SAEM Clinical Image Series: Pediatric Penis Swelling

A 3-year-old healthy uncircumcised male presents to the Emergency Department with five days of penis swelling and pain. Five days prior, his father noted that the patient’s foreskin appeared stuck behind the head of the penis. The patient was seen at an urgent care facility four days prior and was given an antifungal cream for presumed balanitis, however, this did not resolve the patient’s symptoms. Since that time, the penis has been getting progressively more swollen and painful. The patient has not experienced the inability to urinate, decreased urine output, penile discharge, other penile lesions, fever, chills, abdominal pain, nausea, vomiting, testicular pain, or testicular swelling.

Vitals: Within normal limits

General: Alert, anxious

Genitourinary: Penile swelling, erythema, and tenderness to palpation

Non-contributory

Paraphimosis is a medical emergency due to the risk of tissue necrosis. A preputial or phimotic ring – a circumferential band of tissue – caught behind the glans causes swelling of penile tissue.

In the evaluation of painful penile swelling, the first step is to determine whether the patient is circumcised or not through a review of the medical record or discussion with the patient’s family. In an uncircumcised male, the critical next step is to assess for an entrapped and retracted foreskin (paraphimosis). Visualization of the glans penis and the urethral meatus as in this case demonstrates that the foreskin is retracted. Additionally, visualization of the glans penis and urethral meatus makes a scarred and unretractable foreskin (pathologic paraphimosis) unlikely to be the primary diagnosis. The differential diagnosis also includes hair tourniquet syndrome, chigger bites, and inflammation of the glans and foreskin (balanitis and balanoposthitis).

Take-Home Points

  • In any male presenting with penile pain, it is critical to first ascertain his circumcision status. In an uncircumcised male, visualizing the glans and urethral meatus demonstrates that the foreskin is retracted.
  • Paraphimosis is a medical emergency caused by an entrapped, retracted foreskin.
  1. Bragg BN, Kong EL, Leslie SW. Paraphimosis. 2021 May 4. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 29083645.
  2. 2. Simonis K, Rink M. Paraphimosis. In: Urology at a Glance. Springer Berlin Heidelberg; 2014:361-364. doi:10.1007/978-3-642-54859-8_65

 

 

 

By |2021-09-13T10:34:13-07:00Sep 13, 2021|Genitourinary, Pediatrics, SAEM Clinical Images|

Doxycycline vs Azithromycin: Think Twice About the 2020 CDC Guideline Update on Treatment of Gonorrhea and Chlamydia

cdc gonorrhea chlamydia doxycycline

When the new Centers for Disease Control and Prevention (CDC) recommendations1 regarding the treatment of uncomplicated gonorrhea (and indirectly chlamydia) debuted like a slice of antibiotic resistance doom, it felt like another “gift” had arrived from 2020. Intramuscular (IM) ceftriaxone dosing has increased from 250 mg to 500 mg (or 1 g for weight ≥150 kg). Empiric chlamydia coverage switched from a single dose of 1 g of azithromycin to doxycycline 100 mg PO BID for 7 days. Being deferential to CDC expertise, many providers accepted them uncritically. Compliance rates with a switch from a 1-time to a 7-day regimen are not addressed, especially worrisome for a condition that can be minimally or asymptomatic. 

Case

A young woman presents with new and concerning discharge after an unprotected encounter. Her pregnancy test is negative. After agreement for empiric treatment, the patient then refuses empiric treatment when told about the new guidelines (2 injections and 14 chances for esophagitis). Patient specifically asks for the old regime or will just leave against medical advice.

Why a higher dose of ceftriaxone for gonorrhea?

It is important to note that the evidence of ceftriaxone, cefixime, and azithromycin resistance for gonorrhea is substantial.2 Observational data from across the United States and world demonstrate worsening resistance patterns. Many of our pharmacy colleagues are working on obtaining 500 mg/2 mL ceftriaxone for injection vials, so it can be given in single injection (or two for morbidly obese patients). While this guideline may be existentially troubling, this change is practically feasible and should become standard of care.

Read more about the Trick of the Trade on administering IV instead of IM ceftriaxone for gonorrohea.

Why no mention of the single-dose azithromycin option for chlamydia?

The evidence basis for the change to doxycycline for treatment of chlamydia co-infection coverage is substantially weaker. It is also decidedly mute on the risks of partial or non-compliance with treatment. The question then becomes: How profound is the treatment effect and how does it balance against its risks?

