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Course: Pediatric Nursing

Topic: Nursing Care of Child With Genitourinary Disorder Part IV

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Module Goals

Learners will be able to:

Define phimosis, paraphimosis, testicular torsion, and epididymitis.
List signs and symptoms for these disorders in children.
Explain related diagnostic procedures.
Discuss evidence-based management of these disorders in children.
Describe nurse’s role in management of these disorders in children.

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Reproductive Organ Disorders in Children

Phimosis and paraphimosis

Testicular torsion

Epididymitis

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Phimosis

Inability to retract the skin (foreskin or prepuce) covering the head of the penis
Distinguished in two categories

Physiological phimosis

Born with non-retracting foreskins
Normal for uncircumcised infant/child that resolves on its own by 5-7 years of age

Pathological phimosis

Typically caused by balanitis xerotica obliterans (BXO)
Also by scarring, inflammation or infection

McPhee,Stormont,& McKay, 2021

Phimosis, n.d.

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Image from https://www.aboutkidshealth.ca/Article?contentid=889&language=English

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Phimosis (Continued)

Phimosis becomes a problem if following symptoms are present

Swelling and tenderness
Painful urination or a weak flow of pee
Frequent urinary tract infections
bleeding or a thick discharge from under the foreskin
Unpleasant smell
Painful erections

Phimosis is diagnosed based on health history and physical examination

McPhee,Stormont,& McKay, 2021

Phimosis, n.d.

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Phimosis: Management

Physiological phimosis

Reassurance and counselling of concerned parent

Circumcision is preferred treatment for pathological phimosis

Surgically excised skin sent for histology to exclude malignancy

Alternative to circumcision is preputioplasty

Preserves foreskin, achieve retractility post surgery

Topical steroids administration

To achieve full retractile foreskin
Typical treatment course is 4 to 8 weeks, with regular attempts at retraction during this time

McPhee,Stormont,& McKay, 2021

Phimosis, n.d.

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Paraphimosis

Failure to return retracted foreskin over head of penis resulting tight band formation around the shaft of penis
Leads to:

Strangulation of the glans
Painful vascular compromise
Distal venous engorgement
Edema
Even necrosis

A true urologic emergency

Bragg, Kong, & Leslie, 2022

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Paraphimosis (Continued)

Caused by forgetting to unretract foreskin after:

Cleaning
Catheterization
Cystoscopy, Penile examination
Sexual intercourse

Other causes:

Infection
Repeated injuries
Diabetes
Circumcision done incorrectly

Diagnosis: Physical examination of penis
Treatment management:

Pulling foreskin to natural position after reduction of the swelling
Local anaesthetic or analgesia might be necessary
Small incision or circumcision may be required for severe cases

Bragg, Kong, & Leslie, 2022

Paraphimosis, 2021

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Nursing Considerations For Management of

Phimosis and Paraphimosis in Children

Beware of signs/symptoms of phimosis/paraphimosis in children
Provide child and family education::

About phimosis/paraphimosis
Genital hygiene
How to use topical steroid at home (if prescribed)
Prevention of paraphimosis

Ensure foreskin in natural position after cleaning, bathroom use, sex
Never leaving foreskin retracted any longer than needed

Referral to appropriate specialist, support, resources where needed

McPhee,Stormont,& McKay, 2021

Phimosis, n.d.

Bragg, Kong, & Leslie, 2022

Paraphimosis, 2021

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What Would the Nurse Do?

During the assessment of a 2 year old child, the nurse found that the prepuce of the penis could not be retracted, there is absence of swelling or pain or scarring in the area and no discharge. The parents anxiously asked the nurse if it is a serious condition. What would be an appropriate response by the nurse? (Select all that apply).

“Further assessment will be required to determine this condition.”
“Physical assessment indicates physiological phimosis, which is normal for uncircumcised child.”
“Physiological phimosis requires urgent surgical repair to prevent complications.”
“ I cannot provide any information about this. I will refer you to the physician now.”

