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.

Published: 2nd August 2022 | Updated: 15th August 2022

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

Rectal PainNoYesPossibleNoPossible
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.
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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.