The guideline states, as evidence for the doxycycline switch:

“A recent investigation comparing children who received twice-yearly azithromycin with children who received placebo found that the gut’s resistome, a reservoir of antimicrobial resistance genes in the body, had increased determinants of macrolide and nonmacrolide resistance, including beta-lactam antibiotics, among children receiving azithromycin (10).3 A higher proportion of macrolide resistance in nasopharyngeal Streptococcus pneumoniae was demonstrated in communities receiving mass administration of oral azithromycin (11).4 Azithromycin resistance has been demonstrated in another STI, Mycoplasma genitalium, and sexually transmissible enteric pathogens (e.g., Shigella and Campylobacter) (12–14)5-7. In addition, evidence supports increasing concern for the efficacy of azithromycin to treat chlamydial infections, especially rectal infections (15,16)8,9.”

Citations 10 and 11 speak in generalities of resistance patterns, with citation 11 being a secondary analysis of a mass azithromycin treatment trial of young children in Niger. Citations 12-14 discuss rates of coinfection treatment failure – an important consideration, but only secondarily relevant. That leaves 2 citations (15 and 16)– one a meta-analysis and one a small poster that isn’t even available online related to known anorectal chlamydia.

That really leaves the meta-analysis8 to answer our question: how best do we protect the reproductive health of our patients in the setting of diagnostic uncertainty?

The meta-analysis

The meta-analysis is somewhat messy with substantial heterogeneity in many relevant subgroups.8 A single study comprises the majority of the evidence that shows doxycycline superiority in non-gonococcal urethritis.10 It was from 2011 and revealed that while doxycycline may be better for chlamydia treatment, azithromycin was better for coinfection treatment (such as shigella or mycoplasma). And to top the whole thing, the doxycycline superiority line reads:

“We found a pooled efficacy difference in favor of doxycycline of 1.5%… to 2.6%.”

In men with symptomatic urethritis, the superiority of doxycycline increases to 7% (an NNT of 14). If you ignore the heterogeneity and pool everyone, we arrive with an overall NNT for doxycycline over azithromycin of 38 (fixed effects model size was a 2.6% advantage). If the above study10 was removed, the pooled difference would have been non-significant with an NNT of at least 50.

Having thought perhaps they just didn’t include all the evidence, a secondary literature review was undertaken. A few small case studies11 and older observational studies12,13 were found, which showed a potential treatment failure rate of azithromycin of up to 8%, but comparable rates with doxycycline.12 That’s it. There is also genuine concern that use of azithromycin may induce resistance not only for itself but other antibiotic classes3,4 but this concern is based on fecal biome sampling from toddlers and requires a couple of steps to be relevant to our question. Doxycycline, an essential medication in its own right, for treatment of tick-borne disease, ascending genital tract infections, COPD exacerbation and MRSA, also requires our stewardship.

Medication compliance questions

Given patient non-compliance with filling and completing ED prescriptions approach rates of 20%,14,15 the recommendation for a 7-day course of doxycycline for chlamydia over single-dose azithromycin is fraught with peril. Additionally, consider that the patient may be relatively asymptomatic, placing them even more at risk for medication non-compliance for the 7-day course of doxycycline. Contrast this with the risks of pelvic inflammatory disease and infertility if untreated.

Conclusion

Given the sparse, heterogenous literature, we should have strong reservations about recommending doxycycline for patients for whom chlamydia has not been excluded. New gonorrhea treatment recommendations should be followed and efforts made to stock appropriate concentrations of ceftriaxone. A single-dose of azithromycin may be a reasonable alternative for your patient for non-gonococcal disease, after considering and discussing the risks and benefits. Pregnant patients require close follow up but should also continue to receive azithromycin.

If you are prescribing doxycycline, remember:

  • Each pill should be taken with 6-8 oz of liquid, water preferred. 
  • If taken with food, it decreases the risk of dyspepsia.
  • One should sit upright for 30 minutes following each pill, especially those with history of GERD.
  • If substantially sunexposed, sunscreen or full skin coverage should be recommended to prevent photosensitive reactions (which can be mild to quite severe).

If you are prescribing azithromycin, remember:

  • Azithromycin can cause clinically significant increases of QTc even with a single dose, but typically only to those with multiple risk factors.16 Consider ECG if patient on QTc prolonging medications and/or coexisting electrolyte derangements discovered.
  • The risk of treatment failure for chlamydia and other non-gonococcal coinfections is real. For men with symptomatic urethritis, that risk is substantially higher.
  • Have a shared decision discussion about doxycycline versus azithromycin.
  • While all patients should receive verbal and written follow-up instructions, close follow up should be emphasized, given that you are essentially contravening a CDC guideline.

