CASE
The patient is a healthy 6-year-old boy who was taken to the pediatrician because of a 2-week history of nonspecific abdominal pain. His medical history is significant for mild asthma and resolved febrile seizures. Surgical history is limited to elective tonsillectomy. The abdominal pain was generalized and persisted intermittently, progressing to a more specific complaint of his “penis hurting.” The child reported that he had the urge to urinate but it hurt too much to do so. He further explained that the pain resolved in midstream.
The patient's mother initially examined his penis; she observed no swelling, discharge, or signs of infection and saw no blood on his underpants. She reported a normal urine color, but saw more drops of urine around the toilet rim with worsening aim that resulted in spraying of the toilet wall. The patient began leaving for school in the morning without urinating and by day's end went to the school nurse doubled over in pain with an urge to urinate, but he refused to do so for fear of pain. The mother became fearful when her son gave out a horrible shout upon urinating and cried uncontrollably. The patient had no history of fever, nausea, vomiting, or change in bowel habits. He denied flank or low back pain. The patient was circumcised at 8 days of life without complication and was toilet trained by 14 months without relapses or issues of poor control. He had no history of recent travel, sick contacts, recent infections, or antibiotics.
Physical examination The patient appeared well and in no acute distress. Vital signs were normal, and skin had normal turgor with no rashes. Lung and auscultatory examinations were normal. Abdominal examination was unremarkable with no hernias, bladder distention, or costovertebral angle tenderness. Genital examination revealed a circumcised male with no penile discharge or lesions, scrotal swelling, or discoloration. He was nontender to palpation. Meatus was central and pinpoint in size. Testes were descended bilaterally with expected size and consistency. Pulses were 2+ and without pedal edema.
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