What causes a burning sensation in the groin area?

Burning Sensation in the Groin Area

Most Likely Causes

The most common causes of burning groin sensation are infectious urethritis (particularly from Chlamydia trachomatis or Neisseria gonorrhoeae), dermatologic conditions (especially fungal infections and lichen sclerosus), and neuropathic pain syndromes. 1, 2

Infectious Etiologies

• In sexually active individuals, urethritis is the primary consideration, with Chlamydia trachomatis and Neisseria gonorrhoeae being the predominant organisms in men under 35 years 3, 1
• Burning at the urethral meatus or penile tip strongly suggests urethritis, which may present with or without visible discharge 1
• Enteric organisms become more likely in older patients or those with urinary tract abnormalities 3

Dermatologic Causes

• Fungal infections (tinea cruris) are among the most common groin lesions, presenting with burning, pruritus, and characteristic scaling borders 2
• Lichen sclerosus causes penile dysaesthesia with abnormal burning sensation on the glans or around the urethral meatus, which persists despite resolution of visible skin lesions 3, 1
• Bacterial infections including erysipelas and folliculitis can cause burning groin pain 2

Neuropathic Pain Syndromes

• Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) should be considered when burning persists ≥3 months, particularly if exacerbated by urination or ejaculation 1
• Patients with CP/CPPS characteristically describe "pressure" rather than "pain" localized to the perineum, suprapubic region, or penile tip 1
• Neuropathic pain from lichen sclerosus will not respond to topical corticosteroids; treatment must target neuronal sensitization 3, 1
• Entrapment of the ilioinguinal, iliohypogastric, genitofemoral, or lateral femoral cutaneous nerves can cause burning groin pain 4

Critical Diagnostic Workup

Immediate Assessment Required

• Urinalysis and urine culture are mandatory first steps 1
• Gram-stained smear of urethral exudate or intraurethral swab, plus nucleic acid amplification test for N. gonorrhoeae and C. trachomatis on intraurethral swab or first-void urine 3, 1
• Microscopic examination and culture of skin scrapings if dermatologic lesions are present 2
• Wood's light examination to identify erythrasma (coral-red fluorescence) 2

Additional Testing Based on Clinical Presentation

• Syphilis serology and HIV testing should be offered to all patients diagnosed with urethritis 3, 1
• Skin biopsy if lichen sclerosus is suspected and diagnosis is uncertain 3

Empiric Treatment Algorithm

For Suspected Infectious Urethritis

First-line therapy: Azithromycin 1 g orally single dose OR doxycycline 100 mg orally twice daily for 7 days 3, 1

• If gonococcal infection suspected, add ceftriaxone 250 mg IM single dose 3, 1
• All sex partners within preceding 60 days should be treated empirically 1
• Patients should abstain from sexual intercourse until treatment is completed and symptoms resolve 3

For Fungal Infections

• Topical antifungal agents (clotrimazole, miconazole) applied twice daily for 2-4 weeks 3, 2
• Avoid high-potency topical corticosteroids for prolonged periods as they can be deleterious 2

For Lichen Sclerosus with Neuropathic Pain

• Neuropathic pain does not respond to topical corticosteroids 3, 1
• Treatment must be directed at neuronal sensitization using neuropathic pain medications 3
• Topical corticosteroids (potent class) are appropriate for active inflammatory lesions but not for established dysaesthesia 3

Critical Pitfalls to Avoid

• Do not dismiss patients who describe "pressure" rather than "pain"—this is characteristic of CP/CPPS and interstitial cystitis/bladder pain syndrome 1
• Recognize that CP/CPPS and interstitial cystitis have overlapping presentations; some patients meet criteria for both conditions 1
• Unnecessary or inappropriate use of over-the-counter antifungal preparations can lead to delay of treatment of other etiologies 3
• Failure to improve within 3 days of antibiotic therapy requires reevaluation of diagnosis 3
• Persistent symptoms after using OTC preparations or recurrence within 2 months mandates medical evaluation 3

Red Flags Requiring Urgent Evaluation

• Systemic signs including fever, tachycardia, and diaphoresis suggest necrotizing infection (Fournier's gangrene) requiring immediate surgical consultation 3
• Progressive swelling, crepitus, or skin discoloration indicate potential necrotizing fasciitis 3
• Inability to void or severe urinary retention requires urgent urologic evaluation 3