Penile Pain

Differential Diagnosis

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

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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