Penile Ulceration/ Sores

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

Rare Diagnoses

  • Syphilis (Chancre)
  • Carcinoma of the Penis
  • Tuberculosis
  • Dermatological Conditions (e.g. behçet’s Syndrome, Lichen Planus)
  • Fixed Drug Eruption

Ready Reckoner

Key distinguishing features of the most common diagnoses

Herpes SimplexBoilBalanitisTraumaBXO
DysuriaPossibleNoPossiblePossiblePossible
Contact with SymptomsPossibleNoPossibleNoNo
Inguinal Nodes EnlargedYesPossiblePossibleNoNo
Discrete Single LesionNoYesNoPossibleNo
Generally UnwellPossibleNoNoNoNo

Possible Investigations

Likely:Swab, syphilis serology.

Possible:Urinalysis, FBC, ESR/CRP.

Small Print:Patch testing, biopsy.

  • Urinalysis: In balanitis, may detect undiagnosed diabetes.
  • Swab: May reveal infectious cause, e.g. herpes simplex, Candida, chancroid, lymphogranuloma venereum and granuloma inguinale (if STD suspected, then other appropriate swabs and blood tests for coexistent disease will be performed at GUM clinic).
  • FBC and ESR/CRP: Raised WCC and ESR/CRP in significant infection or inflammation (e.g. Reiter’s syndrome).
  • Syphilis serology: If syphilis suspected (Note: May take up to 3 months to become positive after initial infection).
  • Patch testing: If allergic contact eczema a possibility.
  • Biopsy (in secondary care): To confirm suspected malignancy or reveal underlying skin condition (e.g. lichen planus).

Top Tips

  • Take a full sexual history, even in the older patient. If STD is suspected, refer to a GUM clinic for investigation, counselling and contact tracing.
  • A diagnosis of HSV may induce a number of worries in the patient, some of them well founded, others less so. Give the patient plenty of time to talk through the diagnosis and its implications properly.
  • Whatever the cause, the patient is very likely to fear an STD. Ensure that inappropriate anxieties are resolved.
  • Enquire after coexistent or previous dermatological problems in obscure cases – this may provide the diagnosis (e.g. lichen planus).

Red Flags

  • A history of travel or sexual contact with travellers is important – a number of the more obscure causes are ‘tropical’.
  • Take a sexual history – syphilis is rare generally but is more common in homosexuals.
  • Balanitis and urethritis, arthritis and conjunctivitis form the triad of Reiter’s syndrome. Always make a thorough general systemic enquiry.
  • A single, unexplained, persistent ulcer needs thorough investigation as significant disease (infection or malignancy) is likely.
  • Remember the possibility of underlying diabetes in severe or recurrent candidal balanitis.

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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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.