What is the diagnosis and treatment for constant burning and pressure in the genitals?

Diagnosis and Management of Constant Genital Burning and Pressure

The most likely diagnosis is dysaesthetic genital pain (vulvodynia in females, dysaesthetic peno/scroto-dynia in males), which requires treatment with neuropathic pain medications rather than topical corticosteroids, after excluding infectious, dermatologic, and structural causes.

Initial Diagnostic Approach

Rule Out Infectious Etiologies First

• Obtain urethral swab or first-void urine for gonorrhea and chlamydia testing if sexually active, particularly with urethral involvement or dysuria 1
• Screen for sexually transmitted infections including syphilis serology 2
• Evaluate for urethritis with Gram-stained smear showing ≥5 polymorphonuclear leukocytes per oil immersion field 2
• Examine first-void urine for leukocytes and pyuria 2

Screen for Dermatologic Conditions

• Perform biopsy if lichen sclerosus is suspected (presents with hyperkeratosis, ecchymoses, fissuring, erosions, atrophy, and color change) 3, 1
• Look for signs of introital narrowing causing dyspareunia or micturition difficulties 3
• Assess for vulvar/penile anatomical changes suggesting chronic inflammatory conditions 3

Consider Structural and Hormonal Causes

• In transgender patients on testosterone, evaluate for vaginal/genital atrophy causing dryness and pain 1
• Rule out testicular torsion in males with acute onset, especially adolescents (requires immediate specialist consultation) 2
• In males over 35, consider enteric Gram-negative organisms causing epididymitis with pyuria 2

Diagnosis of Neuropathic Genital Pain

When to Suspect Dysaesthesia

• Burning sensation persists despite clinical improvement or resolution of any skin lesions 3
• No positive physical findings or laboratory abnormalities despite persistent symptoms 4
• Previous failure to respond to antibiotics, antifungals, and topical corticosteroids 4
• Pain described as burning, stinging, irritation, or rawness without identifiable cause 5

Key Diagnostic Features

• In females: vestibulodynia or vulvodynia occurring after inflammatory vulvar conditions 3
• In males: abnormal burning sensation on glans or around urethral meatus 3
• Symptoms present for at least 3 months without clearly identifiable cause 6
• This is a diagnosis of exclusion after ruling out other etiologies 5, 6

Treatment Algorithm

For Confirmed Infectious Causes

• If sexually transmitted epididymitis suspected in men under 35: ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 2
• Alternative: ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 2
• In men over 35 with enteric organisms: fluoroquinolones (levofloxacin or ofloxacin) 2

For Lichen Sclerosus

• Initiate clobetasol propionate ointment once nightly for 4 weeks, then alternate nights for 4 weeks, then twice weekly for the third month 3
• A 30-g tube should last 12 weeks 3
• Continue as needed for maintenance after initial 3-month course 3
• Hyperkeratosis, ecchymoses, fissuring, and erosions should resolve, though atrophy and color change remain 3

For Neuropathic/Dysaesthetic Pain (Primary Treatment)

• Start with lidocaine 5% ointment as first-line therapy 3
• Progress to selective serotonin reuptake inhibitors (SSRIs) if lidocaine fails, as patients report improvement in symptoms and quality of life with SSRIs 4
• Amitriptyline for unresponsive cases 3
• This neuropathic pain will NOT respond to topical corticosteroids 3

For Testosterone-Induced Atrophy (Transgender Patients)

• Vaginal estrogen therapy is first-line treatment for vaginal dryness and painful intercourse caused by testosterone-induced atrophy 1
• Do not discontinue testosterone without thorough evaluation, as this worsens gender dysphoria and quality of life 1

Adjunctive Measures

• Pelvic floor physical therapy has consistent evidence of benefit 6
• Cognitive behavioral therapy for psychological components 6, 7
• Vulvar care measures and avoidance of irritants 6
• Vaginal lubricants and moisturizers 6

Critical Pitfalls to Avoid

• Do not treat neuropathic genital pain with topical corticosteroids—it will not respond 3
• Do not assume all genital pain requires antibiotics; confirm infectious etiology first 2
• In transgender patients, avoid discontinuing testosterone and avoid making patients remove gender-affirming garments unnecessarily 1
• Do not miss testicular torsion in males with sudden severe pain onset—this requires emergency specialist consultation 2
• Recognize that documented bias and undertreatment of pain occurs in transgender populations 1
• If no improvement within 3 days of antimicrobial therapy for suspected infection, reevaluate for tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal infection 2

Follow-Up Considerations

• Address psychosexual concerns, as chronic genital pain significantly impacts quality of life and sexual functioning 3, 1
• Screen for comorbid anxiety, depression, and substance use, which are more prevalent and affect pain management 1
• Sexual partners of patients with confirmed STI-related conditions should be evaluated and treated 2
• Consider referral to sexual health specialist for comprehensive management when pain persists 1