Penile Pain

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

Rare Diagnoses

  • Anal Fissure/Inflamed Haemorrhoid
  • Carcinoma of Penis
  • Carcinoma of Rectum/Anus
  • Tuberculosis of Urinary Tract
  • Schistosomiasis (Schistosoma Haematobium): Common in Africa and the Middle East

Ready Reckoner

Key distinguishing features of the most common diagnoses

BalanitisProstatitisCalculusPhimosisUrethritis
DysuriaPossiblePossiblePossiblePossibleYes
DischargeYesPossibleNoPossibleYes
Rectal PainNoYesPossibleNoPossible
HaematuriaNoPossibleYesNoPossible
Tender GlansYesNoNoPossibleNo

Possible Investigations

Likely:Urinalysis, MSU, swabs.

Possible:FBC, ESR/CRP, PSA.

Small Print:Renal tract imaging, cystoscopy, terminal stream urine.

  • Urinalysis: May reveal proteinuria, haematuria, pus cells and nitrites in the presence of infection; haematuria alone with a stone or tumour. Will also reveal glycosuria in the previously undiagnosed diabetic (may present with candidal balanitis).
  • MSU (for MC&S): To establish pathogen in UTI (may also reveal infective agent in prostatitis).
  • Swabs for microbiology: Urethral swab if urethritis likely (best performed at GUM clinic). In balanitis with discharge, a swab may help guide treatment.
  • FBC and ESR/CRP: WCC and ESR/CRP raised in significant infection and inflammation (e.g. prostatitis or prostatic abscess). ESR/CRP may be raised in malignancy.
  • PSA: Consider this test if carcinoma of the prostate a possibility.
  • Renal tract imaging (usually hospital-based) to investigate the urinary tract if stone or carcinoma suspected, or if chronic UTI suspected.
  • Terminal stream urine: For schistosomiasis.
  • Cystoscopy: May be required in secondary care to confirm and treat stone or tumour.

Top Tips

  • The man who has symptoms suggesting cystitis but who has sterile pyuria on MSU probably has urethritis.
  • GUM clinics are organised to undertake full investigation, counselling and contact tracing. Referral is essential if STD is likely.
  • Prostatitis is often forgotten as a diagnosis – but is very difficult to diagnose with certainty, especially when chronic. A trial of a prolonged course of antibiotics may be justified.
  • Painful intercourse: Usually a sudden pain – accompanied by bleeding suggests a torn frenulum. This often occurs in a younger man who is frequently very alarmed by the event. Reassure him by explaining that this is not sinister and is easily treatable.

Red Flags

  • Pain after micturition suggests cystitis. This is unusual in men, and further investigation is indicated if recurrent.
  • Intermittent pain with passage of blood clots interspersed with painless haematuria suggests a carcinoma (bladder, ureter [rare] or kidney).
  • Remember that candidal balanitis may be the first sign of diabetes.
  • Refer the elderly man with an adherent foreskin and balanitis. There could be an underlying carcinoma.

Published: 2nd August 2022 Updated: 10th April 2024

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Based on the best-selling book Symptom Sorter, Nursing in Practice Reference is designed to help nurses working in primary and community care make sense of patient presentations. Written by GPs and adapted by nurses, it covers the vast majority of symptoms seen in primary care to inform different nursing disciplines with a range of responsibilities. Each symptom is organised into common, occasional or rare differentials, with distinguishing features, possible investigations and key points. It also provides guides on managing more than 350 conditions. The perspective is very much grass roots primary care, informed by the latest evidence and guidance.

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Disclaimer

Nursing in Practice Reference is based on the best-selling book Symptom Sorter. The experts behind Nursing in Practice Reference are Marilyn Eveleigh who is Nursing in Practice’s editorial advisor and a primary care nurse in East Sussex, Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.