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Testicular Torsion

Abnormal twisting of spermatic cord and testis compromises blood supply to these structures

Results in ischemic injury and pain

Torsion can be complete (usually twisting > 360°), incomplete or intermittent
Can occur at any age
Most common in adolescence, with a peak at 14 years of age
Permanent damage to testis likely to occur if lack of blood supply to the testis for more than about six hours

Clinical Practice Guidelines for Nurses in Primary Care - Pediatric and Adolescent Care, 2010

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Testicular Torsion: Causes

Usually spontaneous and idiopathic (often occurs during sleep)
Predisposing structural (genetic) defect (for example, inadequate fixation of testis to tunica vaginalis, bell clapper deformity)
Occasionally caused by minor trauma to the groin
Strenuous physical activity
Sexual activity or arousal
Undescended testicle
Testicular tumour

Clinical Practice Guidelines for Nurses in Primary Care - Pediatric and Adolescent Care, 2010

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Testicular Torsion: Signs/Symptoms

Incomplete or partial testicular torsion:

Intermittent sharp testicular pain (resolve within seconds/ minutes)
Long periods without symptoms

Complete torsion:

Sudden onset of severe, constant, unilateral pain in scrotum or testicle, usually for < 12-24 hours
Pain may radiate to lower abdomen, made worse by elevation of scrotum, not relieved by lying down
Decreased appetite, nausea/vomiting may be present
Unilateral scrotal swelling and redness

Clinical Practice Guidelines for Nurses in Primary Care - Pediatric and Adolescent Care, 2010

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Image from Queensland Government, Queensland Health

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Testicular Torsion: Assessment/Diagnostics

Health history on sign/symptoms, risk factors of testicular torsion
Physical findings:

In acute distress, bent over/unable to walk
Unilateral scrotal swelling, redness
Testis acutely tender, swollen and found higher up in scrotal sac than expected on affected side
Testis might be lying horizontally (epididymis not posterolateral)
Hydrocele, scrotal skin erythema may be present
Cremasteric reflex almost always not present

Clinical Practice Guidelines for Nurses in Primary Care - Pediatric and Adolescent Care, 2010

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Testicular Torsion: Diagnostics

Testicular Torsion: Management

Doppler ultrasonography helps distinguish testicular torsion from strangulated hernia, undescended testes or epididymitis
Slight manual elevation of the testis increases pain

Urgent surgery under general anaesthesia
Post-surgery bruising, swelling at surgical site for about a week or so
Pain medication and antibiotics
Children able to return to normal activities after a week or two

Clinical Practice Guidelines for Nurses in Primary Care - Pediatric and Adolescent Care, 2010

Queensland Health, 2020

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Nursing Considerations in Management of

Testicular Torsion of Children

Immediate surgical referral of suspected case
Nothing by mouth before surgery
Child/family education about post-surgical care at home:

Reduce swelling: Cold pack scrotum 10-20 minutes at a time, supine position 15 minutes several times a day
Incision site care:

Wash site with warm, soapy water at least 2 times a day
Pat dry
No bath until approved by health care provider
Do not use alcohol, hydrogen peroxide

Queensland Health, 2020

Healthwise Staff, 2021a

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Nursing Considerations in Management of

Testicular Torsion of Children (Continued)

Post-surgical care at home

Slowly increase amount of walking: boosts circulation, prevents pneumonia/constipation
Avoid lifting, driving, and strenuous activities such as cycling, jogging until indicated by health care provider
Eat regular diet
Take full course of prescribed antibiotics, and pain medication

Queensland Health, 2020

Healthwise Staff, 2021a

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What Would the Nurse Do?

A 13 year old boy was diagnosed with testicular torsion after thorough assessment and doppler ultrasonography. What would the nurse do next?

Check blood pressure and temperature
Inform child/parent that child should not eat or drink anything until further notice
Assess for signs/symptoms of testicular torsion to prevent further complications
Inform parents and child that pain medication and antibiotics may be prescribed for treatment

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Answer: b

Testicular torsion is a medical emergency that requires immediate surgical operation under general anesthesia. Therefore, the parent and child should be immediately informed that nothing should be taken by mouth to prevent aspiration during surgery. Taking vital signs can be done after providing this information.

Signs/symptoms of testicular torsion need not be assessed now as the diagnosis has been made through thorough assessment, and monitoring signs/symptoms of the testicular torsion at this point is without merit in prevention of further complication.

Pain medications and antibiotics does not treat this condition. However, nurse can counsel the parents on pain medications and antibiotics after they have been prescribed by the doctor to treat pain and prevent infection post surgery.

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Epididymitis in Children

Inflammation or infection of the epididymis
Common causes:

Urinary tract infection in boys younger than 14 years age
Sexually transmitted infections (STI) in boys older than 14 years of age

Acute epididymitis: Pain and scrotal swelling present for less than six weeks
Chronic epididymitis: Pain in absence of scrotal swelling lasting more than three months
Often occurs with orchitis (inflammation of the testis)

University of Rochester Medical Center, n.d.

Healthwise Staff, 2021b

McConaghy & Panchal, 2016

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Epididymitis in Children: Risk Factors

Epididymitis in Children: Sign/Symptoms

Anatomic abnormalities causing reflux of infected or sterile urine into the ejaculatory ducts
Prostate or urinary tract surgeries or instrumentation
Prolonged sitting, cycling, or trauma

University of Rochester Medical Center, n.d.

