What is the best course of treatment for a 41-year-old male with penile pain?

Treatment of Penile Pain in a 41-Year-Old Male

The best initial approach is to establish the specific etiology through targeted history and diagnostic testing, as penile pain has multiple distinct causes requiring different treatments—most commonly urethritis (treated with azithromycin 1g single dose or doxycycline 100mg twice daily for 7 days), Peyronie's disease (managed conservatively in acute phase with NSAIDs), or chronic pelvic pain syndrome (requiring multimodal therapy). 1

Initial Diagnostic Approach

The critical first step is determining whether this represents:

• Urethritis/STI-related pain: Look for urethral discharge, dysuria, or recent sexual exposure. Document presence of white blood cells and perform NAAT testing for gonorrhea and chlamydia 1

• Peyronie's disease: Assess for palpable penile plaque, penile curvature (especially with erection), and whether pain occurs primarily with erections. Distinguish between active disease (pain with/without erection, changing symptoms, developing deformity) versus stable disease (symptoms unchanged for ≥3 months, minimal pain, established curvature) 2, 3

• Priapism: Determine if there is prolonged, unwanted erection. Any erection lasting >4 hours requires immediate intervention with intracavernosal phenylephrine and aspiration 1

• Chronic penile pain syndrome: Consider if pain persists >3 months without identifiable pathology, often associated with perineal or pelvic discomfort, irritative voiding symptoms, or pain with ejaculation 1

Treatment Algorithm by Etiology

If Urethritis is Suspected or Confirmed

Initiate treatment immediately upon diagnosis without waiting for test results 1:

• First-line: Azithromycin 1g orally single dose OR Doxycycline 100mg orally twice daily for 7 days 1
• Dispense medication on-site and directly observe first dose to maximize compliance 1
• Instruct patient to abstain from sexual intercourse for 7 days after single-dose therapy or until completion of 7-day regimen 1
• Test for concurrent syphilis and HIV 1
• Treat all sexual partners from preceding 60 days empirically 1
• Retest in 3-6 months due to high reinfection rates 1

If Peyronie's Disease is Present

For active disease (pain present, symptoms changing):

• NSAIDs are first-line for pain management 3
• Daily tadalafil 5mg may reduce curvature progression and improve symptoms 2, 3
• Reassure patient that 20% of cases resolve spontaneously 4
• Avoid surgery during active phase 3

For stable disease (symptoms stable ≥3 months):

• If curvature is 30-90° with palpable plaque and intact erectile function: Consider collagenase clostridium histolyticum (CCH) injections—the only FDA-approved non-surgical therapy, providing average 17° reduction in curvature 2, 3
• Surgery only after disease stable for 3-6 months and curvature compromises sexual function 2, 3

If Priapism is Present

For erections >4 hours:

• Intracavernosal phenylephrine injection as initial treatment 1
• Aspiration with or without saline irrigation 1
• Monitor blood pressure and heart rate during phenylephrine administration 1
• Critical timing: Permanent erectile dysfunction occurs after 36 hours; smooth muscle edema begins at 6 hours 1

If Chronic Penile Pain Without Clear Etiology

• Rule out prostatitis/chronic pelvic pain syndrome if pain persists >3 months with perineal, penile, or pelvic discomfort 1
• Consider manual therapy techniques targeting lumbar and inguinal areas for possible nerve entrapment (L1 or ilioinguinal nerve) 5
• Cryoablation of penile nerves is a last-resort option after failed medical management 6

Common Pitfalls to Avoid

• Do not delay treatment for urethritis while awaiting test results—initiate empiric therapy immediately 1
• Do not perform surgery for Peyronie's disease during active phase—wait until stable for 3-6 months 3
• Do not ignore the 4-hour window for priapism—permanent damage begins early 1
• Do not assume symptoms alone indicate persistent urethritis—require objective signs (urethral inflammation, laboratory evidence) before retreatment 1
• Do not overlook partner treatment—all partners within 60 days require empiric therapy for suspected STIs 1

Follow-Up Considerations

• For treated urethritis: Return if symptoms persist or recur; retest at 3-6 months regardless of symptom resolution 1
• For Peyronie's disease: Monitor disease stability over 3-6 months before considering invasive interventions 2, 3
• For chronic pain: Consider psychological evaluation as 54% of men with penile conditions report relationship difficulties 3