What is the appropriate management and treatment for a patient with a swollen penis?

Management and Patient Education for Penile Swelling

The approach to a swollen penis depends critically on distinguishing between traumatic injury (penile fracture), priapism, infectious causes, and benign conditions—each requiring vastly different management strategies.

Immediate Assessment: Rule Out Emergencies

Penile Fracture (Traumatic Injury)

• Suspect penile fracture if the patient reports penile ecchymosis, swelling, a cracking or snapping sound during intercourse or manipulation, and immediate detumescence 1
• This is a urological emergency requiring prompt surgical exploration and repair to prevent long-term complications including erectile dysfunction 1
• If signs are equivocal, ultrasound may be performed, but if diagnosis remains uncertain, surgical exploration should still be performed 1
• Evaluate for concomitant urethral injury if blood is present at the urethral meatus, gross hematuria, or inability to void 1

Priapism (Prolonged Erection)

• Ischemic priapism presents with completely rigid corpora cavernosa and is a medical emergency requiring immediate intracavernous treatment 1
• Non-ischemic priapism presents with tumescent but not completely rigid corpora, is non-painful, and is NOT an emergency 1
• Non-ischemic priapism should be managed with an initial 4-week period of observation, as spontaneous resolution often occurs 1
• If non-ischemic priapism persists and bothers the patient, embolization is first-line therapy (85% success rate) 1

Infectious Causes

Epididymitis/Orchitis

• Presents with unilateral testicular pain, tenderness, and swelling of the epididymis 2
• Testicular torsion must be ruled out first, especially in adolescents—this is a surgical emergency 1, 2
• For sexually transmitted epididymitis: ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days 1, 2
• For enteric organisms or antibiotic allergies: ofloxacin 300 mg orally twice daily for 10 days 1, 2
• Adjunctive therapy includes bed rest, scrotal elevation, and analgesics until fever and inflammation subside 1, 2
• Reevaluate if no improvement within 3 days 1, 2

Balanoposthitis (Glans/Foreskin Infection)

• Inflammation of the glans penis, often involving the prepuce, most commonly infectious 3
• Candida albicans is the most frequently isolated organism, followed by Staphylococcus and Streptococcus species 3
• Treatment typically involves antifungal agents for candida infections; bacterial infections require appropriate antibiotic therapy 3

Penile Abscess

• Rare but serious condition presenting with penile pain and swelling 4, 5
• Can occur from trauma, foreign bodies, or in immunocompromised patients (especially uncontrolled diabetes) 5
• Requires drainage (surgical or image-guided aspiration) plus broad-spectrum antibiotics 4, 5
• Streptococcus intermedius and other organisms can cause severe complications including abscess rupture 4

Benign/Non-Emergency Causes

Penile Friction Edema

• Results from traumatic lymphatic drainage disruption during vigorous sexual activity 6
• Presents as local or total penile edema without infectious signs 6
• Diagnosis is by exclusion after ruling out infectious and obstructive causes 6
• Treatment is temporary abstinence from sexual intercourse for several weeks 6

Foreign Body Reactions (Paraffinoma)

• Chronic granulomatous reaction from injection of foreign substances (paraffin, silicone) for penile augmentation 7
• Presents with elastic, painful penile swelling and can cause skin necrosis, deformity, and chronic ulceration 7
• Treatment requires radical surgical excision with possible reconstruction 7

Patient Education Key Points

When to Seek Emergency Care

• Immediate evaluation needed for: sudden penile swelling with cracking sound and detumescence (fracture), painful rigid erection lasting >4 hours (ischemic priapism), blood at urethral meatus, inability to void, or signs of severe infection (fever, rapidly spreading redness) 1

Non-Emergency Situations

• Painless tumescent erection can be observed at home for up to 4 weeks 1
• Mild swelling after vigorous sexual activity without other symptoms may resolve with abstinence 6

Sexual Activity Restrictions

• Avoid sexual intercourse during treatment of infectious causes until both patient and partner complete therapy and are symptom-free 1, 2
• Partners of patients with STI-related infections require evaluation and treatment 1, 2

Follow-Up Requirements

• Return for evaluation if no improvement within 3 days of starting treatment for infectious causes 1, 2
• Persistent swelling after completing therapy requires comprehensive reevaluation to exclude tumor, abscess, or other serious pathology 1, 2

Common Pitfalls to Avoid

• Never delay surgical consultation for suspected penile fracture—conservative management leads to worse long-term erectile function outcomes 1
• Do not treat ischemic priapism with systemic therapy alone in patients with sickle cell disease or hematologic disorders—intracavernous treatment must be provided concurrently 1
• Do not confuse non-ischemic priapism with ischemic priapism—the former is not an emergency and does not require urgent intervention 1
• Always rule out testicular torsion in patients presenting with testicular/scrotal swelling and pain, especially in younger patients 1, 2