Penile Pain
Pain in the penis occurs not just as a result of local causes, but also by referral from remote lesions. It frequently generates embarrassment for the patient, who may also be frightened that he has a sexually transmitted disease. The diagnosis will often be clear after a carefully taken history and appropriate examination.
Differential diagnosis
Common Diagnoses
- Balanitis (Fungal, Bacterial or Allergic)
- Acute Urethritis
- Phimosis (e.g. Balanitis Xerotica Obliterans)
- Urinary Calculus (at any Point in Ureter or Urethra)
- Prostatitis/Prostatic Abscess
Occasional Diagnoses
- Herpes Simplex (and Rarely Zoster)
- Carcinoma of Bladder or Prostate
- Trauma: Torn Frenulum, Zipper Injury, Urethral Injury or Foreign Body
- Acute Cystitis
- Peyronie’s Disease (Pain Usually on Erection)
- Paraphimosis
- Tight Frenulum
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
| Balanitis | Prostatitis | Calculus | Phimosis | Urethritis | |
|---|---|---|---|---|---|
| Dysuria | Possible | Possible | Possible | Possible | Yes |
| Discharge | Yes | Possible | No | Possible | Yes |
| Rectal Pain | No | Yes | Possible | No | Possible |
| Haematuria | No | Possible | Yes | No | Possible |
| Tender Glans | Yes | No | No | Possible | No |
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.