Patient case resolution

You explain to your patient that the new guidelines should be followed for gonorrhea, and so she receives 500 mg of IM ceftriaxone. While the new guideline for doxycycline MAY be slightly more effective for the treatment of chlamydia, using shared decision making, she receives the old regimen (single-dose azithromycin). You verbally emphasize and document in the discharge instructions the importance they follow up with either their PCP, gynecologist, or the local sexually transmitted infection clinic for a recheck, if their symptoms don’t resolve within 7 days.


References

  1. St. Cyr S, Barbee L, Workowski KA, et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1911–1916. DOI: http://dx.doi.org/10.15585/mmwr.mm6950a6external icon
  2. https://www.cdc.gov/std/treatment-guidelines/toe/GCEvidenceTables2020.xlsx [Download file link]
  3. Doan T, Worden L, Hinterwirth A, et al. Macrolide and nonmacrolide resistance with mass azithromycin distribution. N Engl J Med 2020;383:1941–50. PMID 33176084
  4. Doan T, Arzika AM, Hinterwirth A, et al.; MORDOR Study Group. Macrolide resistance in MORDOR I—a cluster-randomized trial in Niger. N Engl J Med 2019;380:2271–3. PMID 31167060
  5. Bachmann LH, Kirkcaldy RD, Geisler WM, et al. Prevalence of Mycoplasma genitalium infection, antimicrobial resistance mutations and symptom resolution following treatment of urethritis. Clin Infect Dis 2020;ciaa293. Epub March 18, 2020. PMID 32185385
  6. Yousfi K, Gaudreau C, Pilon PA, et al. Genetic mechanisms behind the spread of reduced susceptibility to azithromycin in Shigella strains isolated from men who have sex with men in Québec, Canada. Antimicrob Agents Chemother 2019;63:e01679–18. PMID 30455248
  7. Gaudreau C, Pilon PA, Sylvestre JL, Boucher F, Bekal S. Multidrug-resistant Campylobacter coli in men who have sex with men, Quebec, Canada, 2015. Emerg Infect Dis 2016;22:1661–3. PMID 27533504
  8. Kong FY, Tabrizi SN, Law M, et al. Azithromycin versus doxycycline for the treatment of genital chlamydia infection: a meta-analysis of randomized controlled trials. Clin Infect Dis 2014;59:193–205. PMID 24729507
  9. Dombrowski JC, Wierzbicki MR, Newman L, et al. A randomized trial of azithromycin vs. doxycycline for the treatment of rectal chlamydia in men who have sex with men. Presented at the National STD Prevention Conference, Atlanta, GA: September 14–24, 2020.
  10. Schwebke JR, Rompalo A, Taylor S, et al. Re-evaluating the treatment of nongonococcal urethritis: emphasizing emerging pathogens randomized clinical trial. Clin Infect Dis. 2011 Jan 15;52(2):163-70. PMID 21288838
  11. Bhengraj AR, Vardhan H, Srivastava P, Salhan S, Mittal A. Decreased susceptibility to azithromycin and doxycycline in clinical isolates of Chlamydia trachomatis obtained from recurrently infected female patients in India. Chemotherapy. 2010;56(5):371-7. PMID 20938174
  12. Golden MR, Whittington WL, Handsfield HH, Hughes JP, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. New Engl J Med. 2005 Feb 17;352(7):676-85. PMID 15716561
  13. Fortenberry DJ, Brizendine EJ, Katz BP, et al. Subsequent Sexually Transmitted Infections Among Adolescent Women With Genital Infection Due to Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis. Sex Transm Dis. 1999 Jan 1;26(1):26-32. PMID 9918320
  14. Saunders CE. Patient compliance in filling prescriptions after discharge from the emergency department. Am J Emerg Med. 1987 Jul 1;5(4):283-6.
  15. Ho J, Taylor DM, Cabalag MS, Ugoni A, Yeoh M. Factors that impact on emergency department patient compliance with antibiotic regimens. Emerg Med J. 2010 Nov 1;27(11):815-20. PMID 20513734
  16. Hancox JC, Hasnain M, Vieweg WV, et al. Azithromycin, cardiovascular risks, QTc interval prolongation, torsade de pointes, and regulatory issues: a narrative review based on the study of case reports. Ther Adv Infect Dis. 2013 Oct;1(5):155-65. PMID 25165550

By |2021-01-11T14:32:02-08:00Jan 13, 2021|Genitourinary, Infectious Disease|

Purple Urine Bag Syndrome: A visual diagnosis and what it means for your patient

purple urine bag syndrome

A 78-year-old male is brought in from his nursing home for evaluation of hypotension. He has a prior history of multiple strokes and is bed bound. He arrives febrile, tachycardic, and hypotensive. On your physical exam, you notice that he has an indwelling foley catheter. The catheter tubing and bag have a vibrant purple color. You wonder if this unusual urine color could be caused by something insidious. Could this be related to a toxin, medication, or infection?

