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PED-EM-L  January 2009

PED-EM-L January 2009

Subject:

Balanoposthitis

From:

"Kassutto, Zach" <[log in to unmask]>

Reply-To:

Kassutto, Zach

Date:

Mon, 5 Jan 2009 08:49:39 -0500

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (202 lines)

I share in the dilemma of how to treat this condition.  I was trained that adults receive topical antifungals and children receive an oral antibacterial (Keflex back in the day).  

 

My current (pediatric) practice is sitz baths for all, mild cases topical tx (usually antifungals) and severe cases with oral abx (usually clindamycin or bactrim).  A quick review of my (physical and virtual) desktop libraries (see below) suggests that the treatment of this condition may be fertile ground for future study.  

 

 

Fleisher/Ludwig (2006 Edition): Balanoposthitis: "The acute infection is dealt with adequately by warm soaks and the administration of an appropriate antibiotic, usually ampicillin..." I suspect that this recommendation will change in the next edition.  Even if one opts to treat this orally as a soft tissue infection, ampicillin seems to offer inadequate coverage these days.  

 

Zitelli/Davis (2007 Edition): Acute Balanitis and Posthitis: "Usual treatment involves slight dilation of a snug preputial opening, warm baths and a broad spectrum antibiotic for a few days if the process is severe".   

 

Emedicine suggests one consider topical antibiotic, &/or topical antifungal &/or topical steroid treatment.  Under balanitis (but not under balanoposthitis) they suggest that "unusual cases" be treated with "appropriate antibiotics":

Balanoposthitis:

http://emedicine.medscape.com/article/1124734-overview <http://emedicine.medscape.com/article/1124734-overview> 

Balanitis:

http://emedicine.medscape.com/article/777026-overview <http://emedicine.medscape.com/article/777026-overview> 

 

First Consult 

"Drug treatment is chosen according to etiology:

*	Candidal infection: first choice is a broad spectrum topical antifungal <https://webmail.chsnj.org/exchange/ZKassutto/Drafts/RE:%20PED-EM-L%20Digest%20-%203%20Jan%202009%20to%204%20Jan%202009%20(%232009-4).EML/1_text.htm?type=med&eid=9-u1.0-_1_mt_1014838#180956>  such as 1% clotrimazole cream  
*	Bacterial infection: first choice is a topical antibacterial <https://webmail.chsnj.org/exchange/ZKassutto/Drafts/RE:%20PED-EM-L%20Digest%20-%203%20Jan%202009%20to%204%20Jan%202009%20(%232009-4).EML/1_text.htm?type=med&eid=9-u1.0-_1_mt_1014838#287979> , such as bacitracin or neosporin ointment 
*	Bacterial infection: second choice (in more severe cases) is a systemic antibiotic <https://webmail.chsnj.org/exchange/ZKassutto/Drafts/RE:%20PED-EM-L%20Digest%20-%203%20Jan%202009%20to%204%20Jan%202009%20(%232009-4).EML/1_text.htm?type=med&eid=9-u1.0-_1_mt_1014838#287990> , such as oral cephalexin that may be needed in addition to topical therapy 
*	Dermatitis: first choice is topical weak steroid 1% hydrocortisone <https://webmail.chsnj.org/exchange/ZKassutto/Drafts/RE:%20PED-EM-L%20Digest%20-%203%20Jan%202009%20to%204%20Jan%202009%20(%232009-4).EML/1_text.htm?type=med&eid=9-u1.0-_1_mt_1014838#288001>  
*	Dermatitis: second choice is topical steroid <https://webmail.chsnj.org/exchange/ZKassutto/Drafts/RE:%20PED-EM-L%20Digest%20-%203%20Jan%202009%20to%204%20Jan%202009%20(%232009-4).EML/1_text.htm?type=med&eid=9-u1.0-_1_mt_1014838#288001>  in conjunction with other antifungal or antibacterial treatments if dermatitis severe"

 

Pediatric Urologic Emergencies and Urgencies: Leslie J, Cain M: Pediatric Clinics of North America - Volume 53, Issue 3 (June 2006) 

