What is the diagnosis and treatment for an itchy penis?

Diagnosis and Management of Penile Pruritus

For an itchy penis, first determine if infectious symptoms are present (discharge, dysuria, fever, lesions), then treat accordingly with antimicrobials; if no infection is evident, apply topical hydrocortisone for symptomatic relief while investigating underlying dermatologic or allergic causes.

Initial Diagnostic Approach

Critical History Elements

• Onset and duration of itching, including whether symptoms are constant or intermittent 1
• Sexual history including recent partners, condom use, and timing of symptoms relative to sexual activity 2, 3
• New exposures to soaps, detergents, lubricants, condoms, or spermicides that may cause contact dermatitis 2, 4
• Medication history including recent antibiotics (trimethoprim-sulfamethoxazole can cause fixed drug eruption with intense penile itching) 5
• Associated symptoms such as urethral discharge, dysuria, fever, or systemic symptoms that suggest infection rather than simple irritation 6
• Skin conditions elsewhere on the body suggesting psoriasis, eczema, or lichen planus 2, 4

Physical Examination Findings

• Inspect for lesions: erythema, scaling, vesicles, ulcers, plaques, or white patches 2, 4
• Distinguish primary lesions from secondary changes due to scratching 1
• Check for discharge from the urethral meatus indicating urethritis 6
• Examine the entire skin for evidence of systemic dermatologic disease 4, 1
• Look for specific patterns: white atrophic patches suggest lichen sclerosus; red-orange plaques suggest plasma cell balanitis; typical psoriatic lesions may lack scale due to moisture 2

Treatment Algorithm

If Infectious Etiology Suspected (Discharge, Dysuria, Lesions)

Candidal balanitis (most common fungal cause):

• Local antifungal treatment is first-line for superficial infections 3
• Consider sexual transmission and treat partner if recurrent 3
• Systemic antifungal therapy reserved for widespread or refractory cases 3

Bacterial infection (urethritis, epididymitis):

• For men <35 years: Ceftriaxone 250 mg IM single dose PLUS Doxycycline 100 mg orally twice daily for 10 days 7, 6
• For men ≥35 years: Levofloxacin 500 mg orally once daily for 10 days OR Ofloxacin 300 mg orally twice daily for 10 days 7, 6
• Mandatory reassessment at 72 hours if no improvement 6

If Non-Infectious Etiology (Pure Irritation/Inflammation)

Topical hydrocortisone (FDA-approved for genital itching):

• Apply to affected area 3-4 times daily for external genital itching 8
• Clean area with mild soap and water before application, gently dry by patting 8
• For adults only; children under 12 years require physician consultation 8

Conservative measures:

• Avoid irritants: discontinue new soaps, detergents, lubricants, or condoms 2
• Consider condom material: switch from latex to lambskin or polymer if latex allergy suspected 9
• Maintain hygiene without excessive washing that causes further irritation 2

Critical Pitfalls to Avoid

• Do not assume trauma alone without obtaining urethral swab or first-void urine for Gram stain and culture to exclude bacterial infection 6
• Do not delay biopsy if lesions persist despite treatment, as squamous cell carcinoma in situ (erythroplasia of Queyrat) can appear clinically benign 2
• Do not miss fixed drug eruption: consider recent medication exposure, especially antibiotics like trimethoprim-sulfamethoxazole, which can cause intense penile itching within minutes 5
• Do not overlook systemic disease: persistent or atypical lesions may represent psoriasis, lichen planus, or lichen sclerosus requiring specific management 2, 4
• Do not ignore HPV risk: persistent lesions warrant evaluation for condyloma acuminatum or premalignant changes, especially with high-risk HPV types 2

When to Escalate Care

• No improvement within 72 hours of appropriate treatment requires reevaluation of diagnosis 6
• Persistent lesions despite topical therapy warrant biopsy to exclude malignancy 2
• Recurrent candidal infections may require systemic antifungal therapy and partner treatment 3
• Progressive symptoms with phimosis or meatal stenosis suggest lichen sclerosus requiring specialist referral 2