(more…)
By |2020-09-02T11:30:29-07:00Sep 23, 2020|Diagnose on Sight, Genitourinary|

ALiEM AIR | Renal/Genitourinary 2020 Module

Welcome to the AIR Renal/Genitourinary Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index, the ALiEM AIR Team is proud to present the highest quality online content related to renal and genitourinary emergencies. 6 blog posts within the past 12 months (as of May 2020) met our standard of online excellence and were curated and approved for residency training by the AIR Series Board. We identified 1 AIR and 5 Honorable Mentions. We recommend programs give 3 hours (about 30 minutes per article) of III credit for this module.

AIR Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.

Take the AIR Renal/GU Quiz on ALiEMU

 

Interested in taking the renal/GU quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, 1-time login account.

Highlighted Quality Posts: Renal/GU Emergencies

SiteArticleAuthorDateLabel
emDocsComplications of Nephrostomy Tubes: ED Presentations, Evaluation, and ManagementMichael J. Yoo, MD11/11/2019AIR
RebelEMPost Contrast Acute Kidney InjurySalim Rezaie, MD1/16/2020HM
EMCritThe Myth of Contrast NephropathyJosh Farkas, MD5/2/2019HM
EMCritNon-Anion Gap Metabolic Acidosis (NAGMA)Josh Farkas, MD9/19/2019HM
emDocs[email protected]: Kidney Transplant ComplicationsRachel Bridwell, MD12/29/2019HM
CanadiEMTesticular TorsionSubhrata Verma11/12/2019HM

(AIR = Approved Instructional Resource; HM = Honorable Mention)

 

If you have any questions or comments on the AIR series, or this AIR renal/genitourinary module, please contact us! More in-depth information regarding the Social Media Index.

Thank you to the Society of Academic Emergency Medicine (SAEM) and the Council of EM Residency Directors (CORD) for jointly sponsoring the AIR Series! We are thrilled to partner with both on shaping the future of medical education.

Trick of the Trade: Angiocatheter for manual aspiration of priapism

needle position for priapism

A 25-year-old man presents with 6 hours of penile pain and swelling after recreational penile injection of Trimix (alprostadil, papaverine, and phentolamine). He denies any history of sickle cell disease or penile trauma. On exam, he is in moderate discomfort and has a tumescent penis with a soft glans. You suspect the patient is suffering from ischemic, low-flow priapism. Manual compression and ice application have been attempted with no significant improvement in the patient’s clinical status.

(more…)

By |2020-05-13T11:19:13-07:00Jun 10, 2020|Genitourinary, Tricks of the Trade|

Beyond the Abstract: Systemic Online Academic Resources Review: Renal and Genitourinary

Production and use of free open access medical education resources (FOAM) has had a meteoric rise over the last decade.​1–4​ ALiEM works hard to produce content, disseminate knowledge, and consolidate resources in a democratic and accessible way. However, we recognize that FOAM comes with its own limitations:

  1. Blogs are distinct, individual, and decentralized. How can we search for topic-specific content?
  2. FOAM doesn’t often have peer review. How can we assess quality and accuracy? 
  3. FOAM is produced on an as-needed basis. How do we achieve curricular comprehensiveness?

(more…)

By |2020-05-28T12:37:11-07:00May 20, 2020|Genitourinary, Renal|

Diagnose on Sight: Scrotal Swelling

pneumoscrotum

Case: A 58-year-old male with no past medical history presents to the emergency department for evaluation of right lower quadrant abdominal pain associated with right scrotal swelling. The patient reports that he had a colonoscopy the day before to remove a 20 mm polyp, which had been seen on an outpatient CT scan. He states that he noticed that his right scrotum appeared slightly swollen immediately away after the procedure, but since then the swelling had increased and he developed mild right lower quadrant abdominal pain. Physical examination reveals mild tenderness to the right lower quadrant and swelling of the right scrotum with palpable crepitus of the right scrotum and inguinal canal.  There is no overlying skin discoloration.  What is the most likely diagnosis?

(more…)

Go to Top