What is the treatment for a penile fissure?

Treatment of Penile Fissure

For a penile fissure, initiate conservative management with topical metronidazole cream combined with lidocaine 5% applied three times daily, along with measures to prevent trauma and promote healing.

Initial Assessment and Classification

The term "penile fissure" requires clarification of the anatomical location and underlying cause:

• If the fissure is on the penile shaft skin: This is typically a dermatologic issue requiring wound care and infection prevention
• If associated with urethral injury or penile trauma: This requires urgent urological evaluation to rule out fracture of the corpus cavernosum or urethral rupture 1, 2
• If the fissure is in the genital/perineal skin folds: Apply principles similar to other genital fissures 3

First-Line Treatment Protocol

Topical Antibiotic and Anesthetic Combination

• Apply metronidazole cream with lidocaine 5% three times daily for 4 weeks, which has demonstrated healing rates of 86% compared to 56% with lidocaine alone 4
• This combination shows statistically significant pain reduction by week 2 (VAS 2.6 vs 3.3, p=0.004) and week 4 (VAS 1.36 vs 2.47, p<0.001) 4
• Topical antibiotics are specifically indicated when there is evidence of infection or poor genital hygiene 4

Pain Management

• Lidocaine 5% serves as the primary topical anesthetic, reducing pain and breaking the pain-spasm cycle 4, 5
• For severe pain, add oral paracetamol or ibuprofen 4
• Pain control is fundamental as it reduces reflex spasms, decreases local ischemia, and promotes healing 4

Supportive Measures

Hygiene and Wound Care

• Maintain meticulous genital hygiene to prevent secondary infection 4
• Keep the area clean and dry between applications
• Avoid activities that cause friction or trauma to the affected area

Lifestyle Modifications

• Increase fiber intake to 25-30g daily through diet or supplementation to prevent constipation if the fissure extends to the perineal area 5, 6
• Ensure adequate hydration to soften stools and reduce straining 4, 6
• Warm sitz baths can help promote relaxation and healing 4, 6

Escalation of Therapy

If No Improvement After 2 Weeks

• Reevaluate for underlying conditions such as infection, diabetes, or other dermatologic disorders 6
• Consider adding topical calcium channel blockers (nifedipine 0.3% with lidocaine 1.5%) if sphincter spasm is contributing (particularly for perineal/perianal extension) 4, 5
• Continue treatment for a total of 6-8 weeks before considering alternative diagnoses 5, 6

If Persistent After 4-8 Weeks

• Refer to urology or dermatology for evaluation of atypical causes including inflammatory conditions, infections (HIV, syphilis, tuberculosis), or malignancy 6
• Consider biopsy if the fissure appears atypical or fails to heal with appropriate therapy 6

Critical Pitfalls to Avoid

• Never perform manual dilation, as this carries a high risk of tissue damage and complications (temporary incontinence up to 30%, permanent up to 10% in anal fissures) 4, 6
• Do not use hydrocortisone for more than 7 days due to risk of skin atrophy and thinning, which can worsen the fissure 5
• Avoid surgical intervention in the acute phase; surgery is only indicated for chronic, non-healing fissures after 8 weeks of failed conservative management 4, 6

Special Considerations

If Associated with Penile Trauma

• Urgent urological evaluation is mandatory if there is history of trauma, sudden onset during intercourse, or signs of corporal rupture (sudden pain, swelling, discoloration) 1, 2
• Approximately 10% of penile fractures have associated urethral injury requiring immediate surgical repair 2

Duration and Follow-up

• Apply combined topical therapy three times daily for 4 weeks minimum 4
• Approximately 50% of acute fissures heal within 10-14 days with conservative treatment 4, 6
• Schedule follow-up at 2 weeks to assess response and adjust therapy as needed 4