Case by Nikki Animasaun, CNH PEM Fellow

15 yo previously healthy M presenting with chronic penile and scrotal swelling. Patient has been having swelling without pain for the past few months. The swelling has increased gradually over the past 2-3 months. He went to his PMD today due to having blisters on the scrotum that popped on Saturday with clear fluid drainage. Denies pain of the penis/scrotum or difficulty urinating. No fever, abdominal pain, vomiting, constipation, diarrhea, dysuria, hematuria, penile drainage/discharge, or trauma to the area. No difficulty walking. No swelling anywhere else.  No medical or surgical hx. No NKDA. UTD on vaccines.

H: Lives at home with mom, dad, and sister. Feels safe at home.
E: Currently in high school
A: Plays football
D: Denies drug, alcohol, tobacco use
S: Never been sexually active
S: Denies SI/HI 

T37.4, HR 80, RR 20, BP 111/75, 99% on RA
General:  Well appearing, shy and soft spoken but interactive
Skin:  Warm, dry, no rashes 
Eye:  PERRL, EOMI, Normal conjunctiva
Ears, nose, mouth and throat:  No pharyngeal erythema or exudate.  Moist mucosal membranes 
Cardiovascular: RRR, No murmurs/rubs/gallops, <2 sec capillary refill
Respiratory:  CTAB. Good aeration bilaterally. No increased WOB.
Gastrointestinal:  Soft, non-tender, non-distended, no guarding or rebound. No palpable masses. No hepatosplenomegaly. 
Genitourinary: Significant swelling of the b/l scrotum and penis. ~1cm blister on anterior aspect of right scrotum. No tenderness of the scrotum or penis. No overlying erythema, no pustules, no ulcerations
Neurological: No focal neurologic deficits 

Testicular ultrasound was obtained and found “Nonspecific scrotal sac/penile soft tissue thickening without discrete cystic/solid mass or fluid collection. Normal sonographic appearance of bilateral testicles”.  A urinalysis was obtained and resulted as: WBC <1, RBC 1, negative ketone, negative LE,  and negative nitrite.

Urology was consulted for possible lymphatic malformation. On their exam patient was found to have large anal skin tags and hemorrhoids, no fissures. They had low suspicion for lymphatic malformations and recommended GI consult.