Treatment of Penile Pain Associated with Urinary Tract Infection
For penile pain associated with UTI, the recommended treatment is appropriate antibiotic therapy targeting the causative pathogen, with first-line options including doxycycline 100 mg orally twice daily for 7 days for non-gonococcal urethritis or ceftriaxone 1g IM/IV single dose plus azithromycin 1g orally single dose for gonococcal infection. 1
Diagnostic Approach
Before initiating treatment, it's crucial to identify the underlying cause of penile pain:
Determine if urethritis is present:
- Check for purulent or mucopurulent discharge
- Assess for dysuria, urinary frequency, and urgency
- Examine for erythema or inflammation of the urethral meatus
Obtain appropriate specimens:
- Urethral swab for culture and NAAT (nucleic acid amplification test)
- First-void urine sample
- Urine culture to identify causative organisms
Treatment Algorithm
Step 1: Empiric Treatment Based on Likely Pathogen
For Suspected Gonococcal Infection:
- First-line: Ceftriaxone 1g IM or IV single dose PLUS Azithromycin 1g orally single dose 1
- Alternative regimens (for cephalosporin allergy):
- Cefixime 400mg orally single dose plus azithromycin 1g orally single dose
- Gentamicin 240mg IM single dose plus azithromycin 2g orally single dose
- Gemifloxacin 320mg orally single dose plus azithromycin 2g orally single dose
For Non-gonococcal Urethritis (unidentified pathogen):
- First-line: Doxycycline 100mg orally twice daily for 7 days 1
- Alternative: Azithromycin 500mg orally on day 1, then 250mg orally for 4 days
For Specific Pathogens:
Chlamydia trachomatis:
- Azithromycin 1.0-1.5g orally single dose, OR
- Doxycycline 100mg orally twice daily for 7 days
Mycoplasma genitalium:
- Azithromycin 500mg orally on day 1
- For macrolide resistance: Moxifloxacin 400mg daily for 7-14 days
Trichomonas vaginalis:
- Metronidazole/Tinidazole 2g orally single dose
Step 2: Management of Persistent Symptoms
For persistent urethritis after initial treatment:
- After first-line doxycycline: Azithromycin 500mg orally on day 1, then 250mg orally for 4 days
- After first-line azithromycin: Moxifloxacin 400mg orally daily for 7-14 days PLUS Metronidazole 400mg orally twice daily for 5 days 1
Adjunctive Measures for Pain Relief
While antibiotics address the underlying infection, these measures can help manage penile pain:
- Adequate hydration to dilute urine and reduce irritation
- Avoid alcohol, caffeine, and spicy foods that may irritate the urinary tract
- Over-the-counter pain relievers like acetaminophen or NSAIDs for discomfort
- Warm sitz baths to relieve local discomfort
Partner Management
- Sexual partners should be treated while maintaining patient confidentiality 1
- Patients should refer all sexual partners from the preceding 60 days for evaluation and treatment 1
- Patients should abstain from sexual intercourse until 7 days after therapy is initiated 1
Follow-up Recommendations
- Patients should return for evaluation if symptoms persist or recur after completing therapy 1
- Symptoms alone, without documentation of signs or laboratory evidence of urethral inflammation, are not sufficient basis for re-treatment 1
- Clinical response should be assessed within 48-72 hours of starting treatment 2
Common Pitfalls and Caveats
Antibiotic resistance: Local resistance patterns should guide antibiotic selection, particularly for fluoroquinolones and trimethoprim-sulfamethoxazole.
Inadequate diagnosis: Ensure proper specimen collection before initiating antibiotics to avoid treating asymptomatic bacteriuria.
Incomplete treatment: Emphasize the importance of completing the full course of antibiotics even if symptoms improve.
Missed STI diagnosis: Penile pain may be due to sexually transmitted infections rather than typical UTI pathogens, requiring different treatment approaches.
Recurrent infections: For patients with recurrent symptoms, consider urologic evaluation for anatomical abnormalities or chronic prostatitis.