Healthwise Staff, 2021b

McConaghy & Panchal, 2016

Pain, swelling in testicles
Fever
Feeling of heaviness in testicles
Fluid leaking from the urethra
Blood in the semen

Lump in the testicles
Pain during urination or ejaculation

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Epididymitis in Children: Diagnostics

Health history focused on risk factors and sign/symptoms
Physical exam
Midstream urinalysis, urine culture
Nucleic acid amplification test for N. gonorrhoeae and C. trachomatis in sexually active children
Doppler ultrasonography to differentiate from testicular torsion
Acute phase reactants if doppler ultrasonography not available promptly

Epididymitis is often associated with an elevated C-reactive protein level

University of Rochester Medical Center, n.d.

McConaghy & Panchal, 2016

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Epididymitis in Children: Management

Antibiotics for infections
Pain medication and anti-inflammatory drugs
Elevation of scrotum and ice pack to alleviate pain
In cases of STIs:

Sexual partner of the teen who was in contact within 60 days of symptoms should be contacted and tested
Treated if tested positive for STIs
Teen and their partner should abstain sex until they are treated and are without symptoms

University of Rochester Medical Center, n.d.

McConaghy & Panchal, 2016

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Nursing Implications in the Management of Epididymitis in Children

Suspected cases of epididymitis should be referred to specialist
Provide child/family education:

Disease condition
About prescribed antibiotics, pain medications

Emphasis on completing full course of antibiotics

Applying either heat or cold as tolerated to ease pain

Safe sex education to the teens

University of Rochester Medical Center, n.d.

McConaghy & Panchal, 2016

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Critical Thinking Question

Which of the following statements are true regarding epididymitis? (Select all that apply)

Affects girls or boys under the age of 14 due to urinary tract infection
Sexually transmitted infections are usually the cause for boys over the age of 14
Doppler ultrasonography should be performed to differentiate it from testicular torsion
Surgical repair is the definitive treatment
Sexual partners of the teen, in contact within 90 days of symptoms, should also be tested for infection

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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References:

Bragg, B.N., Kong, E.L., & Leslie, S.W. (2022, February 14). Paraphimosis. In: StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459233/

Carlton, O.A., & Smith, S.D. (2018). Balanitis xerotica obliterans: a review of diagnosis and management. International Journal of Dermatology, 58(7), 777-781. https://onlinelibrary.wiley.com/doi/10.1111/ijd.14236

Clinical Practice Guidelines for Nurses in Primary Care - Pediatric and Adolescent Care. (2010). Government of Canada. https://www.canada.ca/en/indigenous-services-canada/services/first-nations-inuit-health/health-care-services/nursing/clinical-practice-guidelines-nurses-primary-care/pediatric-adolescent-care/chapter-13-genitourinary-system.html#a31

Healthwise Staff. (2021a, February 10). Orchiopexy for Testicle Torsion: What to Expect at Home. [Medically reviewed by A.Husney, & C.G. Wood]. MyHealth.Alberta.ca. https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=ug3915

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References:

Healthwise Staff. (2021b, February 10). Epididymitis and Orchitis in Children: Care Instructions. [Medically reviewed by A.Husney & S.C.Kim]. MyHealth.Alberta.ca. https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=bz1149

McConaghy, J.R. & Panchal, B. (2016). Epididymitis: An overview. American Family Physician, 94(9):723-726. https://www.aafp.org/afp/2016/1101/p723.html

McPhee, A.S., Stormont, G., & McKay, A.C. (2021, Aug 13). Phimosis. In: StatPearls [Internet].StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK525972/

Paraphimosis. (2021, January 27). familydoctor.org. https://familydoctor.org/condition/paraphimosis/

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References:

Queensland Health. (2020, December 14). Testicular torsion - what all men and boys should know. Queensland Government. https://www.health.qld.gov.au/news-events/news/testicular-torsion-urgent-medical-attention-what-all-men-and-boys-should-know

University of Rochester Medical Center. (n.d.). Epididymitis in Children. [Medically reviewed by M.Greenstein, R.K.Turley & R. Turley Jr.]. https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=160&contentid=60#:~:text=Key%20points%20about%20epididymitis%20in,such%20as%20gonorrhea%20or%20chlamydia.

Phimosis. (n.d.). University of California, San Francisco, Department of Urology. https://urology.ucsf.edu/patient-care/children/phimosis#.YnJmJtpBzIUhttps://urology.ucsf.edu/patient-care/children/phimosis#.YnJmJtpBzIU

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