penis into

2. Mannitol or glucose soaked gauze - soak gauze in 20% mannitol or D50 and wrap it around the glans of the penis while applying gentle pressure; this can take 1-2 hours for full effect

Next, attempt manual reduction. Don't forget pain control!

Methods of analgesia: topical EMLA, dorsal penile nerve block, fentanyl, ketamine, procedural sedation (though certain studies have shown topical anesthesia may work best) 

Manual reduction: Have both thumbs on the glans while applying countertraction with the index fingers to the foreskin

If it works, make sure the patient can freely urinate , instruct patients to not retract the foreskin for 2 weeks, and arrange urology followup in 2-3 weeks. 

If it fails, URGENT urology consultation. There are other options in case of a failed manual reduction (injecting hyaluronidase, aspirating the glans, poking the foreskin) that are especially useful if no one is immediately available to assist you 

Phimosis

If causing acute urinary retention, call urology for likely dorsal slit procedure.

If patient is able to freely urinate, educate patient on how to properly clean their foreskin and show them how to retract the foreskin (3 months of this exercise has been shown to lead to resolution of phimosis in 76% of patients).

Topical steroids (triamcinolone for 4-6 weeks) also improve or completely resolve phimosis.

Sources

http://www.emdocs.net/em3am-paraphimosis-and-phimosis/

https://pedemmorsels.com/pediatric-paraphimosis/

https://www.aliem.com/trick-trade-management-paraphimosis/

POTD. Pediatric Grand Round. Pediatric Fevers

Today’s Pediatric grand rounds was given by Dr. Prashant Mahajan, MH, MPH, MBA. 

• Professor and Vice-chair of the department of Emergency Medicine; Professor of Pediatric Medicine, Division Chief of Pediatric Emergency Medicine, Professor of Pediatrics at the University of Michigan

• For those that don’t know him- He’s really smart and has done a ton of research on febrile infants

• and he's proposing a new model to rule out serious bacterial infections in infants <60 days old. 

TL:DR

• Serious Bacterial Infection (SBI) can be ruled out febrile infants from 29-60 days old with a-

  • Negative UA

  • Absolute Neutrophil Count (ANC) < 4090/μg

  • Procalcitonin < 1.72 ng/m

• This prediction rule has a

  • Sensitivity of 97.7% (95% CI, 91.3-99.6)

  • Negative predictive value of 99.6% (95% CI, 98.4-99.9)

  • Negative likelihood ratio of 0.04 (95% CI, 0.01-0.15)

  • Specificity of 60.0% (95% CI, 56.6-63.3)

• This rule requires further validation, but has promise to substantially decrease the use of lumbar punctures, broad-spectrum antibiotics, and hospitalization for many febrile infants 60 days and younger.

The longer and more detailed approach:

- 8-13% of infants <60 days with  fever have a SBI

• ~5-8% have a UTI

• ~1-2% have bacteremia

• ~0.5% have meningitis

- ~500,000 febrile infants are evaluated by healthcare professionals annually

• Missed SBIs may lead to serious complications

• Febrile infants frequently receive invasive management including lumbar punctures, broad spectrum antibiotics, and hospitalization

• Variation exists in the management of febrile infants <60 days

• 90% of those 28 days or less receive lumbar puncture and admission

• The incidence of SBIs has decreased over time

• We need to balance hospital related complications, costs, and increases in antimicrobial resistance with the consequences of missed SBIs

- Our screening tests to assess for SBIs have holes in them

• Physical Exam

  • Yale Observation Scores (YOS) in infants with SBI’s have similar median scores to those without SBI’s

  • I didn't know the YOS was a thing either. It's a clinical score developed on 6 behavioral domains to predict SBI’s, 

• CBC’s are not sensitive in ruling out bacteremia or meningitis

  • WBC< 5,000 has a sensitivity of 10%, specificity of 91%

  • WBC> 15,000 has a sensitivity of 18%, specificity of 87%

• Several of the commonly used rules for febrile infants (Philadelphia, Rochester, Boston, and Pittsburgh) were not statistically derived and therefore lacked optimal balance between test sensitivity (avoiding missed SBIs) and specificity (preventing overtesting and overtreating patients without SBIs). Additionally, several included data from LP’s an invasive procedure not required in the newly proposed rule (Boston, Phladelphia, Pittsburgh, Milwaukee.

- In this study

• Negative UA alone ruled out an SBI in 97.6% of cases

  • Anyone hear of diapedesis? Consult Hector Vazquez for more info

• Negative UA + ANC <4090 ruled out SBI in 99.2% of cases

• Negative UA + ANC <4090 + PCT <1.71 ruled out SBI in 99.8% of cases

- Further validation in a cohort with more SBI’s is needed before implementation of this new rule.

The conclusion

• Dr. Mahajan recommends using this rule in infants 29-60 days old. He currently recommends pursing your institutions’s standard of care (Full Sepsis Workup) in infants 28 days old or less  

The Article:

https://jamanetwork.com/journals/jamapediatrics/fullarticle/2725042

POTD: Foreign Body of the Nose

Foreign body of the Nose

•        Most common age range: 2-5 yo

•        Most common FB: beads, beans, peanuts, toy parts

•        Beware of: button batteries and two magnets, as always.

•        Can lead to septal perforation/necrosis of tissue.

•        Be suspicious of nasal FB when you see unilateral discharge, often malodorous

•        Complications: infection, aspiration, epistaxis

To remove:

•        Topical lidocaine or afrin?

• Pro: improve tolerance of/cooperation with the procedure

• Con: risks displacement of the FB

How to remove

1) Mechanical extraction: You need a cooperative child and good visualization.

2) Suction: must exercise extreme caution not to push further back and aspirated into the trachea

3) Positive Pressure: Parent’s kiss, bag mask, continuous pressure

• Start by asking the child to blow their nose, occluding the unaffected nostril as they do this. Sometimes, this alone may expel the foreign body.

• Parent’s Kiss: One of my preferred methods. Has a 50 % success rate.

Kissing parent: The technique is performed by a parent by placing their mouth over the child’s (giving a ‘big kiss’), while they occlude the unaffected nostril. The parent then exhales into the child’s mouth, generating positive pressure, similar to that of nose blowing. See picture below for demonstration.

Nothing working? You may need an ENT consult because the FB is so posterior that above methods are futile.

Now that it’s removed:

·       Don’t forget to inspect for trauma or retained FB

References:

•        PEM playbook foreign bodies: excellent peds podcast by Dr. T Horeczko - ‎2015

•        Wiki EM: Nose foreign body

Look at this retro parent’s kiss!