Can radiculopathy at L2-L3 (lumbar spine level 2-3) cause penis pain in adult males with a history of lower back problems?

Can L2-L3 Radiculopathy Cause Penis Pain?

Yes, L2-L3 radiculopathy can cause penis pain, though this is an uncommon presentation that requires careful diagnostic evaluation to distinguish from other causes of genital pain.

Anatomical Basis for Genital Pain from L2-L3 Radiculopathy

The L2-L3 nerve roots contribute sensory innervation to the anterior and lateral thigh, but also have connections to the genitofemoral and ilioinguinal nerves that can refer pain to the genital region 1. While L2-L3 disc herniation classically presents with severe thigh pain and sensory disturbance at the anterior or lateral aspect of the thigh, the dermatomal distribution can extend to include genital regions 1.

The key clinical pattern for L2-L3 radiculopathy includes:

• Severe anterior or lateral thigh pain as the predominant symptom 1
• Possible quadriceps weakness (seen in approximately 45% of cases) 1
• Decreased or absent patellar tendon reflex (seen in approximately 80% of cases) 1
• Positive femoral nerve stretch test (seen in approximately 70% of cases) 1

Critical Differential Diagnosis: Sacral Radiculopathy

However, sacral nerve root pathology is a more common cause of isolated penile pain than L2-L3 radiculopathy. A case report documented that Tarlov cysts causing sacral spinal nerve root radiculitis produced severe penile pain during sexual arousal through irritation of sensory fibers coursing within the pelvic nerve 2. This patient experienced complete symptom elimination after surgical repair of the sacral pathology 2.

Diagnostic Approach

When evaluating suspected radiculopathy causing genital pain, the diagnostic workup should proceed as follows:

Initial Imaging

• MRI lumbar spine without contrast is the preferred initial study to evaluate for nerve root compression at L2-L3 or other lumbar levels 3
• If clinical presentation suggests plexopathy rather than simple radiculopathy, MRI lumbosacral plexus with and without IV contrast should be obtained, as this can change management in up to 71% of patients 4, 3

When to Image Immediately vs. Conservative Management

• Obtain immediate MRI if:

  • Severe or progressive neurological deficits are present 3
  • Suspected cauda equina syndrome (bilateral symptoms, bowel/bladder dysfunction, perineal numbness) 5, 3
  • Red flag symptoms suggesting malignancy or infection 3

• Conservative management for 4-6 weeks is appropriate if:

  • Symptoms are less than 4-6 weeks duration 3, 6
  • No progressive neurological deficits 3
  • Neurological examination is normal or stable 3

Advanced Diagnostic Testing

• Electrodiagnostic testing (EMG/NCS) has clinical utility when:

  • The diagnosis is unclear 6
  • Peripheral neuropathy is a likely alternate diagnosis 6
  • Confirmation of acute radiculopathy is needed despite normal imaging 7

• Fluoroscopically guided diagnostic selective nerve root blocks can confirm the pain generator when imaging and clinical findings are discordant 7

Important Clinical Pitfall

Radiculopathy can occur with completely normal imaging studies. A prospective case series demonstrated that patients can have definitive radiculopathy (with myotomal deficits, positive EMG, and positive diagnostic nerve root blocks) despite MRI showing no local nerve root pathology 7. This implies that biochemical inflammation, rather than mechanical compression alone, can cause radiculopathy and radicular pain 7.

Red Flags Requiring Urgent Evaluation

The following symptoms indicate potential cauda equina syndrome and require emergency MRI within hours:

• Bilateral radicular pain, sensory loss, or weakness 5
• New bladder or bowel dysfunction 5
• Loss of perineal sensation 8, 5
• Progressive neurological deficits 8, 5

Patients treated at the early stage (CESS - Cauda Equina Syndrome Suspected) can avoid permanent dysfunction entirely, while those treated after urinary retention develops have poor outcomes with only 48-93% showing any improvement 5.

Management Strategy

For confirmed L2-L3 radiculopathy causing genital pain:

• Initial conservative management includes physical therapy with strengthening and stretching, NSAIDs, and potentially muscle relaxants 6
• Most cases resolve with conservative treatment (75-90% success rate) 8
• If symptoms persist after 4-6 weeks despite conservative treatment, consider epidural steroid injections or surgical consultation 3, 6
• Surgical decompression is reserved for persistent or progressive neurological deficits despite conservative management 8

If sacral pathology is identified as the cause of penile pain, surgical intervention may provide complete symptom resolution 2.