"In most cases, the etiology is nonspecific, usually caused by inadequate hygiene of the inner prepucial sulcus or by external irritation (contact dermatitis) from soaps, bubble bath, laundry detergents, or persistent manual manipulation (foreskin fiddling). Colonization by Candida albicans or anaerobic gram-positive bacteria may be present, associated with inability to retract the foreskin and accumulation of smegma. In these cases, a discharge is usually absent, and treatment involves gentle cleaning of the foreskin sulcus, sitz baths, and application of 0.5% hydrocortisone cream. In more severe cases, when the foreskin cannot be easily or comfortably retracted, saline solution or water may be injected under the foreskin with a small angiocatheter. If these measures are not effective or if the inflammation recurs, then a short course of oral antibiotics may be required to eliminate the organisms that may produce irritating enzymes."

 

 

Zach Kassutto, M.D., FAAP

Director Pediatric Emergency Medicine

Capital Health System, New Jersey

 

Assoc. Professor of Pediatrics & Emergency Medicine

Drexel University College of Medicine

St. Christiopher's Hospital for Children

Philadelphia, PA 
________________________________


Date:    Sat, 3 Jan 2009 16:36:02 -0800
From:    marc guttman <[log in to unmask]>
Subject: Re: Balanoposthitis

Are others using Bactroban if suspected bacterial infection?


________________________________
From: "D. Scott Moore, DO, MS" <[log in to unmask]>
To: [log in to unmask]
Sent: Saturday, January 3, 2009 1:43:55 PM
Subject: Re: Balanoposthitis

Antifungals topically and penile care for me.

D. Scott Moore, DO, MS, FAAEM

On Sat, Jan 3, 2009 at 10:52 AM, Garth Meckler <[log in to unmask]> wrote:

> I am curious to hear how people manage balanoposthitis...while the reading
> I have done suggests topical treatment with antifungals or local care is
> sufficient, I confess that I usually find myself prescribing oral
> antibiotics (typically keflex) without solid reasoning.  What do others do?
>
> Garth Meckler, MD, MSHS
> Fellowship Director
> Pediatric Emergency Medicine
> Oregon Health & Science University
>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html
>



--
D. Scott Moore, D.O., M.S., F.A.A.E.M.

For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html




For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
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------------------------------

Date:    Sat, 3 Jan 2009 21:33:59 -0500
From:    "Chamberlain, Jim" <[log in to unmask]>
Subject: Re: Balanoposthitis

Unless there's yeast infection, then I give them topical antifingals...

James Chamberlain, MD

Division Chief, Emergency Medicine

Children's National Medical Center

111 Michigan Avenue, NW

Washington, DC 20010

202.476.3253 (O)

202.476.3573 (F)

202.476.5433 (Emergency Access)


-----Original Message-----
From: Pediatric Emergency Medicine Discussion List
[mailto:[log in to unmask]] On Behalf Of Eugene Izsak
Sent: Saturday, January 03, 2009 12:53 PM
To: [log in to unmask]
Subject: Re: Balanoposthitis

Routine penile care and they all resolve.
E Izsak

On Sat, Jan 3, 2009 at 10:52 AM, Garth Meckler <[log in to unmask]> wrote:

> I am curious to hear how people manage balanoposthitis...while the
reading
> I have done suggests topical treatment with antifungals or local care
is
> sufficient, I confess that I usually find myself prescribing oral
> antibiotics (typically keflex) without solid reasoning.  What do
others do?
>
> Garth Meckler, MD, MSHS
> Fellowship Director
> Pediatric Emergency Medicine
> Oregon Health & Science University
>
> For more information, send mail to [log in to unmask] with
the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html
>

For more information, send mail to [log in to unmask] with the
message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html

Confidentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended
recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited.
If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message.

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The URL for the PED-EM-L Web Page is:
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------------------------------

End of PED-EM-L Digest - 3 Jan 2009 to 4 Jan 2009 (#2009-4)
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