What causes a burning sensation in the penis?

Burning Sensation in the Penis: Causes and Evaluation

A burning sensation in the penis most commonly results from infectious causes (candidal balanitis, herpes), inflammatory dermatoses (lichen sclerosus, contact dermatitis), or neuropathic pain syndromes (penile dysaesthesia), with urgent evaluation required to exclude priapism or other emergencies. 1, 2, 3

Immediate Exclusion of Emergencies

Before proceeding with routine evaluation, you must first rule out conditions requiring urgent intervention:

• Priapism (even partial): Any persistent abnormal penile sensation or tumescence lasting >4 hours requires urgent evaluation, as ischemic priapism represents a urologic emergency that can cause permanent erectile dysfunction if not treated within 6-8 hours 4, 5
• Paraphimosis or entrapment injury: These can result in ischemia and necrosis if left untreated 6
• Fournier gangrene: Look for perineal/scrotal involvement with systemic toxicity, fever, or rapidly advancing skin necrosis 1

If any of these are suspected, obtain immediate urologic consultation rather than proceeding with outpatient workup 4.

Most Common Causes by Category

Infectious Etiologies

Candidal balanitis is the most frequent mycotic infection of the penis, with increasing incidence primarily transmitted through sexual intercourse 2, 3. Patients present with:

• Erythema and burning of the glans and prepuce
• White plaques or erosions
• Associated pruritus 2

Herpes genitalis is the most common infectious cause of genital ulceration, with many infections being asymptomatic 3. Burning typically precedes or accompanies vesicular lesions that progress to painful ulcers 3.

Inflammatory Dermatoses

Lichen sclerosus presents as atrophic white patches on the glans penis and foreskin, commonly causing phimosis in uncircumcised men 1, 3. The British Association of Dermatologists recognizes that:

• Men may develop penile dysaesthesia with abnormal burning sensation on the glans or around the urethral meatus 1
• This represents neuropathic pain that persists despite clinical improvement or resolution of skin lesions 1
• This condition does NOT respond to topical corticosteroids and requires neuropathic pain management 1, 5

Contact dermatitis (allergic or irritant) results from condoms, lubricants, feminine hygiene products, or persistent moisture and maceration 3. Irritant dermatitis is more common than allergic 3.

Psoriasis and lichen planus may have atypical appearance in the genital area, with typical psoriatic scale often absent due to moisture 3.

Neuropathic Pain Syndromes

Male genital skin burning syndrome (Dysaesthetic Peno/Scroto-dynia) presents as penile and/or scrotal skin burning with:

• No positive physical signs or laboratory findings
• No response to antibiotics, antifungals, or topical corticosteroids
• Significant stress and disruption in social and sexual relationships
• Improvement with selective serotonin reuptake inhibitors (SSRIs) 7

This mirrors dysaesthetic vulvodynia in women and represents a distinct clinical entity 7.

Sexually Transmitted Infections

Human papillomavirus (HPV) infection may present with subclinical manifestations causing burning or discomfort before visible warts appear 3. Low-risk HPV types 6 and 11 cause condyloma acuminatum, while high-risk types 16 and 18 are associated with premalignant lesions 3.

Diagnostic Algorithm

Step 1: Visual Inspection

• White atrophic patches: Consider lichen sclerosus; biopsy if diagnosis uncertain 1, 3
• Erythematous plaques with white exudate: Likely candidal balanitis 2
• Vesicles or ulcers: Suspect herpes simplex 3
• Smooth, shiny, red-orange plaque: Consider plasma cell balanitis or squamous cell carcinoma in situ; biopsy required 3

Step 2: History Details

• Sexual exposure: Recent partners, condom use, partner symptoms (candida, herpes, HPV) 2, 3
• Contact exposures: New soaps, lubricants, latex condoms, topical products 3
• Duration and pattern: Persistent burning without visible lesions suggests neuropathic pain 1, 7
• Response to previous treatments: Lack of response to antifungals/antibiotics/steroids points toward dysaesthetic syndrome 7
• Associated symptoms: Urethral discharge (epididymitis), systemic symptoms (Fournier gangrene), altered erections (priapism) 1, 4

Step 3: Targeted Testing

• Fungal culture or KOH preparation if candidiasis suspected 2
• Viral culture or PCR for herpes if vesicles/ulcers present 3
• Biopsy for any persistent plaque, especially red-orange lesions that could represent squamous cell carcinoma in situ 3
• Urinalysis and urethral swab if urethritis suspected (burning with urination, discharge) 1
• Cavernous blood gas and duplex ultrasound if any suggestion of priapism 4, 5

Treatment Approach by Diagnosis

Candidal Balanitis

Local antifungal treatment is first-line for superficial infections, with systemic treatment reserved for widespread infection 2. Address provocative factors including:

• Diabetes control
• Sexual transmission (treat partner)
• Hygiene and moisture control 2

Lichen Sclerosus

The British Association of Dermatologists recommends clobetasol propionate ointment for active disease:

• Once nightly for 4 weeks
• Alternate nights for 4 weeks
• Twice weekly for final month
• Adjust frequency based on symptom control 1

However, for penile dysaesthesia associated with lichen sclerosus, topical corticosteroids will NOT work 1. Treatment must target neuropathic pain:

• Lidocaine 5% ointment as first-line 1
• Amitriptyline for unresponsive cases 1

Dysaesthetic Peno/Scroto-dynia

SSRIs are the treatment of choice for this neuropathic pain syndrome, with patients reporting improvement in symptoms and quality of life 7. This diagnosis should be considered when:

• Physical examination is normal
• All cultures and biopsies are negative
• No response to conventional treatments 7

Contact Dermatitis

• Identify and eliminate the offending agent (condoms, lubricants, topical products) 3
• Topical corticosteroids for inflammatory component
• Address moisture and maceration with proper hygiene 3

Herpes Genitalis

• Antiviral therapy (acyclovir, valacyclovir, or famciclovir) for acute episodes
• Suppressive therapy for recurrent disease 3

Critical Pitfalls to Avoid

• Delaying evaluation of persistent abnormal sensation: Any burning or altered sensation lasting >4 hours with any degree of tumescence requires urgent evaluation to exclude priapism 4, 5
• Treating dysaesthesia with corticosteroids: Neuropathic pain in lichen sclerosus does not respond to topical steroids and requires specific neuropathic pain management 1, 5
• Missing malignancy: Any persistent red-orange plaque requires biopsy to exclude squamous cell carcinoma in situ, as clinical appearance can be deceptively benign 3
• Assuming all burning is infectious: When physical examination is normal and cultures are negative, consider dysaesthetic syndrome rather than continuing empiric antimicrobial therapy 7
• Ignoring sexual transmission: Candidal balanitis is primarily sexually transmitted; partner treatment is essential to prevent